An inquest into the death of a patient at an NHS mental health unit in east London has revealed that staff falsified records, slept on duty and were distracted by their phones on the night one patient was fatally attacked by another.
Hugo Henry Holland Flint Cahan, 34, was strangled to death while receiving treatment at Newham Mental Health Centre (NMHC), operated by the East London NHS Trust (ELFT). His attacker, 22-year-old Rolando Torres-Pena, had been admitted to the ward five days before the fatal assault on 3 January 2023.
The coroner delivered a narrative conclusion that Hugo was unlawfully killed, with the death contributed to by neglect. Senior Coroner Graeme Irvine recommended that four members of staff be referred to their regulator and that the Metropolitan Police review their investigation into the incident. Hugo's family have expressed shock at what they describe as "dangerous" failures in his care.
The Trust has stated it has addressed some of the issues identified during the inquest and is launching an investigation into the staff members whose shortcomings have been documented.
What happened on the night of Hugo's death?
On the early morning of 3 January 2023, Topaz ward—an inpatient unit for men experiencing acute mental health crises—was staffed by two nurses and a nursing assistant. CCTV footage captured the sequence of events that led to Hugo's death.
Torres-Pena was observed pacing the corridor, believing he was about to be discharged. Hugo, also unsettled, was seen following one of the nurses at one point. After 01:00, Hugo was recorded wandering the corridor alone. The final CCTV image of him alive was captured at 01:22, shortly before he is believed to have entered Torres-Pena's room.
At 01:26, Torres-Pena was seen walking the corridor. He entered Hugo's empty room before moving out of camera view moments later. The exact timing of the attack remains unclear, but at 01:31, a patient in the adjacent room was observed emerging and looking up and down the corridor, appearing disturbed. No staff members were visible at this time. The patient then appeared to be watching something outside the camera's range—believed to be when Hugo was beaten and strangled.
During this critical period, the two nurses, Rosemary Chukwuji-Ohanachum and Raji Olagunju, were in the staff room with the door closed. Despite three patients being observed moving around the corridor, no staff presence was recorded. Nursing assistant Anthony Onuh was asleep in the therapy room for approximately two hours.
Just before 02:00, Torres-Pena was seen walking the corridor again, without trousers. The coroner noted that Torres-Pena had removed them because they were saturated with blood.
Ward protocols required staff to check on patients hourly. However, the observation log falsely documented that at 02:00 Hugo was in his bed and awake. Onuh admitted to the coroner that he completed the form without verifying the actual whereabouts of patients.
How were the falsified records created?
Around the time the false observation was recorded, CCTV showed Onuh emerging from the therapy room carrying his bedding. He was captured speaking with Torres-Pena while nurse Chukwuji-Ohanachum walked past carrying blankets. She told the coroner she was going to the therapy room to sleep during an unauthorised two-hour break.
Hugo was discovered at 03:19 by nurse Olagunju, nearly two hours after the attack. Olagunju did not attempt cardiopulmonary resuscitation (CPR) or immediately raise the alarm. Instead, he went to find the unit's night manager, Alex Obamwonyi, who was stationed on a neighbouring ward.
Obamwonyi confirmed to the inquest that Hugo was not breathing and had no detectable pulse. He raised the alarm but locked the door to Hugo's room, stating he believed it was too late to begin CPR and that he wanted to preserve the crime scene.
Emergency services were called at 03:37, and CPR finally commenced at 03:45. Witnesses described chaotic scenes as staff responded. Nurse Chukwuji-Ohanachum was screaming and throwing herself on the ground, requiring restraint from other staff members. One member of staff performed chest compressions on Hugo until exhaustion forced her to stop. Hugo was pronounced dead at 04:41.
What pattern of failures has the coroner identified?
Coroner Irvine criticised repeated failures by the Trust affecting multiple patient deaths, not solely Hugo's case. He described the pattern as resembling "ground hog day," with evidence of "the same" errors occurring "over and over again," including falsification of patient observation records and delayed emergency responses.
Over the past 12 years, local coroners have issued at least 29 Prevention of Future Deaths (PFD) notices to the Trust. These formal notices are issued when a coroner identifies systemic problems that, if unaddressed, could result in further deaths.
Analysis of these reports reveals that in more than half of cases, staff failed to properly assess the risk posed by patients to themselves or others. Poor communication between staff members, other agencies and families emerged as a recurring theme. The most serious warnings centred on inadequately conducted observations and falsified records—fundamental care measures essential for patient safety.
A 2021 coroner's report warned that "a culture of impunity existed" at the Trust, where "inaccurate and misleading recording of clinical records was tolerated." In 2024, two further reports documented instances where observations were missed and records were subsequently falsified to suggest patients had been checked. In response to one PFD, the Trust reported introducing extensive training programmes and quality checks.
However, in 2025, a fourth report examining the death of a young woman again highlighted falsified observation records. The coroner stated that despite "assurances" from the Trust in "numerous action plans," the inquest had "revealed widespread concerns" about how observations were being conducted across two wards.
Additional serious concerns documented in the reports include inadequate emergency responses, with delays in resuscitation and, in one instance, nursing staff performing chest compressions on a patient's stomach rather than their chest.
What do Hugo's family and advocates say?
Hugo's father, William Flint Cahan, attended every day of the inquest alongside other family members. He has characterised the failures as reflecting "complacency" by staff and a fundamental lack of care. He maintains that his son's death was "preventable had the level of care been as it should have been."
Hugo's brother, Jolyon, who works as an NHS doctor, described the situation as harrowing. He characterised the evidence as revealing a "litany of failures, both incompetence and dishonesty, that pervaded the care of both patients."
Brian Dow of the mental health charity Rethink has called for a national register of patient safety to monitor the standard of care provided by mental health units across the country. He emphasised that poor observations, falsified records and unacceptable care represent recurring problems. "We have been here before," he stated, calling for "a better approach to patient safety in what are the most difficult and most vulnerable wards with the people who are the most unwell."
What is the status of the criminal case?
Rolando Torres-Pena pleaded guilty at the Old Bailey to manslaughter on the grounds of diminished responsibility. He was issued a hospital order without time limit. A national broadcaster reported in November 2023 that Torres-Pena was sentenced following the killing, marking the conclusion of the criminal proceedings.
What happens next?
According to the East London Coroner's Court schedule, Hugo Flint Cahan's inquest was listed for a conclusion hearing on 14 September 2026. Independent inquest listings also showed the hearing continuing across 15–18 September 2026, again marked as a conclusion hearing. The inquest is being heard at Queens Road, Walthamstow E17 8QP.
The Trust has committed to launching an investigation into the identified staff failings and has stated it is addressing issues raised during the inquest proceedings.
Key Facts
- Hugo Henry Holland Flint Cahan, 34, was strangled by fellow patient Rolando Torres-Pena, 22, on 3 January 2023 at Newham Mental Health Centre in east London
- The coroner found Hugo was unlawfully killed, with death contributed to by neglect, and recommended four staff members be referred to their regulator
- Staff falsified observation records, slept on duty and were on their phones during the night of the attack; Hugo was discovered almost two hours after being fatally assaulted
- Over 12 years, the Trust has received at least 29 Prevention of Future Deaths notices from coroners, with repeated failures in patient observations, record-keeping and emergency responses
- Torres-Pena pleaded guilty to manslaughter on grounds of diminished responsibility and received a hospital order without time limit
