An inquest has revealed that NHS staff at Newham Mental Health Centre in east London falsified records and were sleeping or on their phones when Hugo Flint-Cahan, a patient with acute mental health issues, was killed by another patient, Rolando Torres-Pena, on January 3, 2023. The coroner found the death to be unlawful and due to neglect, recommending four staff members be referred for investigation by their regulator and suggesting the police review their initial inquiry into the incident.
Written by the local model on 2026-09-14,
using this article's own text rather than the other coverage of the
same event (that is the story summary below).
- Published
Staff falsified records, slept and were on their phones on the night one patient was killed by another on an NHS mental health unit in east London, an inquest has heard.
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inquest → publish → London
Hugo Flint-Cahan, 34, was being treated at Newham Mental Health Centre (NMHC), run by the East London NHS Trust (ELFT), when he was fatally attacked by 22-year-old Rolando Torres-Pena.
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he → treat → Pena
Hugo's family say they have been shocked by the "dangerous" failures in his care.
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they → say → care
The Trust told the coroner they had addressed some of the issues raised in the inquest, and are launching an investigation into the staff whose failings have been identified.
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failings → tell → staff
In a narrative conclusion, the coroner found Hugo was unlawfully killed which was contributed to by neglect, recommended four members of staff be referred to their regulator and that the Metropolitan police review their investigation into what happened that night.
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what → find → investigation
Hugo, who had been a patient at the NHMC for six months, was strangled in the early hours of 3 January 2023 by Torres-Pena who had arrived on the ward five days earlier.
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who → strangle → ward
Torres-Pena pleaded guilty at the Old Bailey to manslaughter on the grounds of diminished responsibility.
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Pena → plead → responsibility
He was given a hospital order without time limit.
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He → give → limit
A coroner criticised repeated failures by the Trust in a number of patient deaths - not just Hugo's.
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coroner → criticise → deaths
Graeme Irvine, the Senior Coroner for East London, said it was like "ground hog day" as he heard evidence of "the same" errors, "over and over again," including the falsification of patient observation records and slow emergency responses.
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he → say → records
Torres-Pena was pacing the corridor believing he was about to leave, the inquest was told.
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inquest → pace → corridor
CCTV shows him following one of the nurses at one point.
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him → show → point
After 01:00, Hugo is seen wandering the corridor on his own.
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Hugo → see → own
The CCTV last shows him alive at 01:22.
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CCTV → show → 01:22
It's thought he went into Torres-Pena's room shortly afterwards.
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he → think → room
At 01:26 Torres-Pena is seen walking the corridor.
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Pena → see → corridor
He went into Hugo's empty room, before he disappears out of shot a couple of minutes later.
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he → go → minutes
It is not known exactly when Hugo was attacked, but at 01:31 the patient in the room next to Torres-Pena can be seen on CCTV coming out of his room.
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patient → know → room
He appears to be looking up and down the corridor, seemingly disturbed by something.
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He → appear → something
The patient is then seen watching something that's out of shot.
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that → see → shot
It is thought this is when Hugo was beaten and strangled.
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Hugo → think → ?
During this period, the two nurses, Rosemary Chukwuji-Ohanachum and Raji Olagunju, were in the staff room with the door shut.
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door → shut → room
Despite three patients having been seen walking around the corridor, no staff are seen.
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staff → see → corridor
Just before 02:00, Torres-Pena is seen walking around the corridor again.
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Pena → see → corridor
He was not wearing any trousers.
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He → wear → trousers
The coroner at Hugo's inquest said Torres-Pena had taken them off because they were soaked in blood.
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they → say → blood
Patients on the ward should have been checked by staff hourly.
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Patients → check → staff
The observation log for the ward falsely shows that at 02:00 Hugo was in his bed awake.
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Hugo → show → bed
False records
Onuh admitted to the coroner that he filled out the form without checking where people were.
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people → admit → form
At about that time, CCTV shows Onuh emerging from the therapy room holding his bedding.
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Onuh → show → bedding
He can be seen speaking to Torres-Pena whilst nurse Chukwuji-Ohanachum walks past with her blankets.
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Ohanachum → see → blankets
She told the coroner she was going to the therapy room to sleep during her unauthorised two-hour break.
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she → tell → break
Hugo was discovered at 03:19 by nurse Olagunju, almost two hours after he was attacked.
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he → discover → Olagunju
He didn't attempt CPR or raise the alarm and went to the find the unit's night manager, Alex Obamwonyi, who was on a neighbouring ward.
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who → attempt → ward
Obamwonyi told the inquest Hugo wasn't breathing and he couldn't find a pulse.
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he → tell → pulse
He raised the alarm but locked the door into the room.
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He → raise → room
He said he thought it was too late to start CPR, and he wanted to preserve the crime scene.
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he → say → scene
The emergency services were called at 03:37, and CPR finally started at 03:45.
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CPR → call → 03:45
Witnesses at the inquest described chaotic scenes.
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Witnesses → describe → scenes
Nurse Chukwuji-Ohanachum was screaming and throwing herself on the ground.
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Ohanachum → scream → ground
…and 18 more, not listed.
