Inquest finds neglect contributed to death at London NHS unit

A coroner has concluded that Hugo Flint-Cahan, 34, was unlawfully killed at Newham Mental Health Centre in east London, and that neglect contributed to his death. Graeme Irvine, the Senior Coroner for East London, heard that staff slept, falsified observation records and were on their phones on the night of 3 January 2023.

What happened to Hugo Flint-Cahan?

Hugo Flint-Cahan had been a patient at Newham Mental Health Centre, run by the East London NHS Trust (ELFT), for six months when he was strangled in the early hours of 3 January 2023. Rolando Torres-Pena, 22, who had arrived on the Topaz ward five days earlier, pleaded guilty at the Old Bailey to manslaughter on the grounds of diminished responsibility and was given a hospital order without time limit.

What did the coroner conclude?

Graeme Irvine, the Senior Coroner for East London, recorded a narrative conclusion that Hugo Flint-Cahan was unlawfully killed, contributed to by neglect. He recommended that four members of staff be referred to their regulator and that the Metropolitan police review their investigation into what happened that night. Irvine criticised repeated failures by the East London NHS Trust in a number of patient deaths, not only Hugo Flint-Cahan’s, saying it was like “ground hog day” as he heard evidence of “the same” errors “over and over again”.

What failures were identified on Topaz ward?

Two nurses and a nursing assistant were on duty on Topaz ward, an inpatient unit for men with acute mental health issues. Nurses Rosemary Chukwuji-Ohanachum and Raji Olagunju were in the staff room with the door shut, and Chukwuji-Ohanachum told the inquest she was going to the therapy room to sleep during an unauthorised two-hour break. Nursing assistant Anthony Onuh was asleep for two hours in the therapy room and admitted to the coroner that he filled out an observation form without checking where people were. The observation log falsely recorded that at 02:00 Hugo Flint-Cahan was in his bed awake.

When was Hugo Flint-Cahan found?

Hugo Flint-Cahan was discovered at 03:19 by nurse Raji Olagunju, almost two hours after he was attacked. Olagunju did not attempt CPR or raise the alarm, and went to find the unit’s night manager, Alex Obamwonyi, who was on a neighbouring ward. Obamwonyi raised the alarm but locked the door into the room, saying he thought it was too late to start CPR and that he wanted to preserve the crime scene. Emergency services were called at 03:37 and CPR began at 03:45. Hugo Flint-Cahan was declared dead at 04:41.

What has the East London NHS Trust said?

The East London NHS Trust told the coroner it had addressed some of the issues raised in the inquest and is launching an investigation into the staff whose failings have been identified. Over the past 12 years, local coroners have sent at least 29 Prevention of Future Deaths notices to the Trust; such notices are sent when a coroner identifies problems which, if not dealt with, could lead to further deaths. Scrutiny of how UK health bodies handle harm and payment extends beyond mental health: the UK vaccine damage payment scheme has spent £83m on running costs while paying out £32m.

What has Hugo Flint-Cahan’s family said?

Hugo Flint-Cahan’s father, William Flint Cahan, who attended each day of the inquest with other family members, said there was “complacency” by staff and a lack of care, and maintains his son’s death was “preventable had the level of care been as it should have been”. His brother Jolyon, an NHS doctor, said the “litany of failures, both incompetence and dishonesty, that pervaded the care of both patients was harrowing”. The family said they had been shocked by the “dangerous” failures in his care.

Rules governing death and medical care differ between countries: assisted dying laws now cover about 400 million people worldwide, under frameworks that diverge.

Frequently asked questions

What did the coroner conclude about Hugo Flint-Cahan’s death?

Graeme Irvine, the Senior Coroner for East London, concluded that Hugo Flint-Cahan, 34, was unlawfully killed at Newham Mental Health Centre on 3 January 2023, with neglect contributing to his death. He recommended that four members of staff be referred to their regulator and that the Metropolitan police review their investigation.

Who killed Hugo Flint-Cahan and what happened to him?

Rolando Torres-Pena, 22, strangled Hugo Flint-Cahan at the East London NHS Trust unit. He pleaded guilty at the Old Bailey to manslaughter on the grounds of diminished responsibility and was given a hospital order without time limit.

What failures did the inquest hear about at Newham Mental Health Centre?

The inquest heard that nursing assistant Anthony Onuh slept for two hours and filled out an observation form without checking where patients were, that the ward log falsely recorded Hugo Flint-Cahan in his bed awake at 02:00, and that two nurses were in the staff room with the door shut.

How many Prevention of Future Deaths notices has the East London NHS Trust received?

Local coroners have sent at least 29 Prevention of Future Deaths notices to the East London NHS Trust over the past 12 years, according to evidence given at the inquest.

With reporting from BBC News.

Stock image, not from the events described. Globe World — Jo%E3o%20Silas / Wikimedia Commons (CC0 1.0)