Staff slept while patient killed at NHS mental health unit – BBC News
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Staff falsified records, slept and used phones during patient’s killing at NHS mental health unit
By James Melley, Senior social affairs producer and Alison Holt, Social affairs editor
Published 16 minutes ago
Staff at Newham Mental Health Centre (NMHC), run by the East London NHS Trust (ELFT), falsified records, slept and used their phones on the night a patient was killed by another, an inquest has heard.
Hugo Flint-Cahan, 34, was being treated at NMHC when he was fatally attacked by Rolando Torres-Pena, 22, in January 2023. Hugo’s family have expressed shock at the "dangerous" care failures.
The Trust acknowledged addressing some issues and launched an investigation into staff whose failings were identified.
In a narrative conclusion, the coroner ruled Hugo was unlawfully killed due to neglect and recommended referring four staff members to their regulator, as well as reviewing the Metropolitan Police’s investigation.
Hugo, who had been at NMHC for six months, was strangled by Torres-Pena in the early hours of 3rd January 2023. Torres-Pena pleaded guilty to manslaughter on the grounds of diminished responsibility and received a hospital order without time limit.
The Senior Coroner for East London, Graeme Irvine, criticised repeated failures by the Trust, noting similarities with previous patient deaths. He described it as "groundhog day" regarding errors such as falsified patient observation records and slow emergency responses.
Events leading up to Hugo’s death:
On the night of Hugo’s killing:
- There were two nurses and a nursing assistant on duty on Topaz ward – an inpatient unit for men with acute mental health issues.
- Torres-Pena, pacing the corridor, believed he was about to leave.
- Hugo, unsettled, followed one of the nurses at one point and wandered the corridor alone after 01:00.
- CCTV shows him alive last at 01:22. He likely entered Torres-Pena’s room shortly afterwards.
At 01:31, a patient in the next room appeared disturbed and looked down the corridor; no staff were in sight. At around this time, Hugo is thought to have been attacked and strangled.
During this period:
- Nurses Rosemary Chukwuji-Ohanachum and Raji Olagunju were in the staff room with the door shut.
- Nursing assistant Anthony Onuh slept for two hours in the therapy room.
