Coroner Rules NHS Patient Unlawfully Killed After Staff Slept and Falsified Records on Night Shift

Hugo Flint-Cahan, 34, was strangled to death in the early hours of January 3, 2023, by a fellow patient at Newham Mental Health Centre in east London while the staff meant to be watching him were asleep, on their phones, or hiding in a locked staff room, according to an inquest that concluded this month.

Senior Coroner for East London Graeme Irvine ruled the killing was unlawful and contributed to by neglect. He recommended four staff members be referred to their professional regulator and asked the Metropolitan Police to review its original investigation into what happened that night, according to the BBC.

Flint-Cahan had been a patient at the centre, run by the East London NHS Trust (ELFT), for six months when Rolando Torres-Pena, then 22, arrived on the ward just five days before the attack. Torres-Pena later pleaded guilty at the Old Bailey to manslaughter on the grounds of diminished responsibility and was handed a hospital order with no time limit.

What the CCTV Showed

Two nurses and a nursing assistant were on duty on Topaz ward, an inpatient unit for men with acute mental health issues, the night Flint-Cahan died. CCTV footage reviewed by the coroner showed nursing assistant Anthony Onuh asleep in a therapy room for two hours. Nurses Rosemary Chukwuji-Ohanachum and Raji Olagunju were in the staff room with the door shut, according to London Crime News.

Flint-Cahan was last seen alive on camera at 1:22 a.m. Torres-Pena was seen in the corridor minutes later. The attack is believed to have happened around 1:31 a.m., based on the reaction of a patient in the neighboring room who came out looking startled, with no staff visible anywhere on the corridor.

Nurse Olagunju did not find Flint-Cahan's body until 3:19 a.m., nearly two hours after the attack. Rather than attempt CPR or immediately raise the alarm, he went to find the unit's night manager, Alex Obamwonyi, on a neighboring ward. Obamwonyi told the inquest he believed it was too late to start CPR and wanted to preserve the crime scene. Emergency services were not called until 3:37 a.m. CPR began at 3:45 a.m. Flint-Cahan was declared dead at 4:41 a.m., according to London Crime News.

The ward's observation log falsely recorded that Flint-Cahan had been checked at 2:00 a.m., when he was not in his bed. Onuh admitted to the coroner he filled out the form without actually checking on patients.

Not an Isolated Failure

Coroner Irvine told the inquest the evidence felt like "ground hog day," saying he had heard the "same" errors "over and over again" across multiple patient deaths at the trust, including falsified observation records and slow emergency responses.

Over the past 12 years, coroners have issued at least 29 Prevention of Future Deaths notices to the East London NHS Trust, formal warnings sent when a coroner believes unaddressed problems could cause further deaths. A BBC analysis of those notices found that in more than half the cases, staff had failed to properly assess the risk a patient posed to themselves or others, with poor communication and falsified records recurring throughout.

A 2021 report from the same coroner who handled the Flint-Cahan inquest warned of a "culture of impunity" at the trust, where inaccurate and misleading clinical record-keeping was tolerated. Two further reports in 2024 again cited missed observations followed by falsified records. A 2025 report into the death of a young woman raised the identical concern, despite what the trust had described as action plans and assurances in response to earlier warnings.

The trust has told the coroner it has addressed some of the issues raised in this inquest and is launching an investigation into the staff whose failings were identified. Despite repeated promises of reform following each of these prior warnings, the same pattern of missed observations and falsified records has recurred, which helps explain the coroner's exasperation in invoking "ground hog day" in his ruling.

Family and Advocates Respond

Flint-Cahan's father, William Flint-Cahan, who attended every day of the inquest, said there was complacency and a lack of care, and that his son's death was preventable had proper care been given, according to Symplexia News. His brother Jolyon, an NHS doctor himself, called the failures, both incompetence and dishonesty, "harrowing."

Brian Dow of the mental health charity Rethink Mental Illness called for a national register to track patient safety across mental health units, saying, "We have been here before with poor observations, records being falsified and unacceptable care."

Four staff members now face regulatory referral, and the Metropolitan Police has been asked to reopen its review of the case. Whether those steps produce actual consequences, or simply add another entry to a list of warnings that already runs to at least 29, is the question the trust has yet to answer.