- 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.
asserted
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.
asserted
he → treat → Pena
Hugo's family say they have been shocked by the "dangerous" failures in his care.
asserted
they → say → care
The Trust says it has undertaken a significant programme of work to "improve our inpatient culture, behaviours and practice".
asserted
it → say → culture
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.
asserted
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.
asserted
who → strangle → ward
Torres-Pena pleaded guilty at the Old Bailey to manslaughter on the grounds of diminished responsibility.
asserted
Pena → plead → responsibility
He was given a hospital order without time limit.
asserted
He → give → limit
A coroner criticised repeated failures by the Trust in a number of patient deaths - not just Hugo's.
asserted
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.
asserted
he → say → records
Torres-Pena was pacing the corridor believing he was about to leave, the inquest was told.
asserted
inquest → pace → corridor
CCTV shows him following one of the nurses at one point.
asserted
him → show → point
After 01:00, Hugo is seen wandering the corridor on his own.
asserted
Hugo → see → own
The CCTV last shows him alive at 01:22.
asserted
him → show → 01:22
It's thought he went into Torres-Pena's room shortly afterwards.
asserted
he → think → room
At 01:26 Torres-Pena is seen walking the corridor.
asserted
Pena → see → corridor
He went into Hugo's empty room, before he disappears out of shot a couple of minutes later.
asserted
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.
asserted
patient → know → room
He appears to be looking up and down the corridor, seemingly disturbed by something.
asserted
He → appear → something
The patient is then seen watching something that's out of shot.
asserted
that → see → shot
It is thought this is when Hugo was beaten and strangled.
asserted
Hugo → think → ?
During this period, the two nurses, Rosemary Chukwuji-Ohanachum and Raji Olagunju, were in the staff room with the door shut.
asserted
door → shut → room
Despite three patients having been seen walking around the corridor, no staff are seen.
asserted
staff → see → corridor
Just before 02:00, Torres-Pena is seen walking around the corridor again.
asserted
Pena → see → corridor
He was not wearing any trousers.
asserted
He → wear → trousers
The coroner at Hugo's inquest said Torres-Pena had taken them off because they were soaked in blood.
asserted
they → say → blood
Patients on the ward should have been checked by staff hourly.
asserted
Patients → check → staff
The observation log for the ward falsely shows that at 02:00 Hugo was in his bed awake.
asserted
Hugo → show → bed
False records
Onuh admitted to the coroner that he filled out the form without checking where people were.
asserted
people → admit → form
At about that time, CCTV shows Onuh emerging from the therapy room holding his bedding.
asserted
Onuh → show → bedding
He can be seen speaking to Torres-Pena whilst nurse Chukwuji-Ohanachum walks past with her blankets.
asserted
Ohanachum → see → blankets
She told the coroner she was going to the therapy room to sleep during her unauthorised two-hour break.
asserted
she → tell → break
Hugo was discovered at 03:19 by nurse Olagunju, almost two hours after he was attacked.
asserted
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.
asserted
who → attempt → ward
Obamwonyi told the inquest Hugo wasn't breathing and he couldn't find a pulse.
asserted
he → tell → pulse
He raised the alarm but locked the door into the room.
asserted
He → raise → room
He said he thought it was too late to start CPR, and he wanted to preserve the crime scene.
asserted
he → say → scene
The emergency services were called at 03:37, and CPR finally started at 03:45.
asserted
CPR → call → 03:45
Witnesses at the inquest described chaotic scenes.
asserted
Witnesses → describe → scenes
Nurse Chukwuji-Ohanachum was screaming and throwing herself on the ground.
asserted
Ohanachum → scream → ground
…and 22 more, not listed.
The Aporia
