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A patient was beaten and then strangled to death on a mental health ward while a staff member took a two-hour nap in a therapy room, an inquest has heard.
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inquest → see → room
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 Rolando Torres-Pena, 22, during the early hours of January 3, 2023.
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he → treat → January
Mr Flint-Cahan, who was unsettled that evening, was last seen on CCTV at 1.22am before he went into Torres-Pena's bedroom and disappeared from view.
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he → see → view
Torres-Pena, who was paranoid and had arrived on the ward five days earlier, was pacing the corridors before he was last seen on CCTV at 1.26am.
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he → arrive → 1.26am
While the exact time of the attack is unclear, a patient in the room next-door appears in the corridor seemingly disturbed by something at 1.31am.
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patient → appear → 1.31am
It is now believed he was watching Mr Flint-Cahan's dying moments.
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he → believe → moments
Just before 2am, Torres-Pena reappeared in the corridor wearing a towel around his waist after he removed his blood-soaked trousers.
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he → reappear → trousers
Hugo Flint-Cahan, 34, was being treated at Newham Mental Health Centre (NMHC) in London , run by the East London NHAS Trust (ELFT) when he was fatally attacked by Rolando Torres-Pena, 22, during the early hours of January 3, 2023
Mr Flint-Cahan, who was unsettled that evening, was last captured on CCTV (pictured) at 1.22am before he went into Torres-Pena's bedroom
Torres-Pena, who was paranoid and had arrived on the ward five days earlier, was pacing the corridors before he was last seen on CCTV (pictured) at 1.26am
Around the same time, Onuh emerged from the therapy room holding bedding.
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Onuh → treat → bedding
Chukwuji-Ohanachum is seen heading into the same room holding blankets.
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Ohanachum → see → blankets
It took staff almost two hours to discover Mr Flint-Cahan's body.
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It → take → body
Emergency services were called 18 minutes later at 3.37am.
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services → call → 3.37am
Olagunju, who found the body, did not attempt CPR or raise the alarm.
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who → find → alarm
He instead went to alert the night manager Alex Obamwonyi.
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He → go → manager
Witnesses described Chukwuji-Ohanachum screaming and throwing herself to the ground while a staff member performed chest compressions from 3.45am.
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member → describe → 3.45am
Mr Flint-Cahan was declared dead at 4.41am.
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Cahan → declare → 4.41am
Patients at the facility are supposed to be observed by a nurse every hour.
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Patients → suppose → nurse
Falsified records at 2am and 3am stated Mr Flint-Cahan was in his room.
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Cahan → state → room
Onuh admitted to filling the document out without checking where patients were.
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patients → fill → document
Torres-Pena admitted manslaughter on the grounds of diminished responsibility and received a hospital order without time limit.
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Pena → admit → limit
Around 2am, Torres-Pena reappeared in the corridor wearing a towel around his waist after he removed his blood-soaked trousers (CCTV of the moment is pictured)
Hugo's father, William Flint-Cahan, who attended each day of the inquest with other family members said his son's death was 'preventable had the level of care been as it should have been' and there was 'complacency' by staff
Graeme Irvine, the Senior Coroner for East London, concluded neglect was a factor in the unlawful killing at an inquest on Monday.
The coroner described repeated failings by the Trust as 'groundhog day' as he heard evidence of the same mistakes 'over and over again'.
He recommended four members of staff be referred to their regulator and that the Metropolitan Police review their investigation into the incident.
His brother, NHS doctor Jolyon Flint-Cahan, made a statement after the inquest.
He said: 'Hugo, the patient that killed him, and both of our families were utterly failed by the staff on duty that night and the lack of ability by the Trust management to investigate their own staff's failings to previous deaths.'
His father, William Flint-Cahan, who attended each day of the inquest with other family members said his son's death was 'preventable had the level of care been as it should have been' and there was 'complacency' by staff.
Dr David Bridle, Chief Medical Officer at ELFT, said the Trust was deeply sorry to Mr Flint-Cahan's family for the failings in his care.
He said the trust had undertaken a significant programme of work to 'improve our inpatient culture, behaviours and practice'.
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trust → reappear → culture
Dr Bridle said: 'Hugo's care fell well below the standards we want to provide.
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we → say → standards
The coroner raised serious concerns regarding behaviours and actions of the staff on duty that evening, and how they didn't keep to established procedures for safe care.
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they → raise → care
We agree this is wholly unacceptable and does not reflect the standards, values or behaviours we expect.
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we → agree → standards
One member of staff has been dismissed.
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member → dismiss → staff
Others involved are subject to further investigation.
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Others → involve → investigation
Since Hugo's sad death in 2023, we have undertaken a significant programme of work to improve our inpatient culture, behaviours and practice.
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we → undertake → culture
'We will ensure the learning from the coroner's findings informs our continuing work to strengthen patient safety and care.'
Over the last 12 years, coroners have sent 29 prevention of future deaths reports to the East London NHS Trust.
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coroners → ensure → Trust
More than half cited failures to assess patients' risk to themselves or others, BBC analysis found.
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analysis → cite → themselves
The Daily Mail has contacted the Metropolitan Police for comment.
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Mail → contact → comment
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