News
An inquest into the death of Hugo Flint-Cahan, 34, who was killed by another patient at the Newham Centre for Mental Health on 3 January 2023, has concluded that he was unlawfully killed and that his death was contributed to by neglect, which included the falsification of observation records. Hugo’s family are being represented by Thomson Snell & Passmore’s Clinical Negligence team.
Hugo, who had been a patient at the centre for six months, was attacked and strangled by fellow patient Rolando Torres-Pena on Topaz ward, an inpatient unit for men with acute mental health issues. Torres-Pena, who had arrived on the ward five days earlier, subsequently pleaded guilty to manslaughter on the grounds of diminished responsibility and was given a hospital order without a time limit.
The inquest heard that, on the night of Hugo’s death, two nurses and a nursing assistant were responsible for the ward. CCTV footage showed Hugo and other patients wanderingg through its corridors in the early hours of the morning without any staff present. Nursing assistant Anthony Onuh was asleep, on an unauthorised break, for two hours in the therapy room, while nurses Rosemary Chukwuji-Ohanachum and Raji Olagunju were in the staff room with the door closed during the period in which Hugo is believed to have been attacked, just a few metres away from the nurses room.
Patients on the ward were required to be checked hourly. However, the observation log recorded that Hugo was awake in his bed at 2.00am, despite CCTV evidence indicating that he had already been attacked in another patient’s room. The inquest heard that Mr Onuh completed the record without checking where any of the patients were.
Hugo was discovered at 3.19am, almost two hours after the attack is believed to have taken place. The inquest heard that CPR was not commenced immediately and the emergency services were not called until 3.37am. Resuscitation only began at 3.45am and Hugo was pronounced dead at 4.41am.
In his narrative conclusion, Graeme Irvine, Senior Coroner for East London, found that Hugo had been unlawfully killed and that his death had been contributed to by neglect. He recommended that four members of staff be referred to their professional regulators and that the Metropolitan Police review its investigation into the events of that night.
The Coroner also raised wider concerns about repeated failures by the East London NHS Foundation Trust, including the falsification of patient observation records and delays in responding to emergencies. Referring to hearing evidence of the same errors repeatedly, he described the situation as being like “groundhog day”.
Over the previous 12 years, local coroners, including Mr Irvine, had issued at least 29 Prevention of Future Deaths reports to the Trust. These included repeated concerns about inadequate patient observations, falsified records, failures to assess the risk patients posed to themselves or others, poor communication and delays in emergency responses.
A report issued in 2021 warned that “a culture of impunity existed” at the Trust, in which inaccurate and misleading clinical records were tolerated. The coroner repeated these concerns in his verdict this week. Further reports in 2024 and 2025 again identified missed observations and records that had been falsified to suggest patients had been checked.
Speaking on behalf of the Flint-Cahan family, Oliver Downes, Solicitor in the Clinical Negligence team at law firm Thomson Snell & Passmore says:
“Hugo was a much loved son, step-son, brother and friend. He should have been kept safe while a patient at the Newham Centre for Mental Health but instead, due to the East London Foundation Trust’s failure to provide proper care, and most notably the falsification of observation records, he was killed, and two sets of families’ lives were ruined.
“While the family welcomes the inquest findings of unlawful killing, contributed to by neglect, they remain deeply concerned that lessons will still not be learned. Despite a number of previous Prevention of Future Death reports from the Coroner relating to this Trust, all highlighting widespread falsification of observation records, no improvements appear to have been made. If they had, Hugo’s death would have been avoided. Hugo’s family are hoping that following this inquest, real and lasting change can finally be effected, helping to spare any other families the same tragedy that they have faced.
“These issues are not isolated to the Trust in question. As a firm, we have dealt with a number of cases involving the falsification of records at mental health units across the UK. It is clear that more needs to be done at a national level to ensure that proper progress is made in dealing with this issue, so that no more lives are lost as a result.”
