A patient was killed on an NHS mental health ward while staff responsible for his care were asleep, taking unauthorised breaks and away from the ward.

An inquest into the death of 34-year-old Hugo Flint Cahan heard that staff failed to carry out required observations, records were completed without checks being made, and there was a significant delay before Hugo was found and emergency treatment began.

Hugo had been receiving treatment at Newham Mental Health Centre in east London for around six months when he was attacked by another patient.

The coroner concluded that Hugo was unlawfully killed and that neglect contributed to his death.

 

Staff were not carrying out patient checks

Patients on the ward were supposed to be checked every hour but on the night Hugo died, the inquest heard that staff were not consistently present on the ward.

CCTV showed several patients walking around the corridor during the early hours. No staff could be seen on the corridor at the time.

Two nurses were in the staff room with the door closed. A nursing assistant, Anthony Onuh, was asleep in a therapy room for around two hours.

One of the nurses, Rosemary Chukwuji-Ohanachum, told the inquest that she had gone to the therapy room to sleep during an unauthorised break.

The inquest also heard concerns about staff using their phones while they should have been monitoring patients.

These were not minor administrative failures. Staff were responsible for vulnerable people on an inpatient mental health ward, where regular observations were required to help keep patients safe.

 

Records said patients had been checked when they had not

One of the most serious concerns was the way observations were recorded.

At around 02:00, the ward’s records stated that Hugo was in his bed and awake.

The inquest heard that this was not based on an actual check. Nursing assistant Anthony Onuh admitted that he had completed the observation record without checking where the patients were.

That meant the written record gave staff a false picture of Hugo’s whereabouts.

Accurate records are essential in care because staff rely on them to understand what has happened during a shift and whether a patient has been monitored as required.

In this case, the records suggested that checks had taken place when they had not.

 

Hugo was left undiscovered for almost two hours

CCTV showed Hugo alive at approximately 01:22.

He was believed to have entered the other patient’s room shortly afterwards.

At 01:26, the other patient, Rolando Torres-Pena, was seen walking along the corridor before entering Hugo’s empty room.

The exact time of the attack could not be established. However, another patient was seen leaving his own room at around 01:31 and appearing to look along the corridor, apparently disturbed by something.

There were still no staff visible.

Torres-Pena was later seen walking around the ward without his trousers. The coroner heard that his trousers were believed to have been removed because they were covered in blood.

Hugo was not discovered until approximately 03:19.

That was almost two hours after the suspected attack.

 

The response after Hugo was found was also delayed

When nurse Raji Olagunju found Hugo, he was not breathing and had no detectable pulse.

Instead of immediately starting CPR, the nurse went to find the night manager, Alex Obamwonyi, who was working on a neighbouring ward.

The inquest heard that the night manager believed it was too late to start CPR and wanted to preserve the room as a crime scene.

Emergency services were not called until approximately 03:37.

CPR finally began at around 03:45.

Hugo was pronounced dead at 04:41.

The inquest heard that the response was chaotic, with one member of staff carrying out chest compressions until she became too exhausted to continue.

 

Concerns had been raised before

The concerns heard during Hugo’s inquest were not the first time problems had been identified at the Trust.

According to BBC analysis, local coroners had issued at least 29 Prevention of Future Deaths notices to the East London NHS Trust over the previous 12 years.

These reports identified repeated concerns about patient safety, including failures to properly assess risks, poor communication, missed observations and inaccurate records.

Previous reports had specifically raised concerns about observations being missed and records being falsified to make it appear that patients had been checked.

One 2021 report warned of a culture in which inaccurate and misleading clinical records were tolerated.

Further reports in 2024 and 2025 raised similar concerns.

That means the issues identified in Hugo’s case were not simply about one missed check on one night. Similar concerns had already appeared in other investigations into patient deaths.

 

A failure of basic care

Hugo’s family described the failures in his care as shocking.

His father, William Flint Cahan, said there had been complacency and a lack of care. He believed his son’s death could have been prevented if the expected level of care had been provided.

His brother, Jolyon, who is an NHS doctor, described the failures in the care of both patients as involving incompetence and dishonesty.

The case raises serious questions about what happened to basic standards of care on the ward that night.

Patients were supposed to be observed.

Staff were supposed to remain alert and available.

Records were supposed to show what had actually happened.

And when Hugo was found unresponsive, emergency action was required.

The evidence heard at the inquest showed failures in each of these areas.

 

What the Trust said

Dr David Bridle, Chief Medical Officer at East London NHS Foundation Trust, apologised to Hugo’s family for the failings in his care.

He said the actions of the staff identified by the coroner were unacceptable and did not reflect the standards, values or behaviours expected by the Trust.

The Trust said it had carried out work to improve inpatient culture, behaviour and practice and would use the coroner’s findings as part of its continuing work on patient safety and care.

The coroner also recommended that four members of staff be referred to their professional regulators and that the Metropolitan Police review its investigation into what happened.

For people receiving mental health care, observations, accurate records and staff presence are not optional extras. They are basic parts of keeping patients safe.

When staff are asleep, away from patients or recording checks that have not actually happened, those safeguards are lost.