Staff slept while patient killed at NHS mental health unit

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.

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.

Hugo's family say they have been shocked by the "dangerous" failures in his care.

The Trust told the coroner they had addressed some of the issues raised in the inquest, and are launching an investigation into the staff whose failings have been identified.

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.

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.

Torres-Pena pleaded guilty at the Old Bailey to manslaughter on the grounds of diminished responsibility. He was given a hospital order without time limit .

A coroner criticised repeated failures by the Trust in a number of patient deaths - not just Hugo's.

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.

On the night of Hugo's death, there were two nurses and a nursing assistant on duty on Topaz ward – an inpatient unit for men with acute mental health issues.

Torres-Pena was pacing the corridor believing he was about to leave, the inquest was told.

Hugo was also unsettled. CCTV shows him following one of the nurses at one point. After 01:00, Hugo is seen wandering the corridor on his own. The CCTV last shows him alive at 01:22. It's thought he went into Torres-Pena's room shortly afterwards.

At 01:26 Torres-Pena is seen walking the corridor. He went into Hugo's empty room, before he disappears out of shot a couple of minutes later.

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. He appears to be looking up and down the corridor, seemingly disturbed by something. There are no staff in sight. The patient is then seen watching something that's out of shot. It is thought this is when Hugo was beaten and strangled.