Patient unlawfully killed at Newham mental health centre
Inquest finds neglect contributed to death, with four staff members to be referred to regulator.
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Hugo Flint-Cahan, 34, was unlawfully killed at Newham Mental Health Centre on the night of 3 January 2023, an inquest has concluded. The Senior Coroner for East London, Graeme Irvine, found that neglect contributed to his death. The inquest recommended that four members of staff be referred to their professional regulator.
Mr Flint-Cahan was being treated at the centre, run by the East London NHS Trust (ELFT), when he was fatally attacked by fellow patient Rolando Torres-Pena, aged 22. Mr Torres-Pena pleaded guilty to manslaughter on the grounds of diminished responsibility and received a hospital order.
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Failures in care
During the night of Mr Flint-Cahan's death, two nurses and a nursing assistant were on duty on the Topaz ward. CCTV footage showed that during the period Mr Flint-Cahan was attacked, nurses Rosemary Chukwuji-Ohanachum and Raji Olagunju were in the staff room with the door closed. Nursing assistant Anthony Onuh was asleep in a therapy room for two hours. Patients on the ward were meant to be checked hourly.
The observation log for the ward falsely indicated that at 02:00, Mr Flint-Cahan was in his bed awake. Mr Onuh admitted to the coroner that he completed observation forms without verifying patients' locations. Nurse Chukwuji-Ohanachum told the coroner she was going to the therapy room to sleep during an unauthorised two-hour break.
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Mr Flint-Cahan was discovered at 03:19 by nurse Olagunju, nearly two hours after the attack. He did not attempt CPR or raise the alarm, instead seeking the unit's night manager, Alex Obamwonyi, who was on a neighbouring ward. Mr Obamwonyi stated he believed it was too late to start CPR and wanted to preserve the crime scene. Emergency services were called at 03:37, with CPR commencing at 03:45. Mr Flint-Cahan was declared dead at 04:41.
Repeated warnings
The coroner described hearing evidence of repeated errors at the Trust, stating it was like "ground hog day". Over the past 12 years, at least 29 Prevention of Future Deaths notices have been sent to the Trust by local coroners. These notices are issued when a coroner identifies issues that could lead to further deaths if not addressed.
Analysis of these reports by the BBC revealed that in more than half of cases, there was a failure to properly assess patient risk. Poor communication between staff, other agencies, and families was also a recurring issue. The most serious warnings concerned poorly executed observations and falsified records.
A 2021 report by the coroner noted a "culture of impunity" at the Trust where inaccurate record-keeping was tolerated. Despite assurances and action plans from the Trust in response to previous warnings, subsequent reports continued to highlight falsified observation records and concerns about how observations were carried out.
Next steps
The East London NHS Trust has stated it is launching an investigation into the staff whose failings were identified during the inquest. The Trust also told the coroner that some of the issues raised have been addressed.
Hugo Flint-Cahan's family described the failures in his care as "dangerous". His father, William Flint Cahan, stated that his son's death was "preventable had the level of care been as it should have been." His brother, Jolyon, an NHS doctor, called the litany of failures "harrowing."
Questions this report answers
+How did Hugo Flint-Cahan die?
Hugo Flint-Cahan, 34, was unlawfully killed by another patient, Rolando Torres-Pena, at Newham Mental Health Centre on 3 January 2023. An inquest found that neglect, including staff sleeping and falsified records, contributed to his death.
+What were the failings identified by the inquest?
The inquest found that staff falsified patient observation records, slept during their shifts, and were on their phones. Hugo Flint-Cahan was not checked hourly as required, and records falsely stated he was in his bed when he was attacked.
+What happens to the staff involved?
The coroner recommended that four staff members be referred to their professional regulator. The East London NHS Trust is also launching its own investigation into the staff members whose failings were identified.
+Has the Trust received warnings before?
Yes, over the past 12 years, coroners have sent at least 29 Prevention of Future Deaths notices to the Trust. These notices highlight issues that could lead to further deaths if not addressed, with recurring concerns about observations and record-keeping.
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