Original Summary

Family handout / Hugo was strangled to death while staying in an 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. Events leading up to Hugo's death East London NHS Trust / CCTV footage shows the last image of Hugo alive 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. During this period, the two nurses, Rosemary Chukwuji-Ohanachum and Raji Olagunju, were in the staff room with the door shut. Despite three patients having been seen walking around the corridor, no staff are seen. Nursing assistant Anthony Onuh was asleep for two hours in the therapy room. Just before 02:00, Torres-Pena is seen walking around the corridor again. He was not wearing any trousers. The coroner at Hugo's inquest said Torres-Pena had taken them off because they were soaked in blood. Patients on the ward should have been checked by staff hourly. The observation log for the ward falsely shows that at 02:00 Hugo was in his bed awake. False records East London NHS Trust / Rolando Torres-Pena walking in the unit, with his legs covered by material wrapped around his waist. Onuh admitted to the coroner that he filled out the form without checking where people were. At about that time, CCTV shows Onuh emerging from the therapy room holding his bedding. He can be seen speaking to Torres-Pena whilst nurse Chukwuji-Ohanachum walks past with her blankets. She told the coroner she was going to the therapy room to sleep during her unauthorised two-hour break. Hugo was discovered at 03:19 by nurse Olagunju, almost two hours after he was attacked. He didn't attempt CPR or raise the alarm and went to the find the unit's night manager, Alex Obamwonyi, who was on a neighbouring ward. Obamwonyi told the inquest Hugo wasn't breathing and he couldn't find a pulse. He raised the alarm but locked the door into the room. He said he thought it was too late to start CPR, and he wanted to preserve the crime scene. The emergency services were called at 03:37, and CPR finally started at 03:45. Witnesses at the inquest described chaotic scenes. Nurse Chukwuji-Ohanachum was screaming and throwing herself on the ground. According to a statement read in court, she had to be restrained by other members of staff. One member of staff was left to do chest compressions on Hugo until she had to stop, exhausted. Hugo was declared dead at 04:41. Unsafe and unacceptable Hugo's father, William Flint Cahan, who has attended each day of the inquest with other family members, says there was "complacency" by staff, as well as a lack of care. He maintains his son's death was "preventable had the level of care been as it should have been." Hugo's brother, Jolyon, who is an NHS doctor, says the "litany of failures, both incompetence and dishonesty, that pervaded the care of both patients was harrowing." Over the past 12 years, local coroners have sent at least 29 Prevention of Future Deaths (PFD) notices to the Trust. These are sent to an organisation when a coroner identifies problems which, if not dealt with, could lead to further deaths. The BBC has analysed the reports which cover both in patient and community services. In more than half of cases there had been a failure to properly assess the risk the patient posed to themself or to others. Poor communications between staff, other agencies and families were also repeatedly highlightedy. The strongest warnings were about poorly carried out observations and falsified records – basic care needed to keep patients safe. A report in 2021 by the coroner that carried ou

中文概览

中文标题： NHS精神健康病房患者被杀时工作人员在睡觉

伦敦东部NHS精神健康病房内，34岁Hugo Flint-Cahan被22岁Rolando Torres-Pena勒死。死因调查听证称，当晚两名护士和一名护理助理值班；护理助理在治疗室睡了两小时，观察记录虚假显示凌晨2点Hugo在床上醒着。验尸官裁定Hugo遭非法杀害且存在疏忽，建议转介四名工作人员，并要求伦敦警察厅复核调查。

  • 情报分类：综合情报
  • 分类依据：英国NHS精神健康病房死亡事件及验尸调查，无法归入其他类别。
  • 信息来源：英语新闻 / BBC News Top Stories
  • 发布时间：2026/9/14 23:19:26