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.

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 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.

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.

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 out the Flint Cahan inquest warned that "a culture of impunity existed" at the Trust where "inaccurate and misleading recording of clinical records was tolerated."

In 2024, two further reports highlighted observations being missed then records falsified to suggest patients had been checked.

In response to one of the PFD's, the Trust said extensive training programmes and quality checks were introduced.

In 2025, a fourth report, into the death of a young woman, again highlighted falsified observation records. The coroner said, "despite assurances" from the Trust in numerous action plans", the inquest had "revealed widespread concerns" about how observations were carried out across two wards."

Other serious concerns raised in the reports include, how staff have responded to emergencies, with delays in resuscitation and - on one occasion - nursing staff giving chest compressions to a patient's stomach rather than their chest.

Brian Dow of the mental health charity, Rethink, is calling for a national register of patient safety to keep tabs on the type of care mental health units across the country are providing.

"We have been here before" with poor observations, records being falsified and unacceptable care, he says.

"We have got to have a better approach to patient safety in what are the most difficult and most vulnerable wards with the people who are the most unwell."