A United Kingdom inquest on Wednesday, September 16, indicted three Nigerian nurses Rosemary Chukwuji-Ohanachum, Raji Olagunju, and Anthony Onuh, over allegations that they were sleeping while mental health patient Hugo Flint Cahan was being strangled at an NHS unit in east London.
34-year-old Cahan, was receiving treatment at Newham Mental Health Centre (NMHC), managed by the east London NHS Trust (ELFT), when he was fatally attacked by another patient, 22-year-old Rolando Torres-Pena.
Chukwuji-Ohanachum, Olagunju and Onuh were on duty on Topaz Ward, an inpatient unit for men with acute mental health conditions, on the night of Cahan’s death.
An inquest heard that Torres-Pena was pacing the corridor and appeared unsettled as he followed one of the nurses.
CCTV footage showed Cahan walking through the corridor and later wandering alone before he was last seen alive at about 01:22.
Torres-Pena was subsequently seen walking along the corridor and entering Cahan’s empty room before disappearing from view.
At about 01:31, another patient emerged from a nearby room and appeared to be looking up and down the corridor, seemingly disturbed by something.
During the period, Chukwuji-Ohanachum and Olagunju were in the staff room with the door shut, while Onuh was asleep in the therapy room for about two hours.
The inquest heard that patients on the ward were supposed to be checked every hour.
However, the observation log falsely recorded at 02:00 that Cahan was in his bed and awake.
Onuh admitted that he filled out the observation form without checking where the patients were.
CCTV footage later showed Onuh leaving the therapy room with his bedding and speaking to Torres-Pena.
Chukwuji-Ohanachum was also seen carrying blankets and told the coroner that she had gone to the therapy room to sleep during an unauthorised two-hour break.
Cahan was discovered at about 03:19 by Olagunju, almost two hours after he was attacked.
The inquest heard that Olagunju did not immediately raise the alarm or begin CPR but went to find the unit’s night manager, Alex Obamwonyi, who was on a neighbouring ward.
Obamwonyi said Cahan was not breathing and that he could not find a pulse. He raised the alarm but locked the door to the room, saying he believed it was too late to begin CPR and wanted to preserve the scene.
Emergency services were called at 03:37, while CPR finally began at 03:45.
Cahan was declared dead at 04:41.
In a narrative conclusion, the coroner found that Cahan was unlawfully killed and that his death was contributed to by neglect.
The coroner also recommended that four members of staff be referred to their professional regulators and that the Metropolitan Police review its investigation into the circumstances surrounding Cahan’s death.
Torres-Pena pleaded guilty at the Old Bailey to manslaughter on the grounds of diminished responsibility and was given a hospital order without a time limit.
Cahan’s family expressed shock over what they described as dangerous failures in his care.
His father, William Flint Cahan, accused staff of complacency and a lack of care, saying his son’s death was preventable had the appropriate level of care been provided.
Cahan’s brother, Jolyon, an NHS doctor, described the failures in the care of both patients as involving serious problems with competence and dishonesty.
The coroner also criticised repeated failures by the East London NHS Trust in other patient deaths, describing the pattern as “ground hog day” after hearing evidence of similar errors recurring.
The reports found that local coroners had issued at least 29 Prevention of Future Deaths notices to the Trust over the past 12 years.
The notices identified recurring concerns in inpatient and community services, including failures to properly assess the risks patients posed to themselves or others and poor communication between staff, other agencies and families.
The strongest concerns related to poorly conducted observations and falsified records.
A 2021 report by the coroner who conducted the Flint Cahan inquest warned that inaccurate and misleading clinical records were being tolerated at the Trust.
Two further reports in 2024 highlighted cases in which observations were missed and records were later falsified to suggest that patients had been checked.
In 2025, another report concerning the death of a young woman again raised concerns about falsified observation records. The coroner said the inquest had revealed widespread concerns about how observations were carried out across two wards despite assurances from the Trust and several action plans.
Other concerns raised in the reports included delayed emergency responses and poor resuscitation practices.
Brian Dow of mental health charity Rethink called for a national register of patient safety to monitor the standard of care provided in mental health units across the UK.
He said repeated cases involving poor observations, falsified records and unacceptable care showed the need for a better approach to patient safety in mental health wards.
In a statement, East London NHS Foundation Trust Chief Medical Officer, Dr David Bridle, apologised to Cahan’s family for the failings in his care.
He described the actions identified by the coroner as “wholly unacceptable” and said they did not reflect the standards, values or behaviours expected by the Trust.
Bridle said the Trust had undertaken a significant programme of work to improve inpatient culture, behaviours and practice, adding that the coroner’s findings would inform its continuing efforts to strengthen patient safety and care.
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