An inquest has heard how staff at an East London mental health unit were allegedly asleep and later falsified observation records during the night a patient was killed by another resident.
Hugo Flint-Cahan, 34, was strangled on the Cherry Tree Ward at the Newham Centre for Mental Health on 3 January 2023. Evidence presented at an inquest hearing detailed a series of safety failures and professional misconduct by staff members on duty at the time of the attack.
The hearing was told that staff members were sleeping for up to two hours during their shift while the killing occurred. Furthermore, hospital records were reportedly falsified to show that Mr Flint-Cahan had been checked on and was awake at times when he was already dead.
Delays in emergency response
In addition to the failure to monitor the ward, the inquest heard that there was a significant delay in medical intervention once the victim was found. CPR was not commenced on Mr Flint-Cahan until 26 minutes after he was discovered by staff.
The perpetrator, Rolando Torres-Pena, who was 22 at the time of the incident, was a fellow resident on the ward.
The East London NHS Foundation Trust (ELFT), which manages the centre on Glen Road in Plaistow, told the coroner it has launched an investigation into the staff whose failings were identified during the proceedings.
Guidance for families
The Newham Centre for Mental Health is a specialist facility providing inpatient care for adults. Following the revelations regarding faked logs and sleeping staff, the inquest highlights ongoing concerns regarding the reliability of mandatory observation periods in psychiatric settings.
Families who have concerns about the safety or standard of care provided at NHS mental health facilities can take the following steps:
- Patient Advice and Liaison Service (PALS): Each NHS Trust has a PALS team that can provide confidential advice and support if you have concerns about a patient’s treatment.
- Care Quality Commission (CQC): As the independent regulator of health and social care in England, the CQC monitors services to ensure they meet fundamental standards of quality and safety.
- Independent Advocacy: Patients in mental health units are often entitled to support from an Independent Mental Health Advocate (IMHA) to help them understand their rights and voice their concerns.
The inquest into the death of Mr Flint-Cahan is expected to conclude with formal findings regarding the contribution of these staff failures to the final outcome.
