Inquest Finds Neglect as Two UK-Based Nigerian Nurses Slept on Duty While Mental Health Patient Was Strangled to Death

Inquest Finds Neglect as Two UK-Based Nigerian Nurses Slept on Duty While Mental Health Patient Was Strangled to Death

FNA News, Lagos Nigeria, 16th September, 2026

An inquest has concluded that neglect by staff contributed to the unlawful killing of a mental health patient who was strangled by another patient on an NHS ward, after two UK-based Nigerian nurses were found to have slept on duty.

Hugo Flint-Cahan, 34, died in the early hours of 3 January 2023 at Newham Mental Health Centre in east London. He had been receiving treatment on Topaz ward, an acute unit for men, for six months when he was attacked by fellow patient Rolando Torres-Pena, then 22.

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Senior Coroner for East London Graeme Irvine ruled that Mr Flint-Cahan was unlawfully killed and that neglect by staff played a significant role in his death. He recommended that four members of staff be referred to their professional regulator and urged the Metropolitan Police to review its investigation into the incident.

Failings on the night of the attack

The inquest heard that on the night Mr Flint-Cahan was killed, nurses Rosemary Chukwuji-Ohanachum and Raji Olagunju remained in the staff room with the door closed for a prolonged period. Nursing assistant Anthony Onuh slept for approximately two hours in a therapy room. One of the nurses later took an unauthorised break to sleep there.

CCTV evidence showed Mr Flint-Cahan last alive in a corridor at 1:22am. Shortly afterwards, another patient emerged looking disturbed, but no staff were present. Torres-Pena was later captured on camera without trousers after they became soaked in blood.

Despite the requirement for regular patient observations, records were falsified. An entry made at 2am stated that Mr Flint-Cahan was awake in his bed when he had already been attacked. He was not discovered until 3:19am — nearly two hours later.

Emergency services were called at 03:37. CPR began at 03:45. Mr Flint-Cahan was declared dead at 04:41.

Torres-Pena later pleaded guilty to manslaughter on the grounds of diminished responsibility and was given an indefinite hospital order.

Family response and wider concerns

Mr Flint-Cahan’s father, William, said his son’s death was “preventable had the level of care been as it should have been.” He described staff behaviour as complacent.

His brother Jolyon, an NHS doctor, described a “litany of failures, both incompetence and dishonesty.”

East London NHS Foundation Trust said it was “deeply sorry” to the family. Chief Medical Officer Dr David Bridle described the staff conduct identified by the coroner as “wholly unacceptable” and confirmed the Trust is investigating those involved while strengthening patient safety measures.

The coroner criticised repeated failings at the Trust, calling them “groundhog day.” Over the previous 12 years, local coroners had issued 29 Prevention of Future Deaths notices to the organisation, including repeated warnings about falsified observation records.

Expert insight

This case highlights ongoing challenges in NHS mental health services, particularly around night-time staffing, observation protocols, and accountability. Patient safety experts note that similar failings in basic monitoring have appeared in multiple inquests, raising questions about whether systemic lessons are being effectively implemented.

The Nursing and Midwifery Council is expected to consider the conduct of the staff referred by the coroner. No criminal charges against the nurses have been reported.

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