Two Nigerian-origin nurses, Rosemary Chukwuji Ohanachum and Raji Olagunju, were among staff on duty when a patient was killed at an NHS mental health unit in east London, with an inquest hearing that staff slept, used their phones and falsified observation records.
Hugo Flint Cahan, 34, was receiving treatment at Newham Mental Health Centre when he was fatally attacked by fellow patient Rolando Torres Pena, 22, in the early hours of 3 January 2023.
The inquest heard nurses Rosemary Chukwuji Ohanachum and Raji Olagunju were on duty on Topaz ward, alongside nursing assistant Anthony Onuh.
CCTV evidence showed patients moving around the ward while the nurses were in a staff room with the door closed. Onuh was asleep in a therapy room for about two hours.
Hugo was last seen alive at about 01:22. Torres Pena was later seen entering Hugo’s room before disappearing from camera view. Prosecutors said Hugo was beaten and strangled.
Despite requirements for hourly observations, records later indicated Hugo was in bed and awake at 02:00. The inquest heard the entry was false.
Hugo was eventually discovered at 03:19. Emergency services were not called until 03:37 and resuscitation began several minutes later. He was pronounced dead at 04:41.
Torres Pena admitted manslaughter on the grounds of diminished responsibility and received an indefinite hospital order.
Senior Coroner Graeme Irvine described the repeated failures uncovered during the proceedings as resembling “ground hog day”, citing recurring problems with patient observations, falsified records and emergency responses.
At least 29 Prevention of Future Deaths notices have been issued to the Trust over 12 years, with previous warnings about inadequate risk assessments, poor communication and inaccurate records.
The Trust said it had undertaken significant work to improve inpatient culture, behaviour and practice.
The coroner concluded that Hugo was unlawfully killed and that neglect contributed to his death. Four staff members were recommended for referral to their regulators, while police were urged to review their investigation.
