Staff at an NHS mental health unit in east London slept, used their mobile phones and falsified safety logs on the night a patient was strangled to death by another resident, an inquest has heard.

In a narrative conclusion, the coroner found that Hugo, who had spent six months as a patient at the facility, was unlawfully killed and that neglect contributed to his death. The coroner recommended that four members of staff be referred to their professional regulators and urged the Metropolitan Police to review their investigation into the incident.

Hugo died in the early hours of 3 January 2023 on Topaz ward, an inpatient unit for men with acute mental health issues run by East London NHS Trust. He was killed by Rolando Torres-Pena, who had arrived on the ward five days earlier. Torres-Pena later pleaded guilty at the Old Bailey to manslaughter on the grounds of diminished responsibility and received an indefinite hospital order.

Inquest evidence and CCTV footage presented to the court detailed the movements on the ward leading up to the assault. Torres-Pena was seen pacing the corridor under the belief that he was about to leave. Hugo was also unsettled and was recorded following one of the nurses before wandering the corridor alone after 01:00.

Hugo was last seen alive on camera at 01:22, shortly before entering Torres-Pena's room. At 01:26, Torres-Pena walked into Hugo's empty room before disappearing out of camera range a few minutes later. At 01:31, a neighbouring patient stepped into the corridor appearing disturbed and watched something out of shot, which is believed to be the moment Hugo was attacked and strangled.

During this time, the ward was staffed by two nurses, Rosemary Chukwuji-Ohanachum and Raji Olagunju, and nursing assistant Anthony Onuh. Despite three patients wandering the corridors, both nurses remained inside the staff room with the door shut, while Onuh slept for two hours in the therapy room.

Patients required hourly checks, but the ward's observation log falsely recorded Hugo as awake in bed at 02:00. Onuh admitted filling in records without checking on patients. Just before 02:00, Torres-Pena was seen in the corridor without trousers, which the coroner noted had been removed after being soaked in blood.

As Onuh left the therapy room with his bedding, Chukwuji-Ohanachum brought blankets inside to sleep during an unauthorised two-hour break. Hugo was eventually found at 03:19 by Olagunju, nearly two hours after the attack. Olagunju did not sound the alarm or begin CPR, leaving instead to fetch night manager Alex Obamwonyi from an adjacent ward.

Obamwonyi told the inquest he could not find a pulse and locked the room door to preserve the scene, believing it was too late to attempt resuscitation. Emergency services were called at 03:37, and chest compressions began at 03:45. Statements described chaotic scenes upon discovery, with Chukwuji-Ohanachum screaming and requiring restraint, while a colleague performed CPR alone until exhausted.

Hugo's father, William Flint Cahan, criticised staff complacency and an absence of care, while his brother Jolyon, an NHS doctor, described the litany of incompetence and dishonesty as harrowing.

The coroner highlighted wider institutional concerns, noting that local coroners have issued at least 29 Prevention of Future Deaths notices to the Trust over the past 12 years. East London NHS Trust stated it has undertaken a significant programme of work to improve its inpatient culture, behaviours and practice. I will continue following this case as regulatory and police reviews progress.