It may sound strange, but whenever Hugo Flint-Cahan was sectioned, his family felt a measure of relief.
That happened repeatedly over the years as they watched his mental health decline.
Every admission was painful. Yet it also meant that, temporarily at least, they knew where Hugo was and could stop fearing what might happen to him.
‘When we told people, they would always say, “Gosh, how awful!” But every time, our response was simply overwhelming relief that he was safe,’ his stepmother Sue says.
Hugo’s large, close-knit family – he was one of five siblings – held on to that belief until the early hours of January 3, 2023. That was when they learned that the 34-year-old had been killed by another patient on the specialist NHS psychiatric ward where he had spent the previous six months.
The fact that a vulnerable patient could be strangled inside a secure psychiatric unit is shocking in itself.
But the circumstances were even more disturbing. The killing occurred amid a series of alleged failures by staff at the Newham Centre for Mental Health in east London.
A healthcare assistant fell asleep during his shift and later falsified observation records, making it appear that he had checked patients every hour.
When the attack happened, two nurses were inside a staff room with the door closed. Hugo’s body went undiscovered for almost two hours.
Hugo Flint-Cahan, 34, was being treated at Newham Mental Health Centre, run by the East London NHS Trust, when he was fatally attacked during the early hours of January 3, 2023
Nurses Rosemary Chukwuji-Ohanachum and Raji Olagunju were in a closed-door staff room while healthcare assistant Anthony Onuh slept in a therapy room
More than three years passed before an inquest examined Hugo’s death. Last month, East London’s Senior Coroner Graeme Irvine concluded that Hugo had been unlawfully killed by Rolando Torres-Peña and that neglect had contributed to his death.
On October 2, Mr Irvine sent a Prevention of Future Deaths (PFD) report to East London NHS Foundation Trust (ELFT). It listed 14 concerns about the care of both men and warned that further deaths could occur unless the trust addressed its staffing and procedural failures.
The coroner identified repeated shortcomings at the trust, which operates the Newham centre. As he heard evidence of the same mistakes recurring in other cases, he described the situation as ‘Groundhog Day’.
He also condemned what he characterised as a ‘culture of dishonesty and impunity’ and a ‘conspiracy to deceive’.
Those are devastating findings. Weeks later, Hugo’s family remain visibly angry and bewildered.
‘There is one kind of unsafe environment where an unstable patient might attack another,’ says Hugo’s younger brother Jolyon, 33. ‘But the idea that someone could be killed by another patient while staff nearby were neglecting their duties and breaching their professional codes is utterly horrifying.
‘And this is not only about Hugo. Other cases show that it was not an isolated incident. It leaves you feeling that nobody is safe.’
The family has particularly painful ties to the NHS. Jolyon is an anaesthetist, while Sue works as an NHS radiographer.
‘Before this happened, I could never have imagined anything like it,’ Jolyon says.
Long before Hugo became a psychiatric patient, however, he was a much-loved son and brother.
He grew up in Hertford as the eldest of three sons – his brother Rupert is 36 – born to William, 72, a teacher, and his first wife Gillian.
He also had two younger half-siblings, Harry, 26, and Fiona, 23, from William’s second marriage to Sue.
‘Hugo was almost 12 when Harry was born, and he was incredibly patient and gentle with him,’ Sue recalls. ‘The whole family was, and remains, very close.’
A happy child who enjoyed cricket and football, Hugo was also unusually conscientious, William and Sue say.
‘He would write very long thank-you letters for his birthday and Christmas presents. He took those things very seriously,’ Sue says.
He had a strong instinct for fairness, too.
Rupert (dark hair) and Hugo (blond) with parents William and Gillian
Hugo on a ski holiday aged 12. Raised in Hertford, he was the eldest of three sons born to William, 72, a teacher, and his first wife Gillian
‘He cared deeply about social and environmental issues,’ William says. ‘I always hoped he would build a life around those interests.’
It was not until Hugo’s first year of sixth form that his family learned he had been badly bullied at Haileybury, the independent school where William taught French and English literature until retiring earlier this year.
The bullying began with his schoolbag being thrown into a bin and his books being vandalised. It later became physical.
The pupils responsible were suspended for two weeks, but when they returned it became clear that Hugo could not remain at the school. He transferred to a nearby state school.
‘He felt it was deeply unfair,’ Jolyon says. ‘He had effectively been forced to leave, which was especially difficult for someone who valued order and rules so much.’
Despite that experience, Hugo appeared to thrive until April 2007, during his A-level year, when he suffered a psychotic episode. He was sectioned and spent six weeks at the Priory.
‘He had not been himself. Although it was extremely upsetting, we believed it was an episode from which he could make a full recovery with treatment,’ William says.
The following month, Hugo’s mother, to whom he was very close, was diagnosed with pancreatic cancer. She died the next year.
Despite the enormous emotional strain, Hugo went ahead with his A-level examinations.
He secured a place at the University of St Andrews to study Italian, and initially appeared to settle well.
‘He made lifelong friends, some of whom attended the inquest,’ William says.
But towards the end of his university years, his mental health worsened. He became convinced that people had taken his books, and his family believes he had stopped taking his medication. He had also begun using recreational drugs.
After graduating in 2013, Hugo drifted between jobs in bars and stays with friends.
His behaviour became increasingly alarming. He disappeared for weeks, posted bizarre messages on Facebook, told people he had a gun and once prevented a flatmate from leaving because he believed he needed to keep him safe. Eventually, he returned to the care of mental health services and was sectioned for a second time in November 2018.
During that admission, he was diagnosed with schizoaffective disorder. It marked the beginning of a draining cycle in which brief periods of relative stability were interrupted by acute episodes, arrests, police stations and trips to A&E.
On one occasion, he arrived at A&E complaining of stomach pain and insisting he had been stabbed, despite there being no wound or blood.
For his family, those years brought a constant undercurrent of fear.
‘Even now, whenever I hear my father’s ringtone, I think, “Oh God, it’s Hugo. Something has happened,”‘ Jolyon says.
William becomes tearful as he remembers the emotional upheaval of trying to help a son who could be affectionate one moment, distressed or angry the next.
At times, Hugo became convinced that his family were falsely claiming he was ill. He occasionally asked consultants not to share information with them.
Then, on July 5, 2022, following another period of erratic behaviour, Hugo arrived at A&E agitated and said he had overdosed on prescribed medication. He was sectioned for the eighth and final time.
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He was admitted to Topaz Ward, a 17-bed adult male unit at the Newham Centre for Mental Health.
Hugo was popular with staff and fellow patients. He took part in art sessions and was known to visit other patients in their rooms.
‘Because he spoke fluent Spanish, we think he was probably trying to make friends with Ronaldo,’ William says.
He adds: ‘Since then, people have written on online forums to say, “I was in one of the wards with Hugo. He was such a lovely character.” That has brought us a lot of comfort.’
William last saw his son on December 22, when he delivered a Christmas stocking.
‘He was delighted with it and very affectionate. He seemed better than he had been for some time,’ William recalls.
‘He seemed to realise that life was passing him by, and I thought, “That is new. Perhaps he can still turn things around.” Twelve days later, he was dead.’
Hugo in school uniform aged 15 or 16
The family later discovered that staff had been considering discharging Hugo on January 6 and were hoping to arrange a meeting.
They will never know what might have followed. On December 29, Rolando Torres-Peña, a 22-year-old mathematics student at Queen Mary University, was admitted to the ward.
He had been diagnosed as a teenager with bipolar affective disorder accompanied by psychotic symptoms. Previously, he had gone to hospital asking to be admitted but was sent home to his parents with additional medication. His admission came only later.
‘We feel strongly that two families were failed,’ Sue says.
The events leading to Hugo’s death were examined in detail at the inquest.
During the period in which Hugo was killed, supervisory nurses Rosemary Chukwuji-Ohanachum and Raji Olagunju were in the closed staff room. At the same time, healthcare assistant Anthony Onuh slept for two hours in a therapy room, despite being responsible for hourly observations.
He told the coroner that he had completed an observation entry recording Hugo as awake in bed at 2am without carrying out the required check. By then, Hugo was dead in Torres-Peña’s room.
CCTV footage from around 1am showed staff unaware as Hugo and Torres-Peña spoke in the corridor and entered each other’s rooms.
The final image of Hugo alive was recorded at 1.22am. He was walking along the corridor carrying a cup of hot chocolate.
The precise time of his death remains unknown. At 1.31am, CCTV showed a patient from the neighbouring room come outside and appear to watch something beyond the camera’s view. The footage then showed Torres-Peña walking down the corridor without trousers, his lower body covered by a white towel.
Hugo was not found until 3.19am, nearly two hours after the attack. Resuscitation began at 3.45am, and paramedics pronounced him dead at 4.41am.
Ninety minutes later, police arrived at William and Sue’s home.
‘They told us Hugo had died and that someone had been arrested for his murder. Those two sentences came together,’ Sue recalls. ‘We said, “But we thought he was in the unit.” They replied, “Yes, he was.” It was profoundly shocking.’
Torres-Peña later pleaded guilty at the Old Bailey in October 2023 to manslaughter on the grounds of diminished responsibility. He was given an indefinite hospital order.
The family never doubted who had killed Hugo. The far more difficult question has been how his death was allowed to happen.
‘Our discussions with the trust were, frankly, bland and disinterested,’ Jolyon says.
The family believes that attitude was reflected in the trust’s subsequent ‘Serious Incident Review’. They say it contained inaccurate dates and times, as well as references to CCTV footage that did not exist.
When the report was sent to them, it also contained 40 pages of another patient’s medical records.
For the family, the inquest finally offered some of the scrutiny they felt had been missing.
Even so, they fear Hugo’s death has not prompted meaningful change. They point out that Ms Chukwuji-Ohanachum remained employed by the trust and was on duty when another patient died three years and three months after Hugo.
They were also struck by the fact that trust board members attended the inquest while its director of nursing gave evidence, apparently to demonstrate support, but did not return to hear the coroner deliver his conclusions.
‘They were not interested in hearing directly what the coroner had concluded about that night,’ Sue says. ‘There was no interest and no sense of responsibility.’
Hugo’s cousin James Cahan, a medical negligence solicitor at Thomson Snell & Passmore who began representing the family within days of his death, says the case is especially troubling because local coroners have sent the trust at least 29 PFD notices over the past 12 years.
Such notices are issued when a coroner identifies problems that could result in further deaths if they are not addressed.
‘Something has to change because the same problems appear to be happening repeatedly,’ Mr Cahan says.
‘We have seen falsified records, inadequate observations and poor risk assessments – all issues coroners have previously raised with the trust. That is why the coroner described the situation as “Groundhog Day”.’
An independent Serious Incident Review commissioned by NHS England is expected to be shared with the family and the trust. The family fears another opportunity will be wasted unless its findings are circulated widely and acted upon.
Alongside their grief, dealing with the investigations and inquest has been ‘gruelling’, they say.
‘We have each struggled in different ways,’ Sue says.
William adds: ‘There is a gap in our lives that can never be filled.’
The family is inevitably left with questions about what might have been, including whether Hugo had finally begun to make progress in the weeks before his death.
‘It is horrible,’ William says. ‘You cannot avoid wondering. We cannot bring him back, but we can do everything possible to prevent this happening to somebody else.’
For Sue, Hugo’s death ultimately challenges the belief the family once relied on: that although seeing a loved one sectioned was distressing, it meant they were at least protected.
‘We use extraordinary legal powers to take people from the streets, remove their liberty and compel them to take strong and powerful medication,’ Sue says.
‘The assumption is that they will be placed somewhere safer than the outside world.’
That this protection failed Hugo remains almost impossible for his family to understand.
David Bridle, Chief Medical Officer of the ELFT, told the Daily Mail: ‘I offer my deepest sympathies to Hugo’s family, friends and loved ones. We are profoundly sorry for the failures that occurred when he tragically died in our care.
‘The care Hugo received fell far below the standards we expect. The coroner raised serious concerns about the conduct and actions of staff on duty that evening, including their failure to follow established procedures for safe care.
‘We accept that this was wholly unacceptable and did not reflect the standards, values or behaviours we require. One member of staff has been dismissed, while others remain subject to further investigation.
‘Since Hugo’s tragic death in 2023, we have undertaken a substantial programme of work to improve inpatient culture, behaviour and practice. We will ensure the lessons from the coroner’s findings inform our continuing efforts to strengthen patient safety and care.’
For confidential support, call Samaritans for free on 116 123, visit samaritans.org or visit https://www.thecalmzone.net/get-support