At 1:22 in the morning, cameras recorded Hugo Flint-Cahan alive for the last time.
He was 34 years old and was being treated at the Newham Mental Health Centre in east London, under the care of the East London NHS Foundation Trust. Nine minutes later, another patient, 22-year-old Rolando Torres-Pena, began strangling him. While this was happening, two nurses remained locked in a staff room and a support worker slept in a therapy room. At 2:00 am, someone entered in the records that Hugo was awake in his bed. It was a lie: he had already been attacked.
Coroner Graeme Irvine described what happened as unlawful killing aggravated by negligence, and it was not an isolated incident: over 12 years, the same trust had already received 29 formal warnings for similar failings. He summed it up with a phrase that was recorded in the inquiry: ‘ground hog day’, the Groundhog Day that repeats without anyone stopping it. Hugo’s father and brother, the latter a doctor with the NHS itself, did not miss a single hearing.