|Inquest Finds Neglect Contributed To Sophie Bennett's Death|
Home in which Wandsworth Council put teenager replaced therapists with yoga
An inquest jury has concluded this week that neglect was a contributory factor in the death of a teenage girl whose care was the responsibility of Wandsworth Council.
19-year-old Sophie Bennett from Tooting, who had a number of mental health issues including atypical autism, took her own life on 4 May 2016 whilst she was staying at Lancaster Lodge, a therapeutic community run by Richmond Psychosocial Foundation International (‘RPFI’).
Sophie’s father, Ben Bennett, has said that he felt nobody at Wandsworth Council’s social services department gave any proper consideration to her safety.
She had been placed at the centre by social services and had been there for over a year. When she first came to the home it had received a ‘good’ rating from the Care and Quality Commission (CQC) in September 2015. However, subsequently the dismissal of a number of experienced therapists who worked at the centre and other staff changes led to a fall in the standard of care.
The home was managed by Peggy Jughroo, who alongside her work at Lancaster Lodge was also employed by Wandsworth Council, and who accepted in evidence that she did not have the qualifications and experience to be a registered manager of the home.
In January 2016 a number of changes were made to the home following an audit by a consultant, Dr Duncan Lawrence, with input from Elly Jansen, who was said to be a consultant to the RPFI board. A decision was made to cancel all external therapies. Sophie’s therapist gave evidence to the inquest that it was Dr Lawrence’s intention to replace psychotherapy with yoga sessions. The decision to cut therapies and all external clinical supervision compelled the then registered manager, Vincent Hill, to resign.
A new regime was implemented in which residents were to rise early and exercise - Sophie described it to her family as being like a ‘boot camp’. After protests from residents and staff, therapies were continued, but the standard of care at the home fell to the extent that the CQC assessed the service in March 2016 as ‘inadequate’. In evidence, the CQC inspector described the home at that stage as ‘chaotic.’ A former member of staff described the home as “falling apart” and a “shambles”. Some newly recruited support workers had no relevant qualifications or experience.
Wandsworth Council given concerns that had been raised had decided to move Sophie from the centre but had not managed to do so before her death.
On 28 April 2016 Sophie self-harmed and told staff at Lancaster Lodge that she was suffering with suicidal thoughts and her impulse to act on them were high. Staff phoned Crisis Line who advised that Sophie should be taken directly to hospital so that she could be assessed, but the advice was not followed. Despite being placed on ‘close observation’ Sophie managed to find the means to end her life in the centre.
The jury heard that the manager at Lancaster Lodge at the time of Sophie’s death, Peggy Jughroo, had been trained by Elly Jansen and continued to be supervised by her. A trustee of the Board, Jonathan Manson, told the inquest that he thought Ms Jansen’s role was “ambiguous.” Lynn Dade, a former RPFI trustee who resigned in July 2015 following “grave concerns regarding the governance and financial affairs” of RPFI described Ms Jansen as a “sleeping director.”
At the conclusion of a three week inquest with HM Coroner for West London, John Taylor, the jury concluded that Sophie’s death was contributed to by neglect on the part of RPFI.
Deborah Coles, Director of INQUEST, said, “This is a shocking case in which the needs of a vulnerable young woman were completely neglected. She was in a care home where she was supposed to be safe. This death has raised serious concerns about the way in which deaths in mental health settings are investigated and their lack of independence. The monitoring and oversight of private providers, such as RPFI, is not fit for purpose. These shortcomings are particularly significant given the increased reliance on private providers in the delivery of mental health services.”
February 8, 2019