Before HM Assistant Coroner Mr John Taylor
West London Coroner’s Court
22 January – 7 February 2019
An inquest jury today found that “neglect” contributed to the death of Sophie Bennett on 4 May 2016. Sophie died having applied a ligature on 2 May 2016 whilst in the care of Lancaster Lodge, a therapeutic community run by Richmond Psychosocial Foundation International (‘RPFI’). 
Sophie died aged 19. She had diagnoses of Bipolar Affective Disorder, Social Anxiety Disorder, and atypical autism. She had been cared for at Lancaster Lodge since April 2015. The home was, at that time, well run and received a ‘good’ rating from the Care and Quality Commission (CQC) in September 2015.

In January 2016 a number of changes were made to the home following an audit by a consultant, Dr Duncan Lawrence, and also following 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 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”.
The family heard in the course of the evidence that:

  • Dr Duncan Lawrence, although understood by other staff to have a medical degree, in fact had a doctorate in public management and administration from Knightsbridge university – an unaccredited institution in Denmark. In the inquest RPFI were unable to produce any record of Dr Lawrence’s credentials.
  • On the first day of the CQC inspection in March 2016 Dr Lawrence, despite by then being the ‘clinical lead’ for the home, was unable even to tell the inspector where the residents’ care plans were. Dr Lawrence failed to appear for the second day of the inspection. Dr Lawrence also failed to respond to the coroner’s summons to give oral evidence at the inquest.
  • The home was managed by Peggy Jughroo, who alongside her work at Lancaster Lodge also had a post within the London Borough of Wandsworth, and who accepted in evidence that she would not have the qualifications and experience to be a registered manager of the home.
  • Some newly recruited support workers had no relevant qualifications or experience.
  • One support worker, Faiza Adan, insisted that statements bearing her name were fake. Who wrote them remains unknown.

Further to safeguarding concerns at Lancaster Lodge the London Borough of Wandsworth, who funded Sophie’s placement, decided that Sophie should be moved to an alternative and safer placement, but as of 2 May 2016 Sophie remained at Lancaster Lodge.
On 28th 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. In the days after the death Sophie’s care-coordinator was told that this was a decision taken by ‘management’.
Sophie was placed on ‘close observations’, her door was to remain open at all times, and her room was to be periodically searched for items with which she could self-harm. However,  on 2 May 2016 Sophie was allowed to be behind a locked bathroom door and was not subject to close observations   She was subsequently found hanging in the bathroom.  Staff were unable to explain how she came to be in the possession of a skipping rope, in her bathroom, which was used as a ligature.
Elly Jansen OBE established a therapeutic community under a charity, ‘Richmond Fellowship’ in 1959.  Richmond Fellowship was the subject of a Charity Commission inquiry in 1988 which reported concerns as to financial conflicts of interests concerning Ms Jansen. The Commission had reported that Ms Jansen had since “severed all links” with the charity. However, it is apparent that a similar charity was since established – RPFI – with Ms Jansen acting as a ‘consultant to the board’.

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.
In particular, the jury held that:

  • Replacement staff across all levels were not adequately trained, skilled, educated or experienced.
  • Leadership and oversight of the RPFI board was grossly inadequate.
  • A grossly inadequate observation plan of Sophie was put in place and not understood or followed.
  • There were grossly inadequate steps at minimising access to ligature items.
  • Changes were based on a one day audit, grossly inadequate.
  • Advice was provided by the founder and followed by RPFI staff without ever meeting or any knowledge of residents.

In a statement, Sophie’s family said: “We’ve waited nearly three years to find the truth about what happened to our beautiful daughter who, despite her many problems, had a fulfilling life ahead of her. We thank the jury for listening to the at times difficult evidence and their clear conclusions which vindicate our concerns.

We await eagerly to see whether the CQC is to pursue a criminal prosecution, which we believe it should. We also want to see action by the Charity Commission. The Charity Commission has been conspicuous by its absence from this inquest despite our urging it to attend and hear the evidence. It has known about the issues surrounding the governance of RPFI since well before Sophie’s death. I hope that it will now apply the full force of its powers to take action against those trustees who have clearly been negligent in their responsibilities.

Thank you to our legal team – Caoilfhionn Gallagher, Sam Jacobs and Bindmans team led by Rachel Harger, and also to INQUEST.”

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.

Today gives Sophie’s family some measure of accountability. However, it must not stop here. There must be a fresh investigation into the circumstances of her death and those responsible for the flagrant failings which this inquest has uncovered.”

Rachel Harger, Bindmans solicitors, said: “In a matter of months RPFI turned Lancaster Lodge from a well-run care home, into a chaotic one which put residents in danger. The standard of governance was appalling, and left untrained, junior staff without training or guidance. It has taken the inquest process and almost three years before RPFI has even begun to acknowledge the extent of its failings”.

For further information please contact Lucy McKay and Sarah Uncles on 020 7263 1111 [email protected] and [email protected]
The family is represented by INQUEST Lawyers Group members Charlotte Haworth-Hird and Rachel Harger of Bindmans LLP and Caoilfhionn Gallagher QC and Sam Jacobs of Doughty Street Chambers.
Sophie is survived by her parents Ben and Nicki, and her siblings Natasha, Thomas and Jack.
The Coroner will be addressed on matters relating to the prevention of future deaths, including relating to governance of RPFI, at 10am on 8 February 2019 at West London Coroners Court, Bagleys Lane.
In 2018, there were a series of critical findings at inquests following the deaths of young women in mental health care:

  • Jury concluded neglect by the Leicestershire Partnership Trust contributed to the death of Amanda Briley died aged 20,
  • A series of failing contributed to the death of Sophie Payne, aged 22, on a mental health ward on Roehampton.
  • Failings in the care of Zoe Watts, aged 19, contributed to her death on a secure mental health ward.

The other interested persons represented in the inquest proceedings are:

  • Richmond Psychosocial Foundation International
  • LB Wandsworth
  • South West London and St George’s Mental Health NHS Trust
  • Care Quality Commission

The previous manager of Lancaster Lodge, and four previous employees are also separate interested persons but are unrepresented.