Before HM Assistant Coroner Mr John Taylor 

West London Coroner’s Court, 25 Bagleys Lane, Fulham, London, SW6 2QA 

Opens Tuesday 22 January 2019, 10am Expected to last up to 3 weeks

Sophie Bennett was 19 years old when she died on 4 May 2016 in Kingston Hospital. She had been admitted two days earlier after being discovered hanging in Lancaster Lodge, a registered care home run by Richmond Psychosocial Foundation International (RPFI). The inquest opens tomorrow, 22 January 2019.

Sophie had a long history of serious mental ill health and she had received clinical care from the age of 14. Sophie’s placement at Lancaster Lodge was part of a transition from child social services to adult services which was managed by London Borough of Wandsworth local authority, who approved her transfer to the care home in April 2015.

In the final months of Sophie’s life serious concerns were raised by whistle-blowers about Lancaster Lodge following changes at the care home. The CQC and local authorities were sufficiently concerned that they made arrangements to move all residents out.

At the time of Sophie’s death, it was only her and one other resident living in the home. Her mental health deteriorated significantly and in the days prior to her death it appears that the care home staff contacted the crisis line who advised that they should call 999 and take Sophie to hospital but this advice was not acted upon.

The coroner will be holding an Article 2 inquest before a jury. It is hoped that the inquest into Sophie’s death will explore the following issues:

  • What changes were there at Lancaster Lodge between January and May 2016 and how did these impact residents?
  • What obligation was there on RPFI to inform and consult with local authorities and the Lancaster Lodge community before making significant changes?
  • How did local authorities respond to incidents and concerns raised between January and May 2016 and was this sufficient?
  • What ongoing diligence was there by statutory authorities in monitoring the quality and safety of the care regime at Lancaster Lodge?
  • Why Sophie was not admitted to acute psychiatric care days before she was discovered hanging in the bathroom in Lancaster Lodge?

Nickie Bennett, Sophie’s mother, said: “Sophie was the most beautiful person. She was caring, fun, totally unselfish and talented. She was greatly loved by her large immediate and extended family and many friends. We all miss her every day. She had significant problems but with the right care and support she would have gone on to have a fulfilling life. It has now been over two and a half years since her death and we hope that we will finally get answers’.

Selen Cavcav, caseworker at INQUEST said: “This case engages a number of serious concerns in relation to the care provided to a young woman in acute mental health crisis.

At an inquest were there are nine interested parties, many of whom are funded by the public purse, it is unacceptable that Sophie’s family were forced to fight for legal funding to ensure the necessary scrutiny into their daughter’s death.”




For further information, please contact Lucy McKay or Sarah Uncles on 020 7263 1111 or [email protected] [email protected]

Ben and Nickie Bennett, Sophie’s parents, are represented by INQUEST Lawyers Group members Charlotte Haworth-Hird and Rachel Harger of Bindmans solicitors and Caoilfhionn Gallagher QC and Sam Jacobs of Doughty Street Chambers.

The other interested persons represented in the inquest proceedings are:

  1. Richmond Psychosocial Foundation International
  2. LB Wandsworth
  3. South West London and St George’s Mental Health NHS Trust
  4. Care Quality Commission

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

Care Quality Commission undertook two unannounced inspections within one month during March 2018. Both raised serious concerns about the safety of Lancaster Lodge, rating the service as ‘inadequate’.