30 April 2019

Before HM Assistant Coroner Mr John Taylor
West London Coroner’s Court
Wednesday 1 May from 10am

Following the deeply critical conclusions reached by the jury at the inquest into the death of Sophie Bennett in February 2019, HM Assistant Coroner John Taylor is taking the unusual step of holding a hearing to consider sanctions available for a witness who failed to attend and disclose crucial evidence (required under Schedule 5 of the Coroners and Justice 2009).

Duncan Lawrence failed to attend the inquest and comply with disclosure requests, despite his significant involvement in Sophie’s care. He could now face a fine and possibly criminal proceedings. Sophie, 19, died on 4 May 2016 two days after having applied a ligature whilst in the care of Lancaster Lodge, a therapeutic community run by Richmond Psychosocial Foundation International (RPFI).

In January 2016 a number of changes were made to the home following an audit by the consultant and ‘clinical lead’ Duncan Lawrence, including the cancellation of all external therapies. These decisions led senior staff to resign and a new regime which Sophie described 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 Care Quality Commission (CQC) assessed the service in March 2016 as ‘inadequate’. 

The coroner will consider whether a fine should be imposed on Duncan Lawrence, as well as the monetary value of any fine. He will also consider whether the consent of the Director of Public Prosecutions should be sought to institute proceedings against Duncan Lawrence (pursuant to Schedule 6 of the Coroners and Justice 2009), which may result in imprisonment as an alternative or in addition to a fine.

In February 2019 the inquest heard evidence that Duncan Lawrence, although understood by other staff to have a medical degree and be a doctor, in fact had a doctorate in public management and administration from Knightsbridge university – an unaccredited institution in Denmark. At the inquest RPFI were unable to produce any record of Duncan Lawrence’s credentials.

On the first day of a CQC inspection of the home in March 2016, Duncan Lawrence, despite being the ‘clinical lead’, appeared unable to explain what and where the residents’ care plans were. He then subsequently disappeared from Lancaster Lodge, failing to appear for the second day of the inspection.  

The jury at the inquest found that neglect contributed to the death of Sophie Bennett. Sophie had diagnoses of Bipolar Affective Disorder, Social Anxiety Disorder, and atypical autism. She had been cared for at Lancaster Lodge since April 2015. Following the inquest, on 5 April 2019, the Charity Commission opened a statutory inquiry into Richmond Psychosocial Foundation International ('RPFI').  The inquiry is ongoing.

The family of Sophie Bennett said: "The inquest into Sophie's death was damning in its conclusions about the shocking wilful negligence of RPFI's management and its founder and shadow director Elly Jansen. The family was deeply disappointed that a key witness, Duncan Lawrence, failed to attend the inquest to provide oral evidence despite considerable efforts by the court to arrange this at his convenience. He also failed to comply with a notice to provide crucial disclosure.

This conduct has reiterated our serious concerns regarding his competency and qualifications, it remains extraordinary to us that Duncan Lawrence was ever put in charge of the care home. However, we would have liked him to pay us and the Court the common courtesy of accounting for his role in this sorry tale. We would greatly welcome the Coroner imposing sanctions against Duncan Lawrence and we hope to hear him explain himself to us and the Court."

Deborah Coles, Director of INQUEST, said: “Inquests play a vital role in scrutinising the duty of care afforded to people in the care of the state. A full and fair hearing enables the coroner to do their job, and as such it is essential that key witnesses attend and exercise candour. We welcome the coroner’s unusual use of a hearing to follow up on the shocking failure of a man who was deeply involved in Sophie’s care to even attend the inquest.”



For further information please contact Lucy McKay on 020 7263 1111 or email.

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.

Richmond Psychosocial Foundation International background:

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 at the inquest 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.”

Further information:

  • 5 April 2019 - Charity Commission opens inquiry into care charity following Coroner’s reportBindmans Media Release
  • 7 February 2019 - Jury find neglect contributed to self-inflicted death of teenager Sophie Bennett in care homeINQUEST Media Release