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Teenager killed herself after changes at care facility in Richmond, inquest told

A teenager killed herself at a care facility when her mental health unravelled during major changes at the residential home, her mother has told an inquest.

Sophie Bennett

Sophie Bennett, 19, was found hanged at Lancaster Lodge in Richmond after a series of staff changes, a concerning watchdog report and fears of cuts to therapy, the court heard on Tuesday.

Several other residents became ill amid the disruptions in 2016 and "at least one" attempted suicide, West London Coroner's Court heard as the case opened.

Sophie Bennett Credit: PA

Ms Bennett, who had been diagnosed with bipolar, autism and social anxiety, died from her injuries in May that year.

Among jurors' duties, they have been tasked with deciding whether changes at the facility run by charity Richmond Psychosocial Foundation International contributed to her death.

Mother Nickie Bennett, who had been living in Tooting, south-west London, told the court her daughter was "a very bright, loving, very caring person" but was "very vulnerable".

Things had gone well for the teenager under the leadership of the "professional" and "competent" Vincent Hill after she moved there in 2015 and had dreams of one day attending university, her mother said.

But 2016 was a year of upheaval with fresh appointments and staff members, including Mr Hill, leaving, and the teenager feared her therapy sessions would be decreased.

A Care Quality Commission (CQC) inspection followed in March and Sophie Bennett was told on April 7 of her "fairly imminent" move out of the facility, her mother said.

"I would say she was getting very unstable," she added.

"I put it down to the fact she had so many changes going on. Before that she was happy and stable and things were going well for her.

"Had she stayed there and these things hadn't have changed she would've progressed and probably would've had to stay there for another year, two years."

The teenager was found hanged in a bathroom on May 2 2016 and died two days later in Kingston Hospital.

A post-mortem examination recorded her death as a hypoxic brain injury and pneumonia as a result of a cardiac arrest due to hanging.

The court heard she would have had to be moved after the CQC inspection raised concerns about the administration of medication.

Friend and fellow patient Clarissa Jeffrey said the changes in 2016 "made it feel like the residents were running the house".

"The changes felt like they were fuelled by trying to ... save money rather than trying to help the people in the lodge," she said in a statement to the inquest.

Among the changes were the departure of Mr Hill, who was said to have resigned over cuts to therapists.

Mrs Bennett said she heard from her daughter that he was "marched off the premises" in a "very brutal and harsh" manner in front of patients in mid-January.

The teenager told her mother the new regime saw the place become like a "boot camp" with strict rules and exercise, the court heard.

Coroner John Taylor asked Mrs Bennett: "Would it be fair to say that you had a sense that the progress she had made was starting to unravel?"

"Yes," the mother replied.

But she did not believe her daughter meant to end her life and suggested signs of her struggling were missed.

Through tears, Mrs Bennett said: "Sophie was not very good at expressing herself and from what we found out afterward there was clear signs she was trying to say to people she was not coping."

Paul Spencer, representing RPFI, read from a statement given to the inquest by the teenager's father Ben, who is an interested party along with her three siblings.

Three patients became "very ill" and left the lodge and "at least one" attempted suicide in 2016, Mr Spencer said.

The inquest, expected to last up to three weeks, continues on Wednesday.