Neglect by the charity running a west London care home contributed to the death of a teenager who took her own life while living there, an inquest has found.
19 year old Sophie Bennett had complex mental health needs, including bipolar disorder and atypical autism. She moved into Lancaster Lodge in Richmond in the summer of 2015. In May the following year, she ended her life.
The jury at the inquest into Sophie's death pointed out a long list of failures in Sophie's care, and the running of the centre - which, they said, contributed to the tragedy.
Sophie's parents spoke to Katie Barnfield:
When Sophie initially moved in, she was doing well. Her parents told ITV London she had started swimming again, a sport she had enjoyed when she was younger, and her condition was improving. But a few months into her stay,everything changed.
The inquest heard that a new board took over, and the decision was made to fire all of the therapists working at Lancaster Lodge - including those caring for Sophie.
A report by the Care Quality Commission in November 2015 had found the service to be safe, caring and well led. By March 2016, things had deteriorated so much at Lancaster Lodge that it was given the worst possible rating of 'inadequate'.
The centre's manager, Vincent Hill, resigned his post, saying he felt 'bullied' by the new regime and was worried about the direction Lancaster Lodge was taking. He said he had concerns that the patients there would no longer be kept safe.
The inquest jury found that the staff who had replaced the original team were not adequately trained, skilled, educated or experienced. They also said the leadership and oversight of the board at Richmond Psychosocial Foundation (RPFI) - the charity overseeing Lancaster Lodge - was'grossly inadequate'.
The inquest heard that the changes were made in order to alter the purpose of Lancaster Lodge - from a facility caring for those with complex mental health needs, to one caring for those with learning disabilities, employing lower paid staff. The jury found that the changes were based on an inadequate audit of the centre, and that RPFI had made these decisions without ever meeting the residents there.
In total, the jury found 16 failures that contributed to Sophie's death,including: - Replacement staff across all levels were not adequately trained, skilled,educated or experienced
A grossly inadequate observation plan of Sophie was put in place and not understood or followed. After a previous suicide attempt, she was not properly supervised
Changes at the centre were based on a one day audit that was 'grossly inadequate'
Advice was provided by the founder and followed by RPFI staff without ever meeting or having any knowledge of residents at Lancaster Lodge
Wandsworth Council, who were paying for Sophie's place at Lancaster Lodge, were also criticised by the jury for trying to move her out of the centre too quickly, when the decision was made that she would need to live somewhere else.
"There are clearly many lessons to be learned by all those who cared for and provided support to Sophie and her family. We have already acted upon many of these lessons and introduced a series of changes to try and prevent such a tragic event from happening again. We note the jury’s findings regarding the speed of the move and the need to have involved Sophie more fully in the process. We will now review whether further changes need to be made to address those concerns."
The charity Inquest, who have been supporting Sophie's family throughout the process, 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."
Sophie's parents, Ben and Nickie, have been pushing for the Charity Commission to further investigate RPFI and its governance.
They also say they hope the CQC will decide to prosecute RPFI for its failure to keep the patients at Lancaster Lodge safe.
Ultimately, they believe that if she had been given the care she needed and deserved, their daughter may still be alive.