Girl hanged herself in care home run under ‘Victorian rules’

A charity manager and the home she worked for failed to protect a girl who committed suicide after the introduction of a ‘boot camp’ programme, a court heard today. (Fri)

Sophie Bennett, 19, hanged herself at Lancaster Lodge care facility in Richmond, south-west London on 2 May 2016 following the sudden introduction of the harsh regime by management.

Manager Marilene Peggy Jhugroo and Richmond Psychosocial Foundation are today (friday) awaiting sentence for failing to provide care and treatment in a safe way resulting in harm or loss.

Sophie was admitted to the home in 2015 suffering from complex needs, including bipolar disorder, social anxiety and atypical autism.

In February 2019 an inquest sitting with a jury concluded that Sophie’s suicide was contributed to by neglect, a deterioration in the quality of her care and management ‘errors or omissions.’

The unqualified clinical lead at the home, Duncan Lawrence, was jailed for four months in October 2019.

The 61-year-old, from Sydenham, oversaw her Sophie’s treatment ‘like a dictatorship – with 19th-century governance’.

The care home had received a ‘good’ rating from the Care and Quality Commission (CQC) in September 2015 and Sophie was said to have ‘generally settled well’ before the changes to the treatment programme.

By early March 2016 the CQC changed its rating of the home to ‘inadequate’.

By April 28 Sophie’s mental stability had become a serious concern but advice from mental health crisis experts to take her to A&E was ‘not followed’

Craig Rush, prosecuting for the CQC, told Uxbridge magistrates court that Jhugroo began working at Lancaster Lodge as ‘RPFI co-ordinator’ with no clinical experience and while continuing to work part-time as a youth worker for Wandsworth Borough Council.

Experienced registered Manager Vincent Hill also expressed concern about unqualified self-declared ‘doctor’ Duncan Lawrence’s recent recruitment and ‘therapeutic overview’ of the Lodge, the court heard.

Mr Hill was told to leave without handover after expressing concern about the Peggy Jhugroo’s instruction to dismiss the external Clinical Supervisor, his external Staff Team Supervisor, and two external Psychotherapists.

Mr Rush said: ‘RPFI failed to provide safe care and treatment to the service users at the Lodge, including Sophie Bennett, in that it failed to ensure it had done all that was reasonably practicable to mitigate risks to the health, safety and wellbeing of those service users.

‘RPFI also failed to ensure that the persons providing the care and treatment to the service users at the Lodge had the qualifications, competence, skills and experience to do so safely.

‘In particular RPFI implemented a programme of significant strategic change in respect of the care of service users at the Lodge, without fully considering the effect of those changes upon the service users or allowing time for them to adapt to such changes, particularly in light of their fragile mental health and difficulties coping with change.

‘RPFI dispensed with the services of a many experienced staff members, leaving a staff team with insufficient skills, knowledge and experience to ensure that the specific needs of the service users could be met and that safe care could be provided.’

Newly recruited staff were insufficiently qualified or experienced, had not been familiarised with the service users, and did not follow clear procedures or react appropriately to the increased risk of Sophie’s self-harm, Mr Rush added.

Jhugroo failed in her role as manager by removing a Mr Hall, Sophie’s key worker and the senior support worker.

Mr Rush added: ‘Peggy Jhugroo also failed to ensure that any changes were implemented in respect of Sophie Bennett’s care, whether by herself or through clinical staff, following the incident of self-harm on 28th April 2016, particularly in relation to her observation levels and room sweeps.

‘Following RPFI’s recruitment of new employees, she failed to ensure they were provided with any specific training in mental health awareness, challenging behaviours, de-escalation and/or other relevant areas, to ensure they could provide safe care to the service users at the Lodge.

He also described how a part-time art therapist was recruited into the position of Clinical Lead, without any handover, induction, training or job descriptions.

He added that RPFI ‘ignored concerns raised by several employees regarding the risks posed to the mental health of the service users as a result of the extent and speed of changes introduced.

‘Allowed the failures to subsist over a long period of time, in this case, several months; and failed to make changes following previous incidents exposing the risk, most notably the incident of self-harm by Sophie Bennett on 28th April 2016 (prior to the incident on 2 nd May 2016, which led to her death).’

At the inquest it was noted changes meant leadership and oversight was ‘grossly inadequate’ and that a number of key staff had left, replaced by less staff who were ‘not adequately trained, skilled, educated or experienced’.

A new ‘boot camp’ regime was imposed replacing external therapies with morning exercise and yoga which dramatically impacted on Sophie’s wellbeing and led her to be placed on ‘close observations’.

Safety concerns were raised at the time about ‘chaotic’ staff who were described as being ‘in the deep end’ and ‘learning on the job’.

The changes had been brought in after a ‘grossly inadequate’ one day audit by ‘the founder,’ who had never met the residents and knew nothing about them.

Errors or omissions in the management of risk by RPFI included incompetence in crisis management, failure to follow crisis line advice to take Sophie to A&E, confusion over staff chain of command, refusal to allow Sophie’s care coordinator or psychiatrist to visit her.

They described Sophie’s observation plan as ‘grossly inadequate,’ searches of her room as ‘poor’, a single staff member at night, and letting Sophie close the door.

Medically unqualified clinical lead at the home, Duncan Lawrence, was jailed for four months in October 2019 for the rarely prosecuted offence of failing to cooperate with the inquest at West London Coroner’s Court.

The 61-year-old, from Sydenham, oversaw her treatment ‘like a dictatorship – with 19th-century governance’.

His sole qualification for the role was a doctorate of Public Administration from the unaccredited ‘University of Knightsbridge’ in Copenhagen.

He had already been fined £650 by assistant coroner John Taylor, initially saying he was ‘caring for his sick mother’ in the USA, then blaming ‘ongoing stress’ and only providing written statements.

Representing himself at Wimbledon Magistrates’ Court Lawrence denied having a connection to her death and said ‘it was all down to a misunderstanding’.

The charge states that manager Jhugroo failed ‘to discharge a duty resulting in service users including Sophie Bennett being exposed to a significant risk of avoidable harm’ under the Health and Social Care Act 2008.

The charge continues that as manager of the Richmond Psychological Foundation, she ‘failed to provide safe care and treatment to Sophie Bennett by not doing all that was reasonably practicable to mitigate risks to the health and safety of service users had the qualifications, competence, skills and experience to do so safely’.

Jhugroo, of Tooting Bec Road, admitted/was convicted of being a registered person failing to provide care and treatment in a safe way resulting in harm or loss.

Richmond Psychological Foundation, of Heathfield North, Twickenham, admitted being a registered person failing to provide care and treatment in a safe way resulting in harm or loss.

Psychotherapy session notes showed Sophie was becoming unstable because of the regime changes.

In February, March and April she expressed a lack of belonging, confusion over therapy being removed and a sense that her opinions did not count.

The decision to move her resulted in increased levels of ‘low self-esteem’ and ‘excessive self-criticism and self-hatred’ recorded on 26 April.

On 28 April Sophie was kept with staff for the rest of the evening after finding burn marks on her neck, cuts to her arms and a sweep of her room revealed a razor, scissors, tweezers and broken cups.

On 2 May at 5:23pm she was found hanging in the bathroom, seven minutes after the last check, she died as a result of the injuries two days later at Kingston Hospital.

Describing the management of Lancaster Lodge, Mr Rush said: ‘RPFI is a charity registered with the Charity Commission.

‘The charity is connected to the Jansen family, particularly Elly Jansen OBE, who has operated in the development of therapeutic communities for many years

‘A therapeutic community is an environment designed as an alternative to hospital care, aimed at assisting residents with mental health difficulties in working towards semi-independent living.

‘Lancaster Lodge was operated by RPFI as a therapeutic community and residential care home for residents with acute and complex mental health difficulties.

‘The Lodge had the capacity to care for up to 10 service users but would usually operate at around 80 per cent capacity.

‘Under Vincent Hill’s management, staff at the Lodge described it as strong and secure with a solid structure and feeling of stability.

‘Due to the needs of the service users cared for, the Lodge was operated as a “deep democracy” where decisions regarding the care of service users were made jointly between staff and the service users themselves.

‘Each service user would be allocated their own key worker from the staff population at the Lodge, who would ensure that the views of the service user were taken into account in decision making processes.’

Meticulous records of the residents’ care was kept, with constant coordination between staff and clear directions about the level of observation residents required.

After Vincent Hill’s departure and the appointment of Duncan Lawrence as clinical lead operations at the Lodge changed.

Mr Rush said: ‘There was a move from the previous democratic approach to more of a top-down authoritative approach.

‘Staff also found that a blanket, rather than individualised, approach, was taken to the care of service users.’

New staff were from other RPFI locations which operated with different needs and no specialist training for care work or mental health issues.

The only training they received was in the ‘structure’ of RPFI by Duncan Lawrence and Peggy Jhugroo.

Mr Rush added: ‘At the point of commencing work, therefore, the new staff recruited to the Lodge had received no training on mental health awareness or other potentially relevant skills, such as de-escalation and managing challenging behaviour, which would have been required to ensure they could provide safe care to the service users.’

A move to make Lawrence provider of all therapies provided by external professional consultants or counsellors was only shelved when serious concerns were raised about the unstable mental health of residents.

At around the same time Jhugroo requested new contractual terms with RPFI, including ‘CEO Status’.

Two staff members who raised concerns about the new regime were sent to languish at non-existent ‘training’ for two weeks at another centre and dismissed when they returned to Lancaster Lodge for not being ‘team players’.

The Richmond Psychosocial Foundation (RPFI) denied that any of the proposed or enacted changes were in order to ‘cut costs,’ the court heard.

Paul Spencer, for RPFI, said: ‘I attended inquest on behalf of the RPFI, at the inquest RPFI apologised for the very tragic circumstances that lead to Sophie’s death.

‘It was a death that should never have occurred and RPFI is aware of that.

‘It’s recognised now that under Mr Hill there were several years of stability where all residents at Lancaster Lodge were kept safe and all were kept safe from risk, harm and there were no significant harm events.

‘As a result of decisions taken by Ms Jansen that was for Mr Hill to leave, or constructively dismissed, there was a period from early January of 2016 right through and beyond Sophie Bennett’s tragic death there was a degree of instability that directly lead to experienced staff members who felt they had to leave.

‘Where staff in positions of responsibility were inexperienced and tragically Sophie suffered her death, the risk of harm was recognised during that period of time.

‘This wasn’t done as a deliberate mechanism to save money.

‘That change in ethos that would go from a community where residents were involved in all aspects to a new regime where invited to undertake exercise from 7am in the morning.

‘That was disastrous, it led to a significant level of unhappiness that was passed onto families and there was a lot of tension at the time.

‘It was decided not to remove external therapy as a result of the intervention of the Bennett family.

‘RPFI understands and accepts that the CQC will explain to the court that the changes in care were done to save costs, ultimately that change was shelved due to intervention from families.

‘It was unwise and led to unsafe care and treatment, but the changes were not solely made for cost cutting reasons.

District Judge Deborah Wright said: ’I understand, but why would you dispense with external therapies if it wasn’t to save costs?

‘It’s clear from staff who left that they were effectively being dispensed with and the decisions were taken before, because they didn’t’ agree with change in regime.

‘Experienced people who expressed reservations, the minute they expressed them, they were out the door.’

District Judge Wright also rejected Jhugroo’s written basis of plea submitted before sentence that she was not conducting a managerial role in January 2016, when Vincent Hill was manager.

She described Jhugroo’s emails to Mr Hill as ‘imperious,’ and made clear that her role was ‘very significant’.

Alexander Dos Santos, for Jhugroo, said: ‘She recognises that she should have recognised that her skills and background were not suitable for the role she had and accepts responsibility.

‘Looking backwards on the sad events from 2016, the loss, suffering and grief, what she has understood looking back is that it is not enough to undertake structural diminishment, for care homes to operate safely, there are a number of safeguards in place.’

RFPI was ordered to pay prosecution costs to the Care Quality Commission (CQC) of £40,000 and will face compensation proceedings for compensation to the Bennett family.

Jhugroo was fined £3,000, ordered to pay £10,000 prosecution costs and £170 victim surcharge.

She was given seven days to pay the amount in full given her declaration of £29,000 in savings.

RFPI’s costs order was made based on their average turnover as a micro company of £440,000.

District Judge Wright noted the allegations of ‘cost cutting’ by the CQC but also considered the ‘real economic impact’ a large fine would have on them and service users at the two remaining care homes they operate.

She added: ‘Nothing can compensate Sophie’s family.

‘On the day of her suicide, incredibly, although the hand written notes were saying the risk is high, the typed document said the risk was low, three out of ten, notwithstanding the suicidal ideation.

‘Sophie Bennett’s high vulnerability was sufficiently evident, the failure to take into account the impact on her changing therapeutic regime was a serious risk.

‘Indeed, anyone reading the log should have been aware the risk was significant.

‘In all likelihood there was a high risk of death.

Judge Wright also noted that RPFI has accepted the allegations of failures to supervise staff, the change of routine without considering the impact on residents, and the failure to recognise the impact that would have on the needs of Sophie Bennett.

‘There can be no doubt that RPFI have taken the matter seriously,’ she continued.

‘Since even RPFI have taken wide ranging steps to address and I believe that it is unlikely a repetition is to recur and two remaining homes have overall rating good.

‘However I note that Ms Jhugroo remained in post until 2017.’

‘There has been a wholesale change in the RPFI board – I’m told.

‘Elly Jansen is no longer in her role. Ms Jhugroo is no longer employed by them.’

Summarising Jhugroo’s plea, she said: ‘Elly Jansen was the line manager, no major decisions were made without the knowledge of Ms Jansen.

‘She doesn’t accept responsibility for recruiting inexperienced staff.’

But Judge Wright noted again the ‘imperious’ commanding emails Jhugroo sent to Vincent Hill on 3 January.

She wrote: ‘I hope that we can work towards a shared vision’ and ‘you are to give notice to Stacy, January will be your last session together.’

‘She has expressed regret.’

Ends