Inquest Finds Neglect Contributed To Sophie Bennett's Death

Wandsworth Council put teenager in home which replaced therapists with yoga

Sophie Bennett
Sophie Bennett

An inquest jury has concluded this week that neglect was a contributory factor in the death of a 19-year-old whose care was the responsibility of Wandsworth Council.

Sophie Bennett from Tooting, who had a number of mental health issues including atypical autism, took her own life on 4 May 2016 whilst she was staying at Lancaster Lodge, a therapeutic community run by Richmond Psychosocial Foundation International (RPFI).

Sophie’s father, Ben Bennett, has said that he felt nobody at Wandsworth Council’s social services department gave any proper consideration to her safety.

She had been placed at the centre by social services and had been there for over a year. When she first came to the home it had received a ‘good’ rating from the Care Quality Commission (CQC) in September 2015. Subsequently, however, the dismissal of a number of experienced therapists who worked at the centre and other staff changes led to a fall in the standard of care.

The home was managed by Peggy Jughroo, who alongside her work at Lancaster Lodge was also employed by Wandsworth Council, and who accepted in evidence that she did not have the qualifications and experience to be a registered manager of the home.

The inquesy heard how in January 2016 a number of changes were made to the home following an audit by Dr Duncan Lawrence, who was said to be a consultant to the RPFI board. A decision was made to cancel all external therapies. Sophie’s therapist gave evidence to the inquest that it was Dr Lawrence’s intention to replace psychotherapy with yoga sessions. The decision to cut therapies and all external clinical supervision compelled the then registered manager, Vincent Hill, to resign.

A new regime was implemented in which residents were to rise early and exercise - Sophie described it 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 CQC assessed the service in March 2016 as ‘inadequate’. In evidence, the CQC inspector described the home at that stage as ‘chaotic'. A former member of staff described the home as “falling apart” and a “shambles”. Some newly recruited support workers had no relevant qualifications or experience.

Dr Lawrence, although understood by other staff to have a medical degree, in fact had a doctorate in public management and administration from Knightsbridge University – an unaccredited institution in Denmark. In the inquest RPFI were unable to produce any record of Dr Lawrence’s credentials. He failed to respond to the coroner’s summons to give oral evidence at the inquest.

Wandsworth Council had given credence to concerns that had been raised and decided to move Sophie from the centre, but had not managed to do so before her death.

On 28 April 2016 Sophie was self harming and told staff at Lancaster Lodge that she was suffering with suicidal thoughts and her impulse to act on them was high. Staff phoned Crisis Line who advised that Sophie should be taken directly to hospital so that she could be assessed, but the advice was not followed. Despite being placed on ‘close observation’ Sophie managed to find the means to end her life in the centre.

In a statement, Sophie’s family said: “We’ve waited nearly three years to find the truth about what happened to our beautiful daughter who, despite her many problems, had a fulfilling life ahead of her. We thank the jury for listening to the at times difficult evidence and their clear conclusions which vindicate our concerns.”

At the conclusion of a three week inquest with HM Coroner for West London, John Taylor, the jury concluded that Sophie’s death was contributed to by neglect on the part of RPFI.

INQUEST Lawyers Group, who acted for the family, believe that the CQC should pursue a criminal prosecution and that the Charity Commission should also intervene.

Deborah Coles, Director of INQUEST, 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. These shortcomings are particularly significant given the increased reliance on private providers in the delivery of mental health services.”

A spokesperson for Wandsworth Council said, “This was a tragic outcome of a case involving a vulnerable young woman with complex mental health needs who had received a huge amount of care and support from professionals in many different organisations over a very lengthy period of time. Our deepest condolences go out again to Sophie’s family for their loss.

“The jury found that there were serious failings on the part of the organisation that ran Lancaster Lodge. It was particularly concerning that RPFI staff did not communicate properly with us, did not inform nor consult us about significant changes they were making in the operation of the care home. They gave social services false information about their management of a serious incident which occurred just before Sophie’s death, when they were advised by other professionals to take her to A&E and failed to do so. It also emerged that they then, unbeknownst to us, failed to follow their own crisis plan to safeguard Sophie’s health and welfare.

“However 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.”

February 8, 2019