London care home fined £40k as judge rules they failed to protect patient who hanged herself

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A healthcare charity has been fined £40,000 after failing to protect a vulnerable teenager who took her own life whilst in their care.

Sophie Bennett, 19, was found hanged in a bathroom in Lancaster Lodge, a residential care home in Richmond, west London, in May 2016 – just over a year after she was admitted in April 2015.

Staffing changes saw a new ‘boot camp’ regime imposed at the facility – which replaced external therapies with morning exercise and yoga.

This dramatically impacted on Sophie’s wellbeing and led her to be placed on ‘close observations’, an inquest into her death was told.

The teenager, from Tooting in south-west London – who had bipolar, atypical autism and social anxiety – died in Kingston Hospital two days after she was found hanged.

She was described by her family as ‘bright, loving and caring’.

The Richmond Psychosocial Foundation International (RPFI), the charity which ran the facility, was fined £40,000 over a failure to provide safe care and treatment under the Health and Social Care Act 2008.

Peggy Jhugroo, 57, who was employed by RPFI as a co-ordinator and was the registered manager of the care home, has also been handed a £3,000 fine.

Sentencing at Uxbridge Magistrates’ Court on Friday afternoon, District Judge Deborah Wright said: ‘The RPFI fell far short of the appropriate standard in that it failed to heed warnings and concerns raised by employees.

‘They recruited inexperienced staff, failed to ensure proper training was given to newly appointed staff and failed to recognise the needs of Sophie.’

Ms Wright went on to say there was a ‘serious and systemic failure within the organisation to recognise the risk to health and safety’, meaning its culpability level was ‘high’.

She continued: ‘Her (Sophie’s) vulnerability was self-evident […] anyone reading her logs should have been aware the risks were significant.

‘The risk to her was, in all circumstances, a high likelihood of death.’

Ms Wright said that Jhugroo ‘willingly did the RPFI’s bidding’ and was ‘wilfully blind to the risk of offending’ despite Ms Bennett’s vulnerability.

She added: ‘The fine I give must take into account the seriousness of the offence.’

The home had seen a number of staff changes after Jhugroo and interim manager Duncan Lawrence took over, following the resignation of previous boss Vincent Hill over fears of cuts to therapy.

Mr Hill had more than 25 years of experience and had overseen the facility receiving ‘good’ ratings by regulator the Care Quality Commission (CQC).

However, after Jhugroo took over, a number of ‘inexperienced’ staff were appointed and given ‘inadequate’ training, the court heard.

Craig Rush, prosecuting, told the court that under Jhugroo no attempts were made to form relationships between management and the residents, which had an ‘effect’ on the wellbeing of Ms Bennett.

Mr Rush said Jhugroo and the RPFI had been ‘cost-cutting at the expense of safety’ with the underlying motive behind removal of staff and therapy being ‘increased profitability’.

Ms Bennett had said the changes made her feel like being in a ‘boot camp’, which had an ‘adverse impact on her wellbeing’, Mr Rush told the court. 

At the inquest it was noted changes meant leadership and oversight was ‘grossly inadequate’ and that 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. 

On April 28, 2016, two care workers found a number of objects in Ms Bennett’s room ‘that she could have used to self harm’.

They also noticed ‘a burn-like mark’ on the back of her neck, which ‘should have given rise to very genuine, very serious concerns about the risks of her harming herself’, the court heard.

However, the level of risk of Ms Bennett harming herself was only put to three out of 10 following the discovery, as staff were ‘not qualified and untrained’.

Mr Rush added: ‘There’s no one individual thing, it’s a combination of factors, here the combination of factors cumulatively is the removal of experienced staff, replaced with inexperienced staff.

‘The inexperienced staff then don’t receive adequate training, thereby they’re not in a position to provide proper risk assessment.

‘The risk assessment was then not followed’.

Shortly before her death, the CQC criticised the facility as ‘inadequate’ in a number of areas.

Mr Rush went on to say the RPFI ‘fell far short of the appropriate standard’ because it ‘ignored concerns raised by several employees regarding the risk proposed about the residents’.

Paul Spencer, representing the RPFI, said: ‘There have been very significant, long-lasting lesson learnt from the very tragic death of Sophie Bennett.’

He accepted that staff were recruited without ‘an appropriate skillset’, but denied that such steps were ‘knowingly taken’.

The RPFI, which no longer oversees the care facility, accepted its high culpability in the incident, the court heard.

The court also heard that Jhugroo was the ‘wrong person for the job’ due to her background as a youth worker.

Alexander Dos Santos, defending, said: ‘As her role progressed over time, she recognised that her skillset and background was not suitable for the role that she had, and she accepts responsibility for carrying on that post when it became apparent there was more required.’

Jhugroo remained in her position until 2017. 

For confidential support, call the Samaritans on 116123 or visit a local Samaritans branch. See www.samaritans.org for details