Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0476, written 13 Feb 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 13 Feb 2019 |
|---|---|
| Reference | 2019-0476 |
| Deceased | Sophie Bennett |
| Coroner | John Taylor |
| Coroner area | West London |
| Category | Care Home Health related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
e Richmond Psychosocial Foundation International (“RPFI”), and
e Richmond Companions International ("RCI")
CORONER
| am John Taylor, Assistant Coroner for the Coroner Area of West London.
CORONER’S LEGAL POWERS
| make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009
and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
INVESTIGATION and INQUEST
On 19 September 2016, the Senior Coroner commenced an investigation into the death of
Sophie Bennett, aged 19. The investigation concluded at the end of the inquest on 8
February 2019, which took place before me, sitting with a Jury. The conclusion of the
inquest was:
A.The medical cause of death was 1a. Hypoxic brain injury and pneumonia; 1b. Cardiac
arrest (resuscitated) and 1c. Suspension.
B. In their narrative conclusion, the Jury made the following findings, in relation to matters
which they found to be contributory to Sophie's death:
e The changes at Lancaster Lodge in and after January 2016, noting the following:
4. The uncertainty surrounding the discontinuation of external therapies contributed
to a feeling of anxiety and uncertainty.
2. The departures of critical staff members including registered manager, clinical
leads and key workers.
3. Introduction and effect of a regime perceived by Sophie to be akin to a “boot
camp”.
4. Replacement staff, across all levels were not adequately trained, skilled,
educated or experienced and lacked the relevant numbers of staff.
5. Changes resulted in the deterioration in the care provided by Lancaster Lodge.
6. Inadequate rating by the CQC following the March 2016 inspection;
7. Changes ultimately resulted in the decision to move Sophie from Lancaster
Lodge.
8. The changes impacted negatively on Sophie's wellbeing and upon her mental
state.
9. Leadership and oversight of the RPFI board was grossly inadequate.
40. Consultation regarding the changes was not relayed effectively to both staff and
residents.
11. The registered manager was told to leave without carrying out a sufficient
handover or allowing a transition with residents and other staff members.
42. Various RPFl/Lancaster Lodge staff did not hold the relevant qualifications for
the roles in which they were carrying out responsibilities.
43. Various observations that it was ‘chaotic’ staff were ‘in the deep end’ and
‘learning on the job’ this created a feeling for residents of generally being unsafe.
44. If it isn't broken why fix it, no need for the changes when Lancaster Lodge had
been performing well for the residents, especially when it was operating ‘at the
peak of its powers’ up to the end 2015.
15. Changes were based on a 1 day audit, grossly inadequate.
16. Advice provided by the founder and followed by RPFI staff without ever meeting
or any knowledge of residents.
e There were errors or omissions in the management of risk by RPFI (a company limited
by guarantee, and a registered charity) between 28 April 2016 and 2 May 2016, noting
the following:
4. Staff not trained or aware of crisis management and awareness of risks.
2. Didn't follow the appropriate crisis line advice to take Sophie to A&E in an
ambulance.
3. Staff presented as being highly unsure about chain of command between the
crisis line and RPFl management.
4. RPFI declining the care coordinator and treating psychiatrist visiting.
5. Grossly inadequate observation plan of Sophie put in place and not
understood or followed.
6. Grossly inadequate steps at minimising access to ligature items or knowledge
of past history involving ligature.
7. Very poor room searches, only looked for certain items and not trained in what
to look for.
8. Only one night sleeping staff working for Lancaster Lodge with high risk
residents.
9. Lack of staff awareness of risks to let Sophie close the door.
e Neglect on the part of RPFI.
CIRCUMSTANCES OF THE DEATH
The circumstances found by the Jury were:
“Sophie Elizabeth Alice Bennett died on the 4'" May 2016 at Kingston Hospital from injuries
caused by having applied a ligature on 2"4 May 2016 at Lancaster Lodge, Surrey, a care
home operated by Richmond Psychosocial Foundation International (RPFI).
Sophie generally settled well at Lancaster Lodge and in particular from around September
2015 appeared to be making good progress until January 2016. After which changes
implemented to the staff, therapy and the daily routine within Lancaster Lodge led to an
“inadequate” finding by CQC in early March 2016. Following the safeguarding concerns
raised by Richmond local authority, Wandsworth social services decided to find an
alternative placement for Sophie.
There were various concerns raised around 28! &29'n April regarding Sophie's mental
stability. A phone call to the crisis line was made by a staff member of Lancaster Lodge
on the 28" April who was advised to call an ambulance to take Sophie to A&E which was
not followed.
On 24 of May Sophie was presenting as anxious and self isolating and then was found at
approximately 17:20 unresponsive in the bathroom and then was admitted to hospital.”
CORONER’S CONCERNS
During the course of the inquest, the evidence (and other papers produced to me) revealed
matters giving rise to concern. In my opinion, there is a risk that future deaths will occur
unless action is taken. In the circumstances, it is my statutory duty to report to you.
The MATTERS OF CONCERN are as follows:
The governance of Lancaster Lodge, and of the staff, and others, working there during the
material period, was inadequate in the following respects:
4. There was no “registered manager” who met the statutory criteria.
2. The staff were (despite RPFl’s assertions to the contrary), generally, untrained,
unqualified and too few in number.
3. There were no, or no adequate, checks and controls by the staff, or by the
acting manager, on the keeping of essential documents, including risk
assessments and progress notes, which were, in consequence, themselves
inadequate, unreliable and misleading - with corresponding risk to the safety
of the residents.
The changes to which the determined circumstances refer were made
following an audit by nino ut:
as not qualified clinically, or in the field of mental health, to
conduct that audit;
e the audit conducted by him (which led to the proposals for change) took only
a single day, which was grossly inadequate;
e there was no, or no adequate, consultation with the staff, or by the staff with
the residents, regarding the substantial changes introduced, and to be
made; and
e the changes were introduced at a “launch”, with no, or no adequate regard
to the negative impact of their sudden introduction on the mental stability of
the residents.
Leadership and oversight by the Board of RPFI was grossly inadequate, in
relation to:
e the need to have in place robust employment procedures;
e the matters listed under paragraphs 1 to 4 above;
e the appointments of the clinically unqualified i! and,
later, the clinically unqualified art therapist as Clinical Lead, of a statutorily-
approved registered manager, and of an adequate number of trained and
qualified staff;
e supervision and control of the changes introduced at Po
instigation;
e decisions made by the (unqualified) acting manager and staff in relation to
the treatment to be given to the residents, and other steps required to meet
their needs, and safety;
e communication with other agencies involved in the care of the residents;
e the keeping and production (including to the Court, for the purpose of the
inquest) of the Board’s own records, communications and contracts; and
e knowledge and performance of the Board’s fundamental obligations,
including their duty of candour (not least in the Board having failed to fulfil
its mandatory obligation to report to the CQC five instances of admission of
Lancaster Lodge residents to hospital).
Advice to the acting manager was provided by i - the founder of
RPFI - and significant decisions regarding Lancaster Lodge, and the residents,
were made by her (in each case as a “consultant” to the Board, rather than by
the Board of RPFI), and were followed by RPFI staff, when:
was neither a director, nor a Trustee, of RPFI (one Board
member describing her role as “somewhat ambiguous”, and the evidence
suggesting that she was a “shadow director”); and
had never visited Lancaster Lodge, and had never met (or had
any, or any sufficient, knowledge of the residents).
The possibility of there being:
ea conflict between the interests Sc rrirerer NA it appears, may have
had a personal or family connection with the ownership of Lancaster Lodge)
and those of RPFI itself; and
e financial impropriety, in relation to the lease under which Lancaster Lodge
was (it seems) held.
The post-death investigations carried out on behalf of RPFI:
e were inadequate, verging on self-serving, and not objective; and
e give rise to concerns as to their veracity and accuracy (the authorship of
certain supposedly contemporaneous statements being denied by the staff
member whose name appears on them as their maker).
The facts that:
e a director and trustee of RPFI is also the Chairman of RCI; and
appears to have some family connection with the owner of RCI’s
premises
give rise to concerns in relation to RCI corresponding to those itemised under
paragraphs 5 to 7 above.
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths, and | believe each of your
organisations has the power to take such action.
YOUR RESPONSE
You are each under a duty to respond to this report (RPFI to respond to all the concerns
listed under paragraph 9 above and RCI to respond to paragraphs 5 & 7) within 56 days of
the date of this report, namely by 10 April 2019. I, the coroner, may extend the period.
Your response must contain details of action taken or proposed to be taken, setting out the
timetable for action. Otherwise you must explain why no action is proposed.
COPIES and PUBLICATION
| have sent copies of my report to the Chief Coroner, and to the following Interested
Persons:
e The family of Sophie Bennett
e The Care Quality Commission
| have also sent copies of my report to:
e The Charities Commission
e The Registrar of Companies
lam also under a duty to send the Chief Coroner a copy of your response.
The Chief Coroner may publish either or both documents in a complete or redacted or
summary form. He may send a copy of this report to any person who he believes may find
it useful or of interest. You may make representations to me, the coroner, at the time of
your response, about the release or the publication of your response by the Chief Coroner.
13 February 2019
Assistant Coroner
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