Management feared loss of revenue if she went to hospital for assessment
Richmond Psychosocial Foundation International (RPFI) and manager Peggy Jhugroo, who led the care home in which teenager Sophie Bennett died, have received fines of £40,000 and £3,000 respectively after pleading guilty to charges relating to the death of Sophie Bennett.
Uxbridge Magistrates Court was told that when Sophie voiced suicidal thoughts she was not sent to hospital for assessment as advised due to the centre’s management fear of a loss of revenue and rather was left on her own in a locked room in which she took her own life.
Peggy Jhugroo is now also known as Marilene Peggy Moylan. She accepted in evidence during the inquest into Sophie’s death that she did not have the qualifications and experience to be a registered manager of the home.
The Care Quality Commission (CQC) reached the decision to prosecute the charity and manager of the home on 1 May 2019, following the inquest into the death of Sophie Bennett, who had been placed there by Wandsworth Council. The inquest jury concluded that Sophie had not intended to take her own life, that “neglect” contributed to her death and that there had been 16 points of failure in her care.
Sophie died on 4 May 2016 aged 19 year. She had diagnoses of Bipolar Affective Disorder, Social Anxiety Disorder and atypical autism. She had been cared for at Lancaster Lodge in Richmond, specialist accommodation for people with mental ill health run by RPFI, since April 2015.
In the four months leading up to Sophie’s death, significant changes were made at Lancaster Lodge. In January 2016 a number of changes were made to the home following an audit by a consultant, ‘Dr’ Duncan Lawrence, and also following input from Elly Jansen OBE, who was said to be a consultant to the RPFI board. Sophie described the changes as making Lancaster Lodge into a ‘boot camp.’ The changes included sacking external therapists. Sophie’s therapist gave evidence at the inquest that it was Duncan Lawrence’s intention to replace psychotherapy with yoga sessions.
Duncan Lawrence was appointed clinical lead at the home, although he was not qualified for this role. Although he was understood by other staff to have a medical degree, in fact he 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’ Duncan Lawrence’s credentials.
In October 2019 Duncan Lawrence was sentenced to four months in custody for failing to give evidence to the inquest. He arranged for somebody to impersonate him in a preliminary Skype session with the court but a member of the coroner’s staff spotted that it was not him.
The standard of care at the home fell to the extent that the CQC assessed the service as “inadequate” in March 2016. In evidence at the inquest, the CQC inspector described the home at that stage as “chaotic.” A former member of staff also described the home as “falling apart” and a “shambles”.
At the inquest, evidence was heard about the known risk to Sophie’s life, and the failure by RPFI staff to protect her and prevent loss of life. The inquest jury returned damning conclusions about multiple points of failure in her care and concluded that “neglect” contributed to her death.
At the inquest, serious concerns were raised about the role of Elly Jansen OBE in both running Lancaster Lodge, and her involvement in decisions about Sophie’s care, despite never having met her. A trustee of the Board, Jonathan Manson, told the inquest that he thought Ms Jansen’s role was “ambiguous.” Lynn Dade, a former RPFI trustee who resigned in July 2015 following “grave concerns regarding the governance and financial affairs” of RPFI described Jansen as a “sleeping director.”
Alongside Duncan Lawrence, Peggy Jhugroo played a critical role at Lancaster Lodge in the lead up to Sophie’s death, and the aftermath. She was employed by RPFI as a co-ordinator and she was the registered manager. She had been trained by Elly Jansen OBE and at the time of Sophie’s death continued to be supervised by her.
Sophie’s placement at Lancaster Lodge was jointly funded by the London Borough of Wandsworth and Wandsworth Clinical Commissioning Group. However, during the course of the inquest evidence it also emerged that Peggy Jhugroo was employed by London Borough of Wandsworth throughout her employment with RPFI. It was Peggy Jhugroo’s evidence in the course of the inquest that her manager at London Borough of Wandsworth was aware of this dual role at RPFI and took no action, despite there being a clear conflict of interest.
On 28 April 2016 Sophie self-harmed and told staff at Lancaster Lodge that she was suffering with suicidal thoughts and her impulse to act on them were high. Staff phoned the Crisis Line who advised that Sophie should be taken directly to hospital so that she could be assessed, but the advice was not followed. In the days after the death Sophie’s care-coordinator was told that this was a decision taken by “management”. Evidence was heard at the inquest regarding RPFI’s concerns that, if Sophie was taken to hospital, she could be removed from Lancaster Lodge and there would be a loss of revenue.
After this serious incident on 28 April 2016, Sophie was placed on “close observations”, her door was to remain open at all times, and her room was to be periodically searched for items with which she could self-harm. However, on 2 May 2016 Sophie was allowed to be behind a locked bathroom door and was not subject to close observations where she took her own life. Junior staff gave evidence about the lack of training and their lack of knowledge about room searches and items which could be used to self-harm.
At the time of the inquest verdict Wandsworth Council said, “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."
Deborah Coles, Director of INQUEST, said, “Sophie’s family have fought tirelessly through countless legal and investigative processes to get justice for her. Today’s sentencing is a small step forward in holding those involved in the neglect Sophie received to account. We hope this will send a message to providers that those involved in potentially criminally unsafe standards of care will be held to account. However, it is far from enough.
“Bereaved people have to battle a system of denial and delay, which adds another layer of trauma. We must see more accountability in this case, alongside broader strengthening of the duty of candour on care professionals to enable justice for bereaved families and ensure there is change to prevent future deaths.”
Rachel Harger, Bindmans LLP, said, “Unqualified consultants involved in Sophie’s care are still yet to be held to account for their actions. The conduct of Peggy Jhugroo in Lancaster Lodge and the poor management of Richmond Psychosocial International Foundation was enabled by multiple agencies - agencies which failed to challenge them and prevent their harm until it was too late. This includes the London Borough of Wandsworth, and the Charity Commission, who all had opportunities to intervene and who the family feel have done too little, too late.
“The family are broken, exhausted and defeated after a 5 year legal process. They are deeply disappointed by the behaviour of those involved in Sophie’s death, including in their lack of candour and cooperation since.”
The Charity Commission have opened a statutory inquiry into RPFI which is ongoing.
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March 12, 2021