Bereaved mother demands change after NHS trust fined over ‘death trap’ ward

A mother whose daughter killed herself on a “death trap” ward has called for urgent change after an NHS trust was fined more than half a million pounds.

Alice Figueiredo, 22, took her own life in a mental health unit at Goodmayes Hospital, Redbridge, after 18 similar attempts.

Her death on July 7 2015 followed a failure to remove plastic items from the communal toilets on Hepworth Ward that had been used by her to self-harm.

On Tuesday, North East London NHS Foundation Trust (NELFT) was fined £565,000 plus £200,000 costs after being found guilty of breaching health and safety.

In setting the amount, Judge Richard Marks KC noted its finances were in an “absolutely parlous state” and a large fine could impact on services.

Ward manager Benjamin Aninakwa, 54, of Grays in Essex, was convicted of failing to take reasonable care for the health and safety of patients on the ward that Ms Figueiredo was on.

Judge Marks KC sentenced him to six months in prison, suspended for 12 months, plus 300 hours of unpaid work.

Speaking outside the Old Bailey, Alice’s mother Jane Figueiredo said change was needed to prevent more tragedies.

She told reporters that her daughter had been confined to a “death trap” which was “a fatality waiting to happen”.

Rather than being given the “compassion, care and support” she needed, Alice was “failed horribly and experienced a litany of failures which crushed her spirit and ended her life”, Mrs Figueiredo said.

She said her daughter’s pleas for help were not taken seriously and were “regularly shut down, silenced, and her life was eventually distinguished”.

She added: “People behind the locked doors on mental health wards are some of the least seen and heard people in our communities and  society. And their voices are all too easily dismissed, used against them, or silenced.”

In his televised sentencing remarks, Judge Marks described former head girl Alice as a “beautiful vibrant young woman” who was “hugely talented” and had an “extremely” attractive personality.

He said: “Her death at such a young age in the circumstances in which it occurred is a terrible tragedy.”

The judge said the accessibility of plastic in the communal toilets was a “very serious problem”.

He said: “I am in no doubt that there was a complete failure to adequately assess and manage the risk that this posed.”

Keeping the communal area temporarily locked while Alice was on the ward would not have posed a problem beyond one of “inconvenience”, the judge said.

Judge Marks said Aninakwa had also failed to address “major concerns” of Alice’s mother which should have “rung major alarm bells”.

He told the defendant: “You knew that she was suicidal – she was the only patient on the ward that was. Your negligent breach of duty went on for weeks.”

The judge took into account the 10-year delay in the case in his decision to suspend Aninakwa’s jail sentence.

Earlier in a victim impact statement, Alice’s mother and former hospital chaplain Mr Figueiredo said they had been treated with “dismissive contempt, belittling and playing down” their “well-founded” concerns in 2015.

She told the court: “Such attitudes go against everything patient care stands for in our NHS.”

Addressing the ward manager, she told the court: “What she did not like on your watch in 2015, Mr Aninakwa, was being treated by some staff with unkindness, harshness, indifference, ignorance, even at times cruelty or being endangered and left at risk by neglectful and incompetent staff some of whom seemed to be clueless about their duties and responsibilities, a fact you were often in denial of.”

She described her daughter as a “uniquely beautiful, brave, affectionate, generous, kind, colourful, creative and luminous spirit”.

She said: “The impact of Alice’s untimely, preventable death on every aspect of my life and our life as a family has been immeasurable.”

Alice was first admitted to the Hepworth Ward in May 2012 with a diagnosis including non-specific eating disorder and bipolar affective disorder.

During her time on the acute psychiatric ward, the trust failed to remove plastic items from the communal toilets or keep them locked despite repeated suicide attempts.

Aninakwa, who was subject to a performance improvement plan, had also failed to ensure incidents of self-harm were recorded, considered and addressed, jurors heard.

Aninakwa and the trust denied wrongdoing but declined to give evidence.

The investigation into Ms Figueiredo’s death began in 2016 but charges were not brought until September 2023.

NELFT was cleared of corporate manslaughter and Aninakwa was found not guilty of manslaughter by gross negligence.

The first corporate manslaughter trial against an NHS trust collapsed in 2016 after a judge ruled there was no case to answer.

Nina Ali, partner at Hodge Jones and Allen, represents more than 120 families at the Lampard Inquiry which is investigating the deaths of mental health inpatients in Essex.

She said: “What happened to Alice is indefensible. Today’s sentence offers no deterrent to the healthcare professionals and trusts who repeatedly fail vulnerable patients in their care.

“Lip service is repeatedly paid to lessons having been learned when all the evidence makes clear that lessons have not, and are not being learned. Only a custodial sentence for those responsible for wholly preventable deaths like Alice’s will genuinely get trusts to sit up and start taking responsibility for their ongoing failings and take the necessary steps to prevent more deaths.

“Jane is currently excluded from the Lampard Inquiry because of arbitrary rulings about geographical borders but we will now be appealing to the chair to reconsider her initial refusal and to grant Jane core participant status to enable her to fully participate in the inquiry.”