Source · Prevention of Future Deaths
Sophie Bennett
Ref: 2019-0476
Date: 13 Feb 2019
Coroner: John Taylor
Area: London (West)
0 responses identified · 2 indexed addressees
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AI-generated concerns summaryInadequate governance was identified at Lancaster Lodge, including the lack of a registered manager, insufficient trained staff, and poor controls on resident documentation. The coroner also noted grossly inadequate leadership and oversight by the Board, impacting employment and communication procedures.
Date
13 Feb 2019
56-day deadline
10 Apr 2019 est.
estimated from the report date
Responses identified
0 of 2
Coroner's concerns
Inadequate governance was identified at Lancaster Lodge, including the lack of a registered manager, insufficient trained staff, and poor controls on resident documentation. The coroner also noted grossly inadequate leadership and oversight by the Board, impacting employment and communication procedures.
View full coroner's concerns
The governance of Lancaster Lodge, and of the staff,and others, working there during the material period, was inadequate in the following respects: There was no "registered manager" who met the statutory criteria_ The staff were (despite RPFI's assertions to the contrary), generally, untrained, unqualified and too few in number: 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 May and put Very Jury 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_ but: was qualified clinically, or in the field of mental health, to conduct that audit; the audit conducted by him (which led to the proposals for change) took only single day, which was grossly inadequate; 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 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. 5, Leadership and oversight by the Board of RPFI was grossly inadequate, in relation to: the need to have in place robust employment procedures; the matters listed under paragraphs 1 to 4 above; the appointments of the clinically unqualified 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; supervision and control of the changes introduced at instigation; 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; communication with other agencies involved in the care of the residents; the keeping and production (including to the Court; for the purpose of the inquest) of the Board's own records, communications and contracts; and 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 byl the founder of
Report sections
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 o February 2019, which took place before me, with Jury: The conclusion of the inquest was: A. The medical cause of death was Ia. Hypoxic brain injury and pneumonia; 1b. Cardiac arrest (resuscitated) and Ic. Suspension. B In their narrative conclusion, the made the following findings, in relation to matters which they found to be contributory to Sophie's death: The changes at Lancaster Lodge in and after January 2016,noting the following: uncertainty surrounding the discontinuation of external therapies contributed to a feeling of anxiety and uncertainty: The departures of critical staff members including registered manager, clinical leads and key workers Introduction and effect of a regime perceived by Sophie to be akin to a boot camp" Replacement staff, across all levels were not adequately trained; skilled, educated or experienced and lacked the relevant numbers of staff. Changes resulted in the deterioration in the care provided by Lancaster Lodge. 6_ Inadequate rating by the CQC following the March 2016 inspection; Changes ultimately resulted in the decision to move Sophie from Lancaster Lodge_ The changes impacted negatively on Sophie's wellbeing and upon her mental state.
9. Leadership and oversight of the RPFI board was grossly inadequate.
10. Consultation regarding the changes was not relayed effectively to both staff and residents_
11. The registered manager was told to leave without carrying out sufficient handover or allowing a transition with residents and other staff members_ Various RPFIILancaster Lodge staff did not hold the relevant qualifications for the roles in which were carrying out responsibilities
13. 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: 14_ 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_ sitting Jury The they
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 2016, noting the following: Staff not trained or aware of crisis management and awareness of risks: Didn't follow the appropriate crisis line advice to take Sophie to A&E in an ambulance: Staff presented as being highly unsure about chain of command between the crisis line and RPFI management RPFI declining the care coordinator and treating psychiatrist visiting: Grossly inadequate observation plan of Sophie place and not understood or followed: Grossly inadequate steps at minimising access to ligature items or knowledge of past history involving ligature. poor room searches, only looked for certain items and not trained in what to look for: Only one night sleeping staff working for Lancaster Lodge with high risk residents_ Lack of staff awareness of risks to let Sophie close the door: Neglect on the part of RPFI:
9. Leadership and oversight of the RPFI board was grossly inadequate.
10. Consultation regarding the changes was not relayed effectively to both staff and residents_
11. The registered manager was told to leave without carrying out sufficient handover or allowing a transition with residents and other staff members_ Various RPFIILancaster Lodge staff did not hold the relevant qualifications for the roles in which were carrying out responsibilities
13. 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: 14_ 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_ sitting Jury The they
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 2016, noting the following: Staff not trained or aware of crisis management and awareness of risks: Didn't follow the appropriate crisis line advice to take Sophie to A&E in an ambulance: Staff presented as being highly unsure about chain of command between the crisis line and RPFI management RPFI declining the care coordinator and treating psychiatrist visiting: Grossly inadequate observation plan of Sophie place and not understood or followed: Grossly inadequate steps at minimising access to ligature items or knowledge of past history involving ligature. poor room searches, only looked for certain items and not trained in what to look for: Only one night sleeping staff working for Lancaster Lodge with high risk residents_ Lack of staff awareness of risks to let Sophie close the door: Neglect on the part of RPFI:
Circumstances of the death
The circumstances found by the were: "Sophie Elizabeth Alice Bennett died on the 4h May 2016 at Kingston Hospital from injuries caused by having applied a ligature on 2n 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 28th &2guh April regarding Sophie's mental stability. A phone call to the crisis line was made by a staff member of Lancaster Lodge on the 28th April who was advised to call an ambulance to take Sophie to A&E which was not followed: On 2nd 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:
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:
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Report details
- Reference
- 2019-0476
- Date of report
- 13 February 2019
- Coroner
- John Taylor
- Coroner area
- London (West)
Responses identified
Responses identified
0 of 2
2 responses not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 10 Apr 2019 (estimated from the report date).
Sent to
- RCI
- RPFI