A private care home and its manager responsible for a chaotic drop in standards that led to the death of a vulnerable 19-year-old patient have been ordered to pay £43,000 in fines.
Sophie Bennett was receiving mental health treatment at Lancaster Lodge in Richmond when new manager Marilene Jhugroo, 57, took over, overseeing the axing of experienced carers and patients plunged into turmoil.
Senior staff were ejected from the home at short notice and unqualified workers hired in their places, while troubled patients were forced in daily 7am “boot camps”, Uxbridge magistrates court heard.
Sophie took her own life on May 2, 2016, days after staff had found a litany of evidence of self-harm and she had confessed to suicidal thoughts but she was still rated as a low-risk patient.
Richmond Psychosocial Foundation International (RPFI), which ran the care home under the direction of renowned therapist Elly Jansen OBE, was today fined £40,000 and Jhugroo was ordered to pay a £3,000 fine.
“Changing the regime for very vulnerable people, telling them to get up at 7am to exercise, not having experienced members of staff and changing members of staff presented a risk to all of the patients”, said District Judge Deborah Wright.
“An element of cost-cutting at the expense of safety was a prime mover for some of the changes.”
She concluded the risks Sophie posed to herself should have been “self-evident”, adding that while Ms Jansen made key decision Jhugroo was “willing to do her bidding”.
RPFI was also ordered to pay £20,000 in costs and Jhugroo must cover £10,000 of the prosecution’s bill.
Following the hearing, director of the charity INQUEST Deborah Coles 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 candor on care professionals to enable justice for bereaved families and ensure there is change to prevent future deaths.”
Craig Rush, prosecuting the case for the Care Quality Commission, said Jhugroo was appointed as a “co-ordinator” in September 2015 after a recommendation to the RPFI board by its major donor Ms Jansen.
He said Vincent Hill, the experienced manager of the home, believed Jhugroo “was seeking to make financial savings at the Lodge”, and he was instructed to get rid of clinical supervisors and psychotherapists.
The court heard Duncan Lawrence, who used the title ‘doctor’ but was not medically qualified, was brought in by Jhugroo to overhaul the care regime, implementing early morning exercise sessions Sophie referred to as “boot camps”.
When Mr Hill - horrified at the deterioration in standards -resigned from his position, Jhugroo insisted he leave almost immediately rather than carry out a month-long hand-over.
When Mr Lawrence departed from the care home, a freelancer art therapist was appointed by Jhugroo as the new clinical lead despite being “remarkably unqualified for the role”.
Other senior and experienced staff were sent for “training” to force them out of Lancaster Lodge, the court heard, with untrained workers –including an actor who was Jhugroo’s next door neighbour – hired in their place.
“They dispensed with the services of many experienced staff members, leaving the staff team with insufficient skills, experience, and knowledge to ensure the needs of residents would be met, and safe care could be provided”, said Mr Rush.
He said Sophie’s key worker warned, when she was removed from the home, about the possible impact on the teenager’s mental health.
The 19-year-old had complex mental health needs including paranoid delusions, low self-worth, and suicidal thoughts, but had been making progress at the clinic during 2015.
During the turmoil that followed, she was found with an array of sharp implements in her room including scissors and a razor and evidence of self-harm. But staff only assessed her risk level as three out of ten, and did not follow a recommendation for her to be taken to hospital.
“This should have given rise to very genuine and very serious concerns about the risk”, said Mr Rush.
On May 2 a support worker spoke to Sophie through the closed bathroom door – despite a care plan rule that doors were kept open at all times- as the teenager said she was having a bath. Later in the day, there was no response and the teenager was found to have taken her own life.
A jury inquest in February 2019 returned damning verdicts on the care home and its leadership, finding Sophie had died as a result of “neglect”.
A criminal prosecution then followed against Jhugroo and RPFI, who both entered guilty pleas to the charge of failing to provide care and treatment in safe way resulting in harm or loss.
Jhugroo was ordered to pay her fine and costs within the week from her savings, while RPFI, a charity still caring for vulnerable people, was given more than 18 months to settle its bill.