Mental Health System in Crisis

A System in Crisis: How Repeated Failings in Mental Health Care Led to a Preventable Death

A landmark court case has exposed a litany of failings at a mental health provider in London, culminating in the tragic and preventable death of a young woman. The conviction of the North East London NHS Foundation Trust (NELFT) and a former ward manager for serious health and safety breaches has cast a harsh spotlight on the systemic issues plaguing mental health services across the country. Leaked documents and testimonies from former staff and patients paint a harrowing account of a system buckling under pressure, with catastrophic consequences for its most vulnerable patients. The case of Alice Figueiredo, a bright and gifted 22-year-old, is not an isolated incident but a stark symptom of a national crisis defined by chronic understaffing, inadequate risk management, and a dangerous inability to absorb lessons from past errors.

A History of Ignored Warnings  

Alice Figueiredo received care at Goodmayes Hospital, an institution managed by NELFT, when she died by suicide during July 2015. Her death was not a sudden, unforeseen tragedy. In the months leading up to the fatal incident, Alice made 18 separate efforts to self-injure with plastic garbage bags, most of which she obtained from a single communal restroom on the Hepworth Ward. Each attempt was a desperate cry for help, a red flag that the environment meant to keep her safe was, in fact, providing the means for her self-destruction. The trust and Benjamin Aninakwa, the ward manager, were repeatedly alerted to this specific, recurring risk. Yet, the plastic bags, a known ligature risk, remained accessible. The failure to act on these clear and persistent warnings ultimately led to Alice's death on her 19th attempt.

A Cycle of Repeated Errors

A strikingly similar episode occurred not long after. On the very same Hepworth ward during November 2015, another young woman tried to inflict self-injury with a garbage bag; that individual, fortunately, did not die. This event exposed a shocking inability or unwillingness by NELFT to act on its fatal mistakes. This repetition of events suggests a deep-rooted systemic failure, not just an isolated error in judgment. Advocates in the mental health field contend that this pattern highlights a dangerous culture where patient safety is not paramount and where tragedies do not trigger the urgent, comprehensive changes needed to prevent them from happening again. The trust’s failure to remove a simple, known hazard after a patient's death speaks to a profound breakdown in basic safety protocols and risk management.

The Verdict: Accountability Delivered

After a lengthy and complex seven-month trial at the Old Bailey, a jury delivered a historic verdict. While NELFT was cleared of corporate manslaughter and Benjamin Aninakwa was found not guilty of manslaughter by gross negligence, both were found guilty of significant breaches of health and safety protocol. The trust was convicted of failing to ensure the safety of its patients, and Aninakwa was found guilty of breaching his duty to provide adequate care for the wellbeing and security of individuals. The convictions, reached after a record-breaking 24 days of jury deliberation, send a powerful message to every provider of mental healthcare: they are not above the law. The court held that the trust and its manager had a fundamental duty of care, which they breached with devastating consequences.

A Family's Decade-Long Fight for Justice

For Alice’s parents, Jane and Max Figueiredo, the verdicts marked the culmination of a decade-long battle for accountability. They relentlessly pursued justice for their daughter, driven by the belief that her death was not inevitable but the result of institutional negligence. Speaking outside the court, Jane Figueiredo expressed hope that the convictions would serve as a wake-up call to mental health services nationwide, compelling them to prioritise patient safety. Their journey highlights the immense struggle families face when seeking answers and accountability from large healthcare organisations. Their perseverance brought to light not only the specific failings in Alice’s care but also the broader systemic issues that put countless other vulnerable patients at risk.

Understaffing: The Crisis Behind the Crisis

A critical factor contributing to the failures at the Goodmayes facility involved critical and persistent staff shortages. Leaked internal reports and testimony from former staff reveal a ward stretched to its breaking point. The reliance on temporary or agency staff was particularly concerning; the entirety of the support staff tasked with Alice’s one-to-one observations were from agencies. This high turnover of personnel makes it incredibly difficult to maintain continuity of care, build therapeutic relationships, and ensure that all staff are familiar with individual patient risks and care plans. The Care Quality Commission (CQC) has repeatedly warned that workforce shortages throughout the mental health division of the NHS are a major challenge, impacting patient safety and the ability of staff to provide adequate therapeutic interventions.

The Perils of Inadequate Record-Keeping

The investigation into Alice’s death uncovered a catastrophic failure in record-keeping. The trust used a risk monitoring platform known as Datix to log incidents and identify recurring conduct. However, an inside investigation discovered that a staggering 83% of incidents and near misses concerning Alice at Hepworth ward were never entered into the database. Of 81 reportable events, only 14 were recorded. This systematic under-reporting meant that senior managers and clinicians were deprived of the crucial information needed to assess the true level of risk Alice faced. The failure to document her repeated attempts to use bin liners as ligatures made the risk monitoring platform essentially non-functional, obscuring the clear pattern of danger that should have prompted immediate intervention.

A Culture of Blame and Fear

Beyond the practical issues of staffing and record-keeping lies a more insidious problem: a toxic organisational culture. A report by the Health Services Safety Investigations Body (HSSIB) highlighted a prevalent environment of fear and finger-pointing within many mental health services. This atmosphere discourages staff from speaking up about safety concerns for fear of reprisal, and it treats patient safety investigations as punitive exercises rather than opportunities for learning. Former NELFT staff have spoken of a challenging and menacing environment where their concerns about patient safety were not acknowledged by management. This kind of culture stifles transparency and accountability, creating the conditions for repeated failures to occur. Without psychological safety for staff, genuine improvement in patient care is impossible.

National Implications of a Local Tragedy

The failings at NELFT are not unique. Across England, mental health services are described as being at a “breaking point.” Charities like Mind and Rethink Mental Illness have called for a full public inquiry into systemic failings in inpatient care, citing widespread issues of understaffing, crumbling facilities, and violations of patients' human rights. The BMA has labelled the system for mental health as "non-functional" and "broken," with soaring demand far outstripping the capacity of a depleted workforce. Leaked NHS figures revealed that over 15,000 patients died while receiving support from community-based mental health services in a single year, highlighting the scale of the crisis beyond hospital walls.

The CQC's Role and Ratings

The Care Quality Commission, the independent regulator of health and social care in England, has a crucial role in monitoring the safety and quality of services provided by trusts like NELFT. Despite the horrific events surrounding Alice’s death and other patient safety incidents, the CQC upgraded NELFT’s overall rating from “Requires Improvement” in 2019 to “Good” in 2022. This decision was met with shock and dismay by families of patients who had suffered due to the trust’s failings. While the CQC noted improvements in some areas, the upgrade raises serious questions about the effectiveness of the inspection and rating system, and whether it can truly capture the reality of care on the ground.

A System Overwhelmed by Demand

The NHS mental health workforce has seen some growth in recent years, but it has been completely dwarfed by an explosion in demand for services. Between 2016 and 2022, referrals to mental health services increased by 44%, while the workforce grew by only 22%. This growing chasm between need and capacity means longer waiting lists, more pressure on existing staff, and an increased risk of patients falling through the cracks. Trust leaders across the country have expressed grave concerns about their ability to meet the demand, with many services facing vacancy rates of 20% or more. This immense pressure inevitably leads to compromises in care and an increased risk of safety incidents.

The Link Between Staff Wellbeing and Patient Safety

The intense pressure on NHS staff has led to a vicious cycle of burnout and turnover. A report from the Public Accounts Committee highlighted that increased workload is a major contributor to poor staff morale, which in turn leads to higher turnover and exacerbates staff shortages. The percentage of NHS staff leaving their roles due to work-life balance issues has more than tripled in a decade. This is not just a human resources issue; it is a critical patient safety issue. A burnt-out, overstretched, and demoralised workforce cannot be expected to provide the secure, kind, and watchful support that vulnerable patients require.

Failures in Risk Assessment and Management

A recurring theme in the NELFT case and other mental health tragedies is the failure of risk assessment and management. In Alice's case, the risk was clear, present, and repeatedly demonstrated. The failure was in the management of that risk. Former NELFT staff have described how risk assessment records were frequently completed with inaccuracies or left outdated. One support worker recalled an individual who was designated as low risk but was later discovered to have been involved in a serious incident involving assault with a weapon. This demonstrates a dangerous disconnect between the documented risk and the reality of a patient's situation, a gap that can have fatal consequences.

The Illusion of Learning Lessons

NHS trusts frequently state their commitment to "learning lessons" after a serious incident. However, the events at NELFT and elsewhere suggest that this is often a hollow promise. The recurrence of the identical safety breach not long after Alice’s death is a stark indictment of the trust’s learning processes. The HSSIB report found that investigations into patient deaths are often of variable quality and fail to lead to meaningful, system-wide change. Families describe the process as a "tick box exercise" that lacks transparency and accountability. For lessons to be truly learned, there must be a fundamental shift away from an environment of finger-pointing toward one of authentic investigation and a commitment to implementing and sustaining change.

The Broader Social Context

The crisis in mental healthcare does not exist in a vacuum. It is a reflection of broader societal issues, including rising rates of mental illness, particularly among young people, and years of underfunding for mental health services compared to physical health. Psychiatrists have pointed out that society is making people mentally unwell, yet the systems in place are unable to respond adequately. The COVID-19 pandemic has only exacerbated these pre-existing pressures, leading to a further surge in demand for services. Addressing the crisis in mental healthcare requires not only investment in the NHS but also a broader societal commitment to prevention and early intervention.

Calls for Legislative Reform

In response to the growing crisis, there are increasing calls for revisions to the Mental Health Act. The current legislation, which dates back to 1983, is widely seen as outdated and failing to protect patients' rights. Proposed reforms aim to give patients a greater say in their care and treatment, end the inappropriate use of police cells for people in crisis, and address the disproportionate detention of people from Black and minority ethnic backgrounds. While legislative reform is a crucial step, campaigners stress that it must be accompanied by the investment in services and staff needed to make the principles of the new law a reality.

The Way Forward: A Call to Action

The conviction of NELFT and Benjamin Aninakwa is a vital moment of accountability, but it cannot be the end of the story. Alice Figueiredo’s death must be a catalyst for fundamental change. This requires a multi-faceted approach. The government must prioritise mental health, providing the sustained funding needed to build a workforce fit for the 21st century. NHS trusts must cultivate an environment of security, openness, and perpetual improvement, where staff are empowered to raise concerns and mistakes are treated as opportunities for learning. Regulators like the CQC must have the teeth to hold failing organisations to account.

A Mother’s Plea for a Better Future

Jane Figueiredo’s decade-long fight was for her daughter, but her message is for all of us. She calls for a system that delivers secure, kind, and meticulous support to the most susceptible individuals in our community. Her plea is for urgent action, not only within NELFT, but across all facilities, wards, and services for mental health nationwide. The memory of Alice Figueiredo must inspire a collective determination to construct a mental health service which does not let down the people it should safeguard. It is a system where a simple plastic bag is never again allowed to become a fatal weapon, and where every patient is given the chance to live a full and hopeful life.

The Unseen Costs of Negligence

The human cost of the failings that led to Alice’s death is immeasurable. A family was robbed of a beloved daughter, sister, and friend. A young individual with promising prospects was deprived of her future. But there are also significant financial costs associated with such negligence. Between 2019 and 2024, NELFT paid out over £1.3 million in mental health negligence claims. This is money that could have been invested in frontline services, in recruiting more staff, or in improving patient safety. It is a stark reminder that the failure to invest in safe, high-quality care is not only a moral failing but also a false economy.

A Continuing Struggle for Safety

The legal proceedings may be over, but the fight for safer mental health services continues. Charities, campaigners, and bereaved families remain at the forefront of this struggle, pushing for the reforms and investment needed to prevent future tragedies. They advocate for a system that listens to patients and their families, that values its staff, and that is genuinely dedicated to improvement and absorbing lessons. The case of Alice Figueiredo has shown that accountability is possible, but it has also exposed the profound depth of the crisis in mental healthcare. The challenge now is to translate that accountability into meaningful, lasting change, to ensure that no other family has to endure the same heartbreaking and preventable loss.