Justice for Alice After NHS Trust Found Guilty

A Family's Ten-Year Fight for Justice After NHS Failings Led to Daughter's Death 

A decade-long battle for truth culminated in a landmark verdict that held an NHS trust and a ward manager criminally liable for safety failings. The case exposed a series of devastating shortcomings in the care of a vulnerable young woman. Jane and Max Figueiredo embarked on a relentless quest for accountability after their daughter, Alice, died by suicide inside a psychiatric facility that was supposed to ensure her safety. Their fight forced them to leave their careers, on two occasions, sell the family home, and dedicate their lives to uncovering the circumstances that culminated in the tragedy. This is a story of profound loss, parental determination, and a damning indictment of systemic failures in mental healthcare. 

A Final, Deceptive Call 

On the evening of July 6, 2015, a phone conversation took place that felt entirely routine. Alice was receiving care at Goodmayes Hospital in east London's Ilford area, when she spoke with her mother, Jane Figueiredo. Alice asked her mother to bring some snacks on her next visit, a simple request that gave no hint of the impending tragedy. That conversation, at 10:15 pm, became their final communication. Roughly three hours passed before Jane and her husband, Max, were transported at speed by a police car to a hospital. Authorities had informed them their daughter's condition was critical. 

The Unthinkable News 

Once there, their worst fears were confirmed. Alice, an intelligent and beloved young woman who was nearly twenty-three, had ended her life. She had gone into a shared lavatory on a psychiatric care unit known as the Hepworth Ward, using a plastic bin liner to die by suicide. The facility intended to be her safe haven had become the scene of her final moments. The news shattered the lives of her parents, setting them on a painful and arduous path toward understanding how such a catastrophic failure could have occurred. 

A Life of Luminous Presence 

Alice was born in 1992 and was the middle of the couple's three daughters. Friends and family remember a person with a huge personality, someone who was frequently the focus of everyone. A vibrant and lively young person, she possessed a deep love for music, poetry, and reading, with a special fondness for art. Her mother, Jane, described her as having a profoundly considerate, compassionate, and kind disposition. Alice was also incredibly generous. Her stepfather, Max, recounted her numerous achievements, which included serving as head girl at her school, being a representative in the UK's Youth Parliament, and training as a junior chef. Her life was full of promise and engagement. 

The Onset of a Cruel Illness 

During her childhood, Alice developed what later became a severe eating disorder. By the time she was 15, the symptoms of deep depression became apparent, leading to her first admission into a psychiatric unit. The subsequent years were marked by numerous hospital stays as she and her family battled her illness. Despite these challenges, there were extended times when she lived a full life outside of hospital care. She was making university applications and looking toward a more promising future. Her family sought professional help in times of crisis, placing faith in the healthcare system to deliver the protection she required. 

The Hepworth Ward: A Place of Last Resort 

In 2012, at the age of 19, Alice entered the Hepworth Ward inside Goodmayes Hospital for her initial stay. The inpatient unit is operated by an organization called the North East London NHS Foundation Trust, also known as NELFT. It would become a familiar but ultimately fatal setting for her. She had admissions to the facility seven times in total over the next three years. Her family saw each admission as a vital step to navigate the immediate danger and protect her. They trusted the medical professionals to make appropriate decisions for their vulnerable daughter, a trust that would later be completely shattered. 

The Final Admission and Escalating Risk 

Her mental state deteriorated significantly, and on February 13, 2015, Alice entered the Hepworth Ward on what would be her final admission. Three days after, her condition was deemed so serious that authorities detained her using a measure from section three of the Mental Health Act, a measure taken as a measure to keep her safe. This meant she was unable to depart without her doctor's consent. She was placed on the highest level of observation, requiring a staff member to be within arm's reach of her at all hours. Her parents communicated her intense torment and despair to the staff, desperate for them to understand the gravity of her state. 

A Ward in Chaos 

Benjamin Aninakwa was managing the Hepworth Ward during that period and had been employed at the facility since its 2011 opening, so he knew Alice from her previous admissions. However, the ward environment had deteriorated. The consultant and nurse who had formerly been responsible for Alice's care were no longer at the ward. The unit relied heavily on personnel from temporary agencies to fill long-standing rota gaps, creating what her parents described as a chaotic and unsettling atmosphere. Alice reported feeling the instability, a sentiment that foreshadowed the inadequate supervision that would follow. Her parents noticed a sense of disarray within the unit. 

Early Warnings Dismissed 

As a chaplain serving the psychiatric trust, Jane visited Alice daily, while Max, an NHS accountant, visited several times each week. Early in her stay, Alice reported one incident where a temporary healthcare assistant whose duty was providing close supervision, was occupied with a personal call. A subsequent internal message verified that Alice was left by herself and had tried to injure herself with her own bedding. That same communication noted the aide struck Alice upon finding her. Jane noted no protective measures were implemented in response. 

A Pattern of Self-Harm Ignored 

The trial revealed that Alice had made at least 39 attempts to injure herself during her final admission. A significant number of these attempts involved plastic bags and liners from bins, the exact items that caused her death. Despite not knowing the full extent of these events, her parents grew increasingly alarmed. They began raising their concerns with hospital staff, both face-to-face and via multiple emails. Their pleas for greater vigilance seemed to fall on deaf ears, with tragic consequences. 

A Mother's Desperate Plea 

Three months after her admission, on May 16, Jane sent an electronic message to the ward's consultant, Dr Anju Soni, about a particularly frightening incident. Alice used a plastic bag in a self-harm attempt and lost consciousness. In her message, Jane warned that had Alice been discovered a few moments later, the result might have been tragically different, potentially fatal. It later emerged in court that staff failed to document numerous events correctly, and they did not inform the family about them either. This lack of documentation and response to a clear risk pattern was a key element in the legal case against both the trust and its manager. 

A Fleeting Period of Improvement 

For a time, Alice's depressive symptoms started to lift. During June, her progress was reflected in a decrease in her monitoring level, which was ultimately reduced to checks every hour. She received permission for brief leaves from the unit. She even attended a concert by Fleetwood Mac alongside Andrew, who was her boyfriend. This glimmer of hope suggested a path toward recovery was possible. However, her struggle with an eating disorder remained a major obstacle, and her detention according to the Mental Health Act continued. 

Frustration and Renewed Despair 

Alice had requested a transfer to a specialized facility to help with the eating disorder she was battling, but progress was slow. Her family recalled her mood shifting intensely during this period. Alice grew aggravated by her lack of progress, and she was being bullied by others in the unit. When her parents visited on July 4, only three days prior to when she passed away, they found her struggling visibly. The consequences of the eating disorder were severe. Jane recalled Alice sitting mostly quiet as tears streamed down her cheeks, a heartbreaking image of her daughter's silent suffering. 

The Final Hours and Fatal Errors 

On the evening of July 6, she exchanged messages with her boyfriend about their mutual love for the music of Bob Dylan. At about the same time, she requested to see a care assistant with whom she felt comfortable with. Tragically, that assistant was summoned to an urgent situation on another floor. When the care assistant returned to the Hepworth Ward and began to search for Alice, she discovered her unconscious in a shared toilet. It emerged in court that errors from two on-duty nurses delayed the response from an on-call doctor and paramedics. Eventually, Alice was transported to a different medical facility, where her life ended. 

A Flawed Investigation Begins 

In the aftermath of their daughter's loss, the Figueiredos received what is known as a Serious Incident (SI) report from the Trust. The purpose of these investigations is to help stop similar events from reoccurring. However, the family believed it lacked thoroughness and that it seemed the Trust was sidestepping its culpability. The document revealed troubling new details, detailing 13 occurrences of Alice using a plastic bag for self-harm. Jane was horrified, realising the Trust knew of this particular danger but did nothing to stop it, which ultimately resulted in her death. From the family's perspective, the danger ought to have been self-evident. 

From Grieving Parents to Determined Investigators 

Convinced that the story was incomplete, the couple went to a hotel during November 2015, where they began to compile their own investigation. Leveraging their professional experience from working within the healthcare system, they ensured their document reached high-level NHS officials and regulatory bodies. A letter was sent to Sir Bernard Hogan-Howe, the Metropolitan Police chief who was then in charge. He responded, and a formal police inquiry was initiated. In parallel, an organization called the Nursing and Midwifery Council started its own inquiries into some of the nursing staff responsible for Alice's care. The Figueiredos, however, continued their own work. 

The Staggering Personal Cost 

This decade-long pursuit of justice came at an immense personal price. The couple, then in their fifties, both gave up their jobs. They sold their home on two occasions to finance their work on their investigation. The financial strain was enormous, but the emotional cost was far steeper. Jane described the process as "profoundly re-traumatising," forcing them to relive the details of their daughter's suffering over and over again. Their sacrifice was a testament to their love for Alice and their unwavering commitment to ensuring such a tragedy would not befall another family. 

Uncovering the Full, Shocking Truth 

Further examination of Alice's medical records revealed shocking omissions from the hospital's formal report. The family had been informed of 13 instances of self-harm involving plastic bags; in reality, there were 18 or more. The majority of these events were not properly documented. Within the unit, using plastic bags was not permitted in bins within patient bedrooms due to safety concerns. However, they were still used in some communal spaces, one of which was a toilet which was regularly left open. These were the bags Alice utilized on numerous occasions, including in the fatal incident. This discovery pointed to a systemic and shocking level of negligence. 

The £1.26 Decision That Cost a Life 

The trial brought to light a particularly damning piece of evidence. At about the same time as Alice's last admission, the Trust had been undertaking a 'scoping exercise' to review the removal of every plastic bin liner from its wards. The review revealed that a bin requiring no liner was under consideration. The cost of this potentially life-saving item was a mere £1.26. In a powerful statement, Jane asserted that NELFT cared more for its waste bins than it did her daughter's existence. This detail encapsulated the devastating consequences of the Trust's inaction. 

A Historic Verdict Reached 

After a gruelling seven-month trial, a jury at the Old Bailey, the central criminal court, reached its verdicts. Following 24 days of deliberation—a joint record in English legal history—the jury found both NELFT and Benjamin Aninakwa guilty of breaching health and safety regulations. The Trust, however, was acquitted of the graver charge of corporate manslaughter. Aninakwa was also found not guilty of manslaughter by gross negligence. For the family, who had sat through months of painful testimony, the verdicts were a partial victory, a confirmation that not enough had been done to prevent Alice's death. 

Accountability, Fines and Systemic Failings 

In the wake of the verdict, the sentencing brought a measure of legal accountability. The health authority, the North East London NHS Foundation Trust, was ordered to pay a fine of £333,000 for its failings. Benjamin Aninakwa received a four-month suspended prison sentence. For Alice's family and campaigners, the case highlighted profound systemic issues within UK mental healthcare. The charity INQUEST, which supported the family, described Alice's death as the result of repeated failings and a culture of neglect and complacency at the management level that continues to endanger lives. This was a death, they noted, that was forewarned by her own mother. 

A System Under Unprecedented Strain 

The failings in Alice's care do not exist in a vacuum. Recent reports reveal a psychiatric care system in turmoil. In 2023, NHS mental health services received a record 5 million referrals, an 11% increase from the previous year. This surge in demand has put immense pressure on services already struggling with workforce shortages and a reduction in available hospital beds. A 2025 report from the Health Services Safety Investigations Body highlighted a persistent culture of fear and blame, alongside a failure to involve patients and families, which obstructs learning from inpatient deaths. 

A Call for Radical Change 

Following the verdict, the Figueiredos clarified their objective was not revenge, but meaningful reform. Jane sent a strong message to mental health providers, stating that they are not beyond the law and have to do much better. Max called for legal reforms to close loopholes that make it difficult to prosecute healthcare institutions. He challenged the narrative that such deaths are unavoidable, maintaining that NELFT was grossly negligent. Their public statements were a powerful call to action, demanding that lessons finally be learned to prevent future tragedies. 

An Empty Seat at the Table 

For the Figueiredo family, Monday's verdicts are not a cause for celebration. The legal victory cannot bring back their daughter. Jane spoke of the immeasurable loss of Alice's "luminous, kind, thoughtful, generous, warm, humorous and deeply loving presence." A special voice is now silent, and there is forever one empty place at their family table. Their decade-long struggle was a final act of love for Alice, a fight to ensure her memory would serve as a catalyst for meaningful change, so that no other family has to endure such a heartbreaking and preventable loss.