Patient Safety Failure at Hospital

A Systemic Failure: The Preventable Death on a London Mental Health Ward

A court has imposed a financial penalty of more than half a million pounds on a hospital trust for failing a vulnerable patient. In a related ruling, a ward manager faces a six-month jail term, which has been suspended, following the passing of 22-year-old Alice Figueiredo. She died by suicide at the Ilford-based Goodmayes Hospital, an institution operated by the North-East London Foundation NHS Trust (NELFT). The court determined that systemic failures and individual negligence directly led to the preventable tragedy that unfolded on 7 July 2015. This case has cast a harsh spotlight on the state of inpatient mental healthcare and the accountability of those entrusted with the safety of vulnerable individuals.

A Life Full of Promise

Those who knew Alice Figueiredo described her as having a singularly gorgeous, courageous, loving, charitable, gentle, vibrant, imaginative, and bright personality. Previously a head girl at her school, she was deeply involved in her community, serving as a member of the UK Youth Parliament and chairing the Havering Youth Council. Her passions were diverse and dynamic; she loved the arts, music, literature, and acting. Alice was also a powerful voice for the mental health community, drawing on her own experiences to fight for better care and understanding. Despite her struggles with bipolar disorder and an eating disorder, she had periods of living a full and enthusiastic life, demonstrating a resilience that made her subsequent passing all the more devastating for those who knew her.

Admission to a Place of Supposed Safety

In February 2015, Alice became an inpatient at the Hepworth Ward inside Goodmayes Hospital and was sectioned under the Mental Health Act. This was not her first admission; she had previously been treated on the same unit in 2012. Her history of self-harm was thoroughly documented. During her five-month stay in 2015, the severity of her condition became alarmingly clear. She made at least 18 attempts to harm herself using plastic bin liners and bags she found within the unit. Despite this clear and escalating pattern of behaviour, the very items she used to inflict harm remained accessible in a shared lavatory, a fact that would prove to be a catastrophic oversight.

A Family’s Ignored Pleas

Alice's family repeatedly voiced their grave concerns to the hospital staff about the dangers. Jane Figueiredo, Alice's mother and a former hospital chaplain for the same trust, personally warned the unit on multiple occasions that her daughter's life was at risk. The family felt their valid fears were treated with disdainful disregard, condescension, and downplaying. These alerts, which the presiding judge later noted should have triggered serious alarms, were not acted upon. The persistent availability of plastic bags, coupled with what the family described as a mindset characterized by a lack of concern, understanding, and on some occasions, harshness from some staff, created an environment they would later call a "death trap."

A Catalogue of Systemic Failings

The subsequent trial at the Old Bailey, which lasted seven months, exposed a litany of failings at both the trust and unit level. The prosecution detailed how NELFT, as an organisation, lacked a robust system to manage the known danger. It was revealed in court that high-level managers, including the director of nursing and the associate medical director, should have ensured the removal of hazardous items like bin liners. The trust's own internal reporting systems were found to be insufficient. There was a failure to properly complete and analyse incident reports, meaning that the pattern of Alice's self-harm attempts was not appropriately escalated or handled at a senior level.

The Role of the Ward Manager

At the unit level, the responsibility fell heavily on the ward's manager, Benjamin Aninakwa. A court determined he had neglected to provide adequate concern for the welfare and protection of individuals in his care. Jurors were told that Mr. Aninakwa was aware Alice was suicidal; indeed, she was the only patient within the unit with that specific designation. Despite this knowledge and the repeated incidents, he did not take away the plastic bags available in the shared lavatory or ensure the area was kept secured. Furthermore, there were significant failings in record-keeping, with numerous self-harm incidents not being properly documented, considered, or addressed. This poor leadership was compounded by the fact Mr. Aninakwa himself had been subject to a performance improvement plan for three years prior to the incident.

The Long Road to Justice

A formal inquiry into Alice's passing started in 2016, though legal action did not commence until September of 2023, a delay of nearly eight years that prolonged the family’s suffering. The trial itself was a historic and arduous process. The jury deliberated for a record 24 days, highlighting the complexity of the case. Ultimately, although the trust was found not guilty of the weightier accusation of corporate manslaughter and Mr. Aninakwa was similarly acquitted of manslaughter due to gross negligence, both were convicted of significant health and safety breaches. This marked only the second time an NHS trust had faced a corporate manslaughter charge, underscoring the gravity of the management failures identified.

A Judge’s Scathing Verdict

In his sentencing remarks, Judge Richard Marks KC delivered a powerful condemnation of the failures that led to Alice’s passing. He remembered Alice as a radiant and lively young individual, calling her death a dreadful catastrophe. The judge was unequivocal in his criticism, stating there was a total inability to properly evaluate and handle the danger posed by the plastic bags. He noted that simply locking the public toilet would have been an "inconvenience," not an insurmountable problem. Addressing Mr. Aninakwa directly, the judge conveyed that while he may feel sorrow over Alice's death, he lacks genuine comprehension of his own wrongdoing.

The Human Cost of Negligence

In a statement detailing the impact on her as a victim, Jane Figueiredo provided a harrowing account of the family’s immeasurable loss. She spoke of her daughter’s spirit being crushed by a "litany of failures." The impact was profound and multifaceted; Mrs Figueiredo lost her job as a chaplain with NELFT, a role she loved but could never return to. She communicated to the court that the effect of her daughter's preventable and premature passing on every single facet of her own life, and on their existence as a family, was beyond measure. Her statement was a powerful testament to the ripple effect of such tragedies, where the initial loss is compounded by years of seeking truth and accountability.

The Trust’s Response and Financial Penalty

After the court's judgment, a fine of £565,000 was imposed on NELFT, which was also directed to cover legal expenses of £200,000. The trust's chief executive, Paul Calaminus, issued an apology, stating they were "deeply sorry" for Alice's death and the family's suffering for nearly ten years. He also confirmed that extensive efforts were underway to enhance the quality of patient support since 2015. However, he cautioned that the substantial fine could impact services, a sentiment echoed by the judge who acknowledged the trust's finances were in an "absolutely parlous state." This raises difficult questions about the efficacy of fining already-strained public services.

A Broken System? Mental Healthcare in Crisis

Alice Figueiredo's case is not an isolated incident but rather a symptom of a wider crisis in UK mental healthcare. Reports from organisations like the British Medical Association and the charity Mind paint a bleak picture of a system at breaking point. Decades of underfunding have led to chronic staffing shortages, inadequate facilities, and a workforce that feels unable to provide the level of care patients need. Doctors and mental health professionals report being overwhelmed, with high vacancy rates and a lack of resources creating a culture where patient safety is compromised. This environment can lead to the very failings seen in Alice's case: poor risk assessment, inadequate communication, and a failure to learn from mistakes.

The Challenge of Corporate Accountability

Holding large, complex organisations like NHS trusts criminally accountable for systemic failures is notoriously difficult. The Corporate Manslaughter and Corporate Homicide Act 2007 was introduced to make it easier to prosecute organisations for gross failings by senior management. However, prosecutions against NHS trusts remain rare. The case against NELFT was only the second of its kind. Although the trust was not convicted of corporate manslaughter, the guilty verdict for health and safety breaches still delivers a strong signal about organisational responsibility for patient safety.

The Pivotal Role of Ward Leadership

Benjamin Aninakwa's conviction as the ward's manager highlights the critical importance of leadership on the front line of patient care. A person in that role is responsible for creating a safe, therapeutic environment, promoting evidence-based practice, and supporting staff. This involves not just managerial tasks but active clinical leadership. When this leadership fails, as occurred at the Hepworth Ward, the results can be deadly. The court found that Mr. Aninakwa’s failure to act on known risks, to ensure proper recording of incidents, and to respond to the family's desperate warnings constituted a negligent breach of his duty of care.

Patient Safety and a Culture of Blame

A recurring theme in inquiries into healthcare failings is the presence of a "culture of blame." A 2022 Care Quality Commission (CQC) report on NELFT noted that the trust had made significant progress in moving away from such a culture, making it easier for staff to raise concerns. This is a crucial step, as a truly safe environment is one where learning from incidents is prioritised over apportioning blame. The fine imposed on NELFT, while holding the organisation accountable, also raises the question of whether financial penalties, which can deplete resources for patient care, are the most effective way to drive improvement.

The Impact of Financial Penalties on the NHS

Fining an NHS trust hundreds of thousands of pounds inevitably diverts money away from patient services. This has been a point of contention for years, with bodies like NHS Providers arguing that such fines are counterproductive. They can push trusts further into deficit and hinder their ability to invest in the staff and infrastructure needed to improve care. While accountability is essential, the mechanism for achieving it must be carefully considered to avoid punishing the very patients the system is supposed to serve. The judge in Alice's case was clearly aware of this dilemma, noting the trust's precarious financial state.

The Importance of Listening to Families

One of the most tragic elements of this case is the repeated dismissal of the Figueiredo family's concerns. These were not merely family members; they were advocates who saw the danger clearly and tried to intervene. Their experience underscores a fundamental principle of patient-centred care: families are often the most important allies in ensuring a patient's safety. The failure to listen to them was a failure to see the person at the heart of the crisis. The forceful statement from Jane Figueiredo, asserting that mindsets of that nature contradict the core principles of patient support within our national health service, ought to act as a significant caution for all healthcare professionals.

A Call for Fundamental Change

In comments made after the judgment outside the central criminal court, Jane Figueiredo called for urgent change to prevent more tragedies. She spoke of the unseen and unheard people behind the locked doors of mental health wards, whose voices are too easily dismissed. The case of her daughter, Alice, is a brutal illustration of what happens when systems fail and warnings are ignored. It highlights a desperate need for increased funding, better staffing, and a cultural shift within mental health services towards genuine partnership with patients and their families.

Learning from Tragedy

Alice Figueiredo's death was a preventable catastrophe that exposed deep-seated problems in the provision of mental healthcare. The legal proceedings have provided a measure of accountability, but true justice would be the implementation of lasting changes that ensure no other family has to endure a similar loss. The case demonstrates that patient safety is not merely about protocols and procedures on paper; it is about creating a culture of vigilance, compassion, and responsiveness that is robust enough to protect the most vulnerable.

The Future of Inpatient Care

The Health Services Safety Investigations Body (HSSIB) has found that mental health hospitals can be "re-traumatising" for patients, with widespread failures across areas like workforce and the physical environment. To prevent future deaths like Alice’s, there must be a move away from purely reactive, risk-averse models of care towards more proactive, therapeutic, and trauma-informed approaches. This requires investment in staff training, the creation of safer ward environments, and empowering leaders at all levels to prioritise patient safety above all else.

A Legacy of Advocacy

In life, Alice Figueiredo acted as an advocate for the mental health community, and her tragic passing has amplified that role. Her family's relentless pursuit of justice has ensured that the failings in her care were not swept under the carpet. They have shone a light into the darkest corners of a struggling system, demanding accountability and change. The hope is that Alice's legacy will be a catalyst for a re-evaluation of how society cares for its most vulnerable citizens, ensuring that the promise of a safe haven for those in crisis becomes a reality.