Mother of woman who died after NHS failings fears more people will come to harm

The mother of a young woman who died after health and safety failings by an NHS trust has said people will “continue to come to serious, avoidable harm” if “radical changes” are not made.

Jane Figueiredo’s daughter Alice, 22, took her own life in a mental health unit after more than 10 similar attempts at self-harm.

On Monday, ward manager Benjamin Aninakwa, 53, of Grays in Essex, was found guilty at the Old Bailey of failing to take reasonable care for the health and safety of patients on the ward Ms Figueiredo was on.

Jurors last Wednesday found that North East London NHS Foundation Trust (NELFT), the trust which runs the hospital where Ms Figueiredo was a patient, was guilty of “failing to ensure the safety of a non-employee”, it can now be reported.

NELFT was cleared of corporate manslaughter, and Aninakwa was found not guilty of manslaughter by gross negligence.

Speaking to reporters outside the Old Bailey after the verdicts, Ms Figueiredo’s mother said: “We truly hope the fact NELFT (North East London NHS Foundation Trust) has been through a trial of over seven months and convicted of a serious health and safety criminal offence at the Old Bailey will send a very strong message to mental health providers and their staff across this country: You are not unassailable.

“You are not above the law. You need to do far, far better to stop failing those people you have a duty of care to.

“If you don’t make radical changes in your conduct and attitudes towards the people you have a responsibility to care for and keep safe, then people like Alice will continue to come to serious, avoidable harm, or senselessly lose their lives.

“This is happening with impunity, time and again, behind the locked doors of wards and in the community across the country.”

If you don’t make radical changes in your conduct and attitudes towards the people you have a responsibility to care for and keep safe, then people like Alice will continue to come to serious, avoidable harm, or senselessly lose their lives

Ms Figueiredo died at Goodmayes Hospital, Redbridge, on July 7 2015, after a failure to remove plastic items from the communal toilets in the Hepworth Ward that had been used in repeated earlier attempts at self-harm.

She was first admitted to the Hepworth Ward in May 2012 with a diagnosis including non-specific eating disorder and bipolar affective disorder, jurors heard.

During her time on the acute psychiatric ward, the trust failed to remove plastic items from the communal toilets or keep them locked, even though she repeatedly used the items to try to kill herself.

She had used plastic from the toilets to self-harm on at least 10 previous occasions.

However, the court heard of eight more incidents involving similar materials before Ms Figueiredo took her own life.

The suicide attempts were recorded in ward notes and other hospital records.

Aninakwa, who was subject to a performance improvement plan, had failed to remove plastic that could be used for self-harm and failed to ensure incidents of self-harm were recorded, considered and addressed, jurors heard.

Aninakwa and the trust had denied wrongdoing but declined to give evidence.

Ms Figueiredo’s mother began to cry as she paid tribute to her daughter after the trial, saying: “Alice’s light and life shone so brightly, and everyone who knew and loved her has lived the last decade devastated by the immeasurable loss of her luminous, kind, thoughtful, generous, warm, humorous and deeply loving presence, always feeling her absence at every occasion and in our everyday lives, nothing, including these verdicts, will ever bring her back to us, and we will never stop thinking of her and missing her.”

Alice Figueiredo’s stepfather said his stepdaughter’s case has “moved the dial”, in what was only the second time an NHS trust has faced a corporate manslaughter charge.

“We haven’t got the highest charges, but we have moved the dial,” Max Figueiredo said to reporters outside the Old Bailey.

“Whilst disappointed that we have not reached the higher charges of corporate and gross negligence manslaughter in this case, we are glad that we did get the health and safety guilty verdicts.”

The investigation into Ms Figueiredo’s death began in 2016 but charges were not brought until September 2023.

The first corporate manslaughter trial against an NHS trust collapsed in 2016 after a judge ruled there was no case to answer.

Detective Inspector Jonathan Potter, who led the investigation into Ms Figueiredo’s case, said: “My thoughts remain with Alice’s family. They have had to endure years of heartbreak before sitting through a long and difficult trial where they heard time and time again about the tragic series of inactions that led to their daughter’s death.

“This was a complex investigation led by the Metropolitan Police Service, into a unique case that has led to the conviction of the Trust and Benjamin Aninakwa for health and safety offences.

“There is nothing I can say that will bring back Alice, but I hope that today’s verdict offers some comfort to her family.

“While there are thousands of NHS workers that do a commendable job every day, today’s result must also ensure that lessons are learnt to stop the same mistakes happening again.”

Priya Singh, partner at Hodge Jones and Allen which represents more than 120 families at the Lampard Inquiry, which is examining deaths of more than 2,000 people at NHS-run inpatient units in Essex between 2000 and 2023, said: “Given the fact that the state of the mental health services is such that it led to this trial in the first instance, we are of the view that Jane should now be included in the Lampard Inquiry as a Core Participant, irrespective of the verdict. Jane had previously been refused Core Participant status.

“The outcome of the trial will be of disappointment to many families failed by mental health services and we can only hope that this trial will lead to a great deal of reflection on the part of those involved to ensure that cases like this do not reappear.”

The jury in Ms Figueiredo’s case deliberated for 125 hours and 22 minutes to reach its verdicts.

Judge Richard Marks KC thanked the jurors for their “immense hard work” and discharged them from jury service for the rest of their lives.