Just months after the tragic death of 22-year-old Alice Figueiredo in a London mental health unit, a disturbing pattern of patient safety failures emerged, as revealed by leaked documents reviewed by the BBC. Alice, who was a patient at Goodmayes Hospital under the care of North East London NHS Foundation Trust (NELFT), had a documented history of self-harm involving plastic bags taken from a communal toilet on Hepworth ward. Despite repeated incidents, 18 prior attempts to harm herself using plastic bags, the risk was not adequately addressed, leading to her fatal attempt in July 2015. Alarmingly, only four months later, another young woman on the same ward attempted self-harm using a plastic bag, echoing the circumstances that led to Alice’s death, though she survived. This recurrence has been highlighted by mental health campaigners as a serious failure to learn from a preventable tragedy.
The leaked internal inquiry report, which has not been made public, details significant under-reporting of self-harm incidents by hospital staff. During Alice's stay, only 17.2% of the 81 qualifying incidents were officially logged using the NHS's Datix risk management system. Similarly, in the November case involving the second patient, over half of the 45 self-harm events were not recorded, including the key incident involving the plastic bag. This lack of documentation hindered the ward’s ability to identify risks and effectively safeguard patients. The report also sheds light on systemic issues within Hepworth ward, including severe nursing staff shortages, a dysfunctional relationship between ward management and consultant psychiatrists, and the reliance on temporary staff for critical one-to-one observations, further compromising patient care.
NELFT has since removed all plastic bags from wards in accordance with national guidance and has pledged improvements in record-keeping and case management. Yet questions remain about the adequacy and timeliness of those responses. The trust and former ward manager Benjamin Aninakwa are facing sentencing following an Old Bailey jury’s conclusion that they failed to ensure Alice’s safety. Although the trust was acquitted of corporate manslaughter, it was found guilty of failing to safeguard a non-employee, and Aninakwa was acquitted of gross negligence manslaughter but convicted of failing to take reasonable care for patients' health and safety. These legal outcomes underscore the grave breaches in duty of care and organisational oversight contributing to Alice’s death.
Eyewitness accounts from former patients reinforce the picture of a ward struggling under pressure. One patient, speaking under the pseudonym “Jenny,” recalled the insufficient supervision by staff and the falsification of observation records, which are critical for monitoring patients’ mental states. Jenny described an intimidating ward atmosphere and recounted how Alice’s supportive presence provided some relief amidst the challenges they faced. These personal testimonies add to a broader narrative of systemic neglect; over the past decade, coroners and former staff have consistently flagged issues such as poor management, inadequate risk assessments, insufficient staffing, and poor communication within NELFT’s hospital and community mental health services.
Former senior support worker Mark New corroborated these concerns, noting that crucial medical and care reviews were often neglected, resulting in prolonged periods where some patients’ conditions deteriorated untreated. He described how patient risk statuses were frequently misrepresented, sometimes failing to highlight serious incidents, potentially endangering both patients and staff. NELFT acknowledged workforce pressures within the NHS had historically impacted care quality but emphasised ongoing substantial investments in recruiting and retaining staff as part of efforts to improve service delivery.
Mental health advocates, including Brian Dow of the charity Rethink, have called for urgent systemic reforms to prevent vulnerable individuals from escalating into crisis unnecessarily. The case of Alice Figueiredo has become emblematic of wider issues across mental health services in England, where safe, compassionate, and diligent care remains an unmet expectation for many patients. Alice’s mother, Jane Figueiredo, has campaigned persistently for justice and transparency, urging immediate action not just within NELFT, but across all mental health hospitals and services nationally. The trust, while expressing sorrow for Alice’s death, asserts its commitment to ensuring her memory drives positive change and the ongoing delivery of safer patient care.
As the legal proceedings continue, with Benjamin Aninakwa appealing his conviction related to the failure to ensure health and safety, the case remains a stark reminder of the critical need for vigilance, accountability, and reform within mental health care settings.
📌 Reference Map:
- [1] (BBC) - Paragraphs 1, 3, 4, 5, 6, 7, 8, 9
- [2] (The Independent) - Paragraphs 2, 3
- [3] (The Independent) - Paragraph 3
- [4] (The Independent) - Paragraph 3
- [5] (The Independent) - Paragraph 3
Source: Noah Wire Services