Latest news with #NELFT
Sky News
2 days ago
- Health
- Sky News
Ex-classmates died after being treated at same mental health hospital - as concerns raised over other deaths
They were former classmates who both died after receiving care from the same mental health hospital three years apart. Warning: This article contains reference to suicide Multiple failings led to the death of 22-year-old Alice Figueiredo - who took her own life in July 2015 - and the NHS trust responsible for her care was charged with corporate manslaughter. Last week, following a months-long trial, the trust was found not guilty of that charge but was convicted of serious health and safety failings. Karis Braithwate, who had gone to school with Alice, also died in 2018, having been treated by the same NHS trust. Reports seen by Sky News detail a decade of deaths at North East London NHS Foundation Trust (NELFT), with coroners repeatedly raising concerns about the mental health services provided by the trust - in particular at Goodmayes Hospital in Ilford. Rushed assessments and neglect were often cited. One patient was marked as alive and well, even though he had taken his own life inside the hospital the previous day. Another patient told staff he was hearing voices telling him to kill himself, yet staff did not remove crucial items from his possession - items he would later use to take his own life. Karis, 24, was sent to Goodmayes Hospital after she tried to take her own life at a train station in October 2018. The next day, staff spent 27 minutes assessing her and a further two minutes confirming their conclusion. She was discharged from hospital in the afternoon. She then went to a nearby railway station and took her own life. Her death came less than an hour after she had left the hospital. Karis had been friends with Alice, her mother said. The pair had been classmates at the same school. Karis told her mother she was upset at being put on the same ward where Alice had taken her own life three years earlier. Her stepfather Mark Bambridge called Karis sweet and kind and said she often "struggled with life". He felt relief when she was taken to hospital, saying: "She was in a place where she would be taken care of." Karis's mother - who asked not to be named - said her daughter confided in her about the neglect she endured at the hospital. Karis told her mother that her carer would sleep when they were supposed to be watching over her and said she never felt safe. "She spoke of her belongings going missing, of being treated with indifference and disrespect, and of staff who showed little concern for her wellbeing," her mother said. Karis's mother said her daughter was failed by the hospital and the family was offered only a "hollow, superficial and indifferent 'apology' from the administration team of those who were meant to protect her". In the wake of the verdict in Alice's case, Karis's mother said: "I am holding Alice's family in my thoughts and praying they receive the justice they - and we - so clearly need and deserve." A spokesperson for NELFT called Karis's death a "profound tragedy" and said the trust had conducted an in-depth review of patient safety since 2018, "resulting in significant changes in the way we assess risk of suicide". "We train our staff to consider the trauma in a patient's history, rather than focusing solely on their current crisis," the spokesperson added. "This approach allows us to see the person behind the diagnosis, making it easier to identify warning signs and support safe recovery." The trust said it had also improved record-keeping and communication between emergency workers and mental health practitioners. The man marked as alive after he'd died Sky News looked at more than 20 prevention of future death reports, which are written by a coroner to draw attention to a matter in which they think action could be taken to prevent future deaths. Behind each report is a different person, but there are some strikingly similar themes - failure to carry out adequate risk assessments; issues sharing and recording information; neglect. One report said staff at Goodmayes Hospital "panicked and did not follow policy" in the wake of a man's death in 2021, instead writing that he was still alive when he had died the day before. Speaking in response at the time, the trust said it had written a "detailed action plan" to address concerns raised. Another report said one woman developed deep vein thrombosis after she was left to sit motionless in her room. She had not eaten or drunk anything in the two days before her death, and the trust was criticised for failing to record her food intake. Responding to the report at the time, the trust said it had implemented new policies to learn from her death. Issues stretched beyond Goodmayes Hospital and spanned the entire NHS trust. One man was not given any community support and overdosed after his access to medication was not limited. Another man, a father of three, was detained under the Mental Health Act but released from Goodmayes after just a few hours. The 39-year-old was found dead two weeks later after being reported missing by his family. At his inquest, a coroner raised concerns about the lack of a detailed assessment around him, with a junior doctor saying he was the only doctor available for 11 wards and 200 patients. 'Don't kill yourself on my shift' It has been 10 years since Alice took her own life inside the walls of Goodmayes Hospital. But current patients say the issues haven't gone away. Teresa Whitbread said her 18-year-old granddaughter Chantelle was a high suicide risk but she still managed to escape from the hospital "20 times". "I walked in one day and said, 'Where is Chantelle?', and no one could tell me," she told Sky News. On another occasion, Chantelle managed to get into the medical room and stabbed herself and a nurse with a needle. She said one nurse told her granddaughter: "Don't kill yourself on my shift. Wait until you go home and kill yourself." Teresa grew emotional as she talked about her granddaughter, once a vibrant young girl and avid boxer, whose treatment is now managed by community services. "It's made her worse," Teresa said of Chantelle's experience at Goodmayes Hospital. "There's no care, there's no care plan, there's no treatment." The NEFLT said it could not comment on specific cases but added that "patient safety is our absolute priority, and we work closely with our patients and their families to ensure we provide compassionate care tailored to their needs". Chantelle's family say she is a shell of her former self and have begged mental health services not send her back to Goodmayes. "Something has to change, and if it doesn't change, [the hospital] needs to be closed down," Teresa said. "Because people are not safe in there."
Sky News
2 days ago
- Health
- Sky News
Ex-classmates died after being treated at same mental health hospital - as concerns raised over more deaths
They were former classmates who both died after receiving care from the same mental health hospital three years apart. Warning: This article contains reference to suicide Multiple failings led to the death of 22-year-old Alice Figueiredo - who took her own life in July 2015 - and the NHS trust responsible for her care was charged with corporate manslaughter. Last week, following a months-long trial, the trust was found not guilty of that charge but was convicted of serious health and safety failings. Karis Braithwate, who had gone to school with Alice, also died in 2018, having been treated by the same NHS trust. Reports seen by Sky News detail a decade of deaths at North East London NHS Foundation Trust (NELFT), with coroners repeatedly raising concerns about the mental health services provided by the trust - in particular at Goodmayes Hospital in Ilford. Rushed assessments and neglect were often cited. One patient was marked as alive and well, even though he had taken his own life inside the hospital the previous day. Another patient told staff he was hearing voices telling him to kill himself, yet staff did not remove crucial items from his possession - items he would later use to take his own life. Karis, 24, was sent to Goodmayes Hospital after she tried to take her own life at a train station in October 2018. The next day, staff spent 27 minutes assessing her and a further two minutes confirming their conclusion. She was discharged from hospital in the afternoon. She then went to a nearby railway station and took her own life. Her death came less than an hour after she had left the hospital. Karis had been friends with Alice, her mother said. The pair had been classmates at the same school. Karis told her mother she was upset at being put on the same ward where Alice had taken her own life three years earlier. Her stepfather Mark Bambridge called Karis sweet and kind and said she often "struggled with life". He felt relief when she was taken to hospital, saying: "She was in a place where she would be taken care of." Karis's mother - who asked not to be named - said her daughter confided in her about the neglect she endured at the hospital. Karis told her mother that her carer would sleep when they were supposed to be watching over her and said she never felt safe. "She spoke of her belongings going missing, of being treated with indifference and disrespect, and of staff who showed little concern for her wellbeing," her mother said. Karis's mother said her daughter was failed by the hospital and the family was offered only a "hollow, superficial and indifferent 'apology' from the administration team of those who were meant to protect her". In the wake of the verdict in Alice's case, Karis's mother said: "I am holding Alice's family in my thoughts and praying they receive the justice they - and we - so clearly need and deserve." A spokesperson for NELFT called Karis's death a "profound tragedy" and said the trust had conducted an in-depth review of patient safety since 2018, "resulting in significant changes in the way we assess risk of suicide". "We train our staff to consider the trauma in a patient's history, rather than focusing solely on their current crisis," the spokesperson added. "This approach allows us to see the person behind the diagnosis, making it easier to identify warning signs and support safe recovery." The trust said it had also improved record-keeping and communication between emergency workers and mental health practitioners. The man marked as alive after he'd died Sky News looked at more than 20 prevention of future death reports, which are written by a coroner to draw attention to a matter in which they think action could be taken to prevent future deaths. Behind each report is a different person, but there are some strikingly similar themes - failure to carry out adequate risk assessments; issues sharing and recording information; neglect. One report said staff at Goodmayes Hospital "panicked and did not follow policy" in the wake of a man's death in 2021, instead writing that he was still alive when he had died the day before. Speaking in response at the time, the trust said it had written a "detailed action plan" to address concerns raised. Another report said one woman developed deep vein thrombosis after she was left to sit motionless in her room. She had not eaten or drunk anything in the two days before her death, and the trust was criticised for failing to record her food intake. Responding to the report at the time, the trust said it had implemented new policies to learn from her death. Issues stretched beyond Goodmayes Hospital and spanned the entire NHS trust. One man was not given any community support and overdosed after his access to medication was not limited. Another man, a father of three, was detained under the Mental Health Act but released from Goodmayes after just a few hours. The 39-year-old was found dead two weeks later after being reported missing by his family. At his inquest, a coroner raised concerns about the lack of a detailed assessment around him, with a junior doctor saying he was the only doctor available for 11 wards and 200 patients. 'Don't kill yourself on my shift' It has been 10 years since Alice took her own life inside the walls of Goodmayes Hospital. But current patients say the issues haven't gone away. Teresa Whitbread said her 18-year-old granddaughter Chantelle was a high suicide risk but she still managed to escape from the hospital "20 times". "I walked in one day and said, 'Where is Chantelle?', and no one could tell me," she told Sky News. On another occasion, Chantelle managed to get into the medical room and stabbed herself and a nurse with a needle. She said one nurse told her granddaughter: "Don't kill yourself on my shift. Wait until you go home and kill yourself." Teresa grew emotional as she talked about her granddaughter, once a vibrant young girl and avid boxer, whose treatment is now managed by community services. "It's made her worse," Teresa said of Chantelle's experience at Goodmayes Hospital. "There's no care, there's no care plan, there's no treatment." The NEFLT said it could not comment on specific cases but added that "patient safety is our absolute priority, and we work closely with our patients and their families to ensure we provide compassionate care tailored to their needs". Chantelle's family say she is a shell of her former self and have begged mental health services not send her back to Goodmayes. "Something has to change, and if it doesn't change, [the hospital] needs to be closed down," Teresa said. "Because people are not safe in there."
BBC News
4 days ago
- Health
- BBC News
Alice Figueiredo: NHS trust recorded patient ate breakfast three days after he died
An NHS mental health trust, recently found guilty of serious failings in the care of a young patient who took her own life, has had serious concerns raised over the deaths of 20 other patients over the last 10 years, the BBC has have repeatedly highlighted issues about the North East London NHS Foundation Trust (NELFT), including about the quality of risk assessments and two cases patient notes were found to have been falsified. Including one man who was recorded as eating breakfast three days after he had Old Bailey jury last week found the trust guilty of health and safety breaches in the care of 22-year-old Alice Figueiredo who was an inpatient at NELFT's Goodmayes hospital. This article contains distressing material related to suicide. Alice, who died in 2015, had attempted to harm herself on 18 occasions using plastic bags or bin liners, often taken from the same communal toilet. Despite this, the bags were not removed, and the toilet was left unlocked. On the 19th occasion Alice took her own trust was cleared of the more serious charge of corporate the trial, NELFT said it extended its "deepest sympathy for the pain and heartbreak" her family had suffered over the past 10 years, saying that it would "consider the verdict and its implications". It will be sentenced in BBC can now reveal in the decade since Alice's death, NELFT has been repeatedly criticised by coroners for failures in patient care. In the last decade, nearly 30 prevention of future deaths (PFD) reports from coroners have mentioned these, the BBC has analysed 20 which raise the most serious two cases where patients took their own lives inquests concluded records had been altered after their most common criticism found the assessment of the risk patients posed to themselves was poor or incomplete. Cases also highlighted poor record-keeping, a lack of communication between teams, staff shortages and high patients who died of overdoses were said to have been on short-term medication for 18 years and 20 years, with no record of that having been response, NELFT says it is continually improving "safety and treatment for patients, as well as the experience of families and carers". It also says it is improving record-keeping, tackling historical staff shortages and changing the way staff assess and manage risk, with all in-patient staff undergoing Charles, whose husband Winbourne's case is one of the most disturbing, said the Trust needed "to look at everything". Mr Charles was a patient at Goodmayes hospital nearly six years after Alice Figueiredo's describes him as "a beautiful man, a beautiful soul", but during the Covid-19 pandemic, the 58-year-old became increasingly in her kitchen, she is looking at videos and photos of Winbourne. His close childhood friend, Winston Andrews, is sitting alongside her as they laugh and smile at the memories."I had never known a part of my life when he wasn't in it," Winston says. "He was a brother rather than a friend."But at the end of 2020, Winbourne became so unwell he was admitted to Goodmayes says they all felt they had "tried everything", adding: "So maybe it is the right place for him to be, to try and get some help."On 10 April 2021, five months after being admitted to the hospital, Winbourne took his own life. For advice and support, visit BBC Action Line Carole and her children had spoken to him on a video call the day before. She describes her shock at the news, saying she was "absolutely devastated". She had thought "he was going in there to get better and come home".Only at his inquest did Winbourne's family and friends discover the failures in care which contributed to his death. The Prevention of Future Deaths report says a psychologist assessed Winbourne as being at high risk of harming himself. This was on his clinical record, but it was not read or discussed by the team of doctors and other clinicians overseeing his concluded there was "no risk" of him self-harming. The family says it meant the observations or checks on him made by staff were reduced from every 15 minutes to one an then, and against Trust policy, observations were stopped for all patients for an hour on the day he died. Between 16:00 and 17:00, the report says "all patients subject to general observation on the ward were ignored".Winbourne was discovered soon after 17:00, about two hours after he was last checked. Staff 'panicked' The report says "staff agreed they panicked". The alarm bell was not sounded and doctors were not called promptly. A ligature cutter was locked in a box and no one knew the combination to unlock it. It also says: "Staff could not or would not provide a clear and relevant history to paramedics."The report questions the credibility of the Trust staff who gave evidence to the inquest. It says observation records appeared to have been cut and pasted, including three entries that were made after he had died."They'd written observations of Winbourne being in the day room, sitting there eating his breakfast, and this was three days after he'd passed away," says Carole."Key to the observations is that you actually do the observations," says Winston. "You fill in the log. Clearly, they hadn't done it." Carole and Winston also say they were deeply shocked when one of the staff members who gave evidence by video link, tried to do this from his bed."He was actually in bed. My mouth dropped," says Winston. "In a microcosm that showed me what kind of care Winbourne was getting."A second staff member was on the tube heading to catch a flight. In both cases the family says the coroner, Graeme Irvine, intervened Irvine, senior coroner for east London, concluded Mr Charles had died from suicide, contributed to by neglect. He sent his PFD report to the trust and the Department of Health and Social Care to highlight what he had found. NELFT, which provides mental health services for nearly five million people living in north-east London, Essex, Medway and Kent and employs about 6,500 staff, said it "apologised unreservedly" for his added: "We accepted all the findings from the coroner in April 2023, as well as the unacceptable behaviour of staff at the inquest."Those staff were managed in line with human resources policies and disciplinary procedures, it said. The charity, Inquest, has provided support for many families around the country who believe their loved ones have been failed by the mental health system. In Ms Figueiredo's case, her family spent 10 years fighting to get director, Deborah Coles, said: "It should not be down to families to have to fight for cultural and policy change."She said she believed avoidable deaths were happening "far too often" and trusts should "move away from a culture of defensiveness and denial and cover-up" to one that is concerned about learning and improvement and protecting said she hoped plans for a new duty of candour, known as the Hillsborough Law, would change Charles, who has been a care worker for older and disabled people and says she knows what care is needed when people are vulnerable, remains sceptical about whether NELFT will learn from the deaths of patients like her husband and Alice Figueiredo."They keep saying they are going to change and they don't," she says. "These are people's lives which are taken. It leaves families devastated."
The Sun
10-06-2025
- Health
- The Sun
Our ‘kind and funny' Alice, 22, went into an NHS hospital to be kept safe – instead she came out dead
JANE Figueiredo's daughter Alice took her own life in an NHS hospital after more than 10 similar attempts at self-harm. The 22-year-old, who had been diagnosed with bipolar and an eating disorder, died while under care at the Hepworth Ward at Goodmayes Hospital in Redbridge. 3 3 The unit is run by the North East London NHS Foundation Trust (NELFT), which has only twice faced corporate manslaughter charges. Her family described the former head girl as having a "luminous, kind, thoughtful, generous, warm, humorous and deeply loving presence" and a bright future ahead of her. Despite her mental health challenges, Alice had periods where she lived a full, motivated and enthusiastic life in the community, they said. She was a member of the UK youth parliament, chair of the Havering Youth Council and worked with local police to improve relations between the youth community and police This week, following a seven-month trial at the Old Bailey, NELFT and a ward manager were found guilty of serious safety failings linked to her death. A jury concluded that not enough had been done to prevent Alice from taking her own life. Speaking outside court, her mother said: '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.' She added: '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.' Living with Bipolar Disorder The court heard NELFT repeatedly failed to remove plastic bin bags from toilets on the ward, despite Alice using them in at least ten previous self-harm attempts. Ward manager Benjamin Aninakwa, 53, was found guilty of failing to take reasonable care for the health and safety of patients. He was cleared of gross negligence manslaughter. NELFT was convicted of failing to ensure the safety of a non-employee, but found not guilty of corporate manslaughter. Alice 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 there, she used plastic bags from the same toilets to self-harm on at least ten occasions - but the court heard they were never properly removed or locked away. 3 The suicide attempts were recorded in ward notes and other hospital records. Between admissions, Alice had long periods when hospital treatment wasn't needed. She had been applying to go to university and was planning a brighter future, according to reports from the BBC. Alice was also admitted to the same ward in February 2015, where she was under close observation. Her death in July 2015 came after eight further incidents involving similar items. Benjamin, who was subject to a performance improvement plan, had failed to remove plastic bags that could be used for self-harm and failed to ensure incidents of self-harm were recorded, considered and addressed, jurors heard. 'Tragic series of inactions' Alice's stepfather Max Figueiredo said: 'We haven't got the highest charges, but we have moved the dial.' Detective Inspector Jonathan Potter, who led the Met Police investigation, said: '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.' Priya Singh, lawyer for more than 120 families affected by mental health failings in Essex, said: 'We are of the view that Jane should now be included in the Lampard Inquiry as a Core Participant, irrespective of the verdict.' The jury deliberated for more than 125 hours. Judge Richard Marks KC thanked them for their 'immense hard work' and excused them from further jury service for life.
BBC News
10-06-2025
- Health
- BBC News
Alice Figueiredo: We quit our jobs, sold our home twice and spent 10 years fighting the NHS
WARNING: This article contains upsetting details and reference to suicide There didn't seem to be anything out of the ordinary when Jane Figueiredo spoke to her daughter that night on the phone."Alice asked me to bring her some snacks for the next time we visited," Jane says. But that call, at 22:15 on 6 July 2015, was the last conversation they ever three hours later, Jane and her husband, Max, were being driven to hospital in a police car at speed. They had been told their daughter was gravely had got into a communal toilet at Goodmayes Hospital, in Ilford, east London, where she was a mental health patient, and took her own life using a bin liner. She was just months away from her 23rd Monday, almost 10 years later, the North East London NHS Foundation Trust (NELFT), which runs the hospital, and Benjamin Aninakwa, the manager of the ward Alice was on, have been found guilty of health and safety failings over her jury decided not enough was done by NELFT, or Aninakwa, to prevent Alice from killing herself. 'You are not above the law' It's taken a decade of battling by Alice's parents to uncover the truth about how the 22-year-old was able to take her own life in a unit where she was meant to be twice had to sell their home, quit their jobs and have worked full-time on the jury deliberated for 24 days to reach all the verdicts, after which time the Trust was cleared of the more serious charge of corporate manslaughter, while Aninakwa, 53, of Grays, Essex, was cleared of gross negligence the seven-month trial, we sat a few seats away from the family. They've sometimes been overwhelmed, leaving the court angry or in tears, as they felt their voices - and that of Alice - were not being Jane hopes the verdicts will bring major change to psychiatric care providers around the country. "You need to do far, far better to stop failing those people who you have a duty of care to," she said after the verdict. Weeks earlier, in mid-March this year, the Figueiredos were living in a hotel room in central folding their clothes, they spoke to the BBC during a break in the trial, which was already running months longer than had been living out of suitcases since the end of October, when court hearings before the pain of hearing evidence about their daughter's death, they said simply existing like this had been a huge challenge. For the couple, it was important to be at the Old Bailey every day in person - no matter the cost - because they felt this was their only chance to see the Trust held to account for their daughter's death. Sensitive and caring Alice was born in 1992, the second of three daughters. She was a bright and energetic child, and often the centre of attention. She loved music, poetry, reading and, in particular, art. Family and friends say she had a big personality."She had a really deeply thoughtful, sensitive, caring nature. She was really kind. She was really generous," remembers a child, Alice started to develop what became an eating disorder, and by 15 she was showing symptoms of severe depression and was admitted to a mental health the following years she would be hospitalised on many more 2012, then 19, she was admitted to the Hepworth Ward, at Goodmayes Hospital, for the first time. It is an inpatient mental health unit for women, run by NELFT. She was admitted there a total of seven times over the following three years."She needed safety. She was a risk to herself," says Jane. "It was a question of, somehow managing the crisis and trusting the medical profession to make the right decisions," adds Max, Alice's admissions, Alice had long periods when hospital treatment wasn't needed. She had been applying to go to university and was planning a brighter on 13 February 2015, as her mental health took a serious turn for the worse, Alice was admitted to the Hepworth Ward for what would prove to be the final days later, Alice was detained on the unit under section three of the Mental Health Act to undergo treatment for her own safety and could not leave without her consultant's was put on one of the highest observation levels, reserved for patients at most risk of harming themselves. It meant a member of staff had to stay within arm's length of her a letter to staff just over a month into her admission, Max and Jane wrote: "She cannot contain the sense of sheer torment, intense depression and overwhelming despair she is experiencing." The manager for Hepworth Ward at the time was Benjamin Aninakwa. The now 53-year-old had been working on the unit since it opened, in 2011. He was in charge of the unit during each of Alice's previous admissions, so knew her other things on the ward had changed. The nurse and the consultant, who had previously cared for Alice, had both moved on and there was a high level of temporary agency staff filling long-standing gaps in the rota. Her parents say Alice felt unsettled."I think it became clear that there was an element of chaos in the ward," says who was a chaplain to the mental health trust, would visit Alice every day; Max, who worked for the NHS as an accountant, would stop by a few times a week, often with told her parents that staff weren't carrying out observations properly. On one occasion, within the first fortnight of her admission, she said an agency health care assistant who was supposed to be staying close to her, was instead making a phone family later saw an internal email saying Alice had been left alone while the care worker continued this conversation. In that time, Alice attempted to harm herself using her same email said that once the care assistant returned and found Alice she slapped her. "Nothing was done about that. There was no safeguarding," says Jane. During the trial, the court heard that Alice had attempted to harm herself on at least 39 occasions during her admission - many of these involved plastic bags or bin though they were in the dark about many of these incidents, her parents became so concerned they started raising it with staff at the hospital, in person and in several 16 May, three months into Alice's stay, Jane emailed the consultant for Hepworth Ward, Dr Anju Soni, about an incident of self-harm with a plastic bag in which Alice lost consciousness."If it had been a few minutes longer before she was found, the outcome could have been very different - she could have died," she court heard that many of these incidents were not recorded properly by staff, nor communicated to the several months, Alice's depression began to ease. In June, her observation levels were lowered to reflect her progress, and they were eventually reduced to hourly was able to leave the unit for short periods, even going to a Fleetwood Mac concert with her boyfriend her eating disorder remained a serious challenge, and she was still under section. She asked to be moved to a specialist unit to help her recovery. On 30 June, Alice complained of chest pain and was transferred to nearby King George Hospital. When she came back to Hepworth Ward a couple of days later, the court heard she was told she was too frail to go on planned family remember intense fluctuations in her mood around this time. They say she was frustrated that her eating disorder wasn't improving, little progress was being made on her moving to another unit and she was getting bullied by other patients on the 4 July, three days before Alice died, Jane and Max went to visit her. The eating disorder was taking its toll. They could see their daughter was struggling."She sat there almost in silence, tears were rolling down her face," remembers on the night of 6 July, Alice and her boyfriend exchanged messages with each other, talking about their love of Bob Dylan's music. At 23:30 he wrote: "I can't stop thinking about you, x."The court heard that around that time Alice had asked to speak to a care assistant she got on care assistant was called away to an emergency elsewhere in the hospital. When she returned to Hepworth Ward she looked for Alice. She eventually found her slumped in the communal by two nurses on duty on Hepworth Ward slowed the arrival of an on-call doctor and paramedics. Alice was eventually taken to another hospital where she died."It's a moment where your entire life has changed and will never be the same. That's what we have had to learn to live with," says Jane. Still dealing with the devastating shock of losing their daughter, the Figueiredos set about piecing together what had happened to Trust produced a Serious Incident (SI) report. These investigations are meant to help prevent similar incidents the Figueiredos felt it was incomplete and the Trust was avoiding accepting responsibility for Alice's their concerns, the report contained information that was new and troubling. It mentioned 13 incidents in which Alice had used a plastic bag or bin bag to self-harm."I was shocked and horrified when I saw that," says Jane. "I thought, [the Trust] knew this had happened, and [they] still let her carry on doing this, and she died," she family felt the risk of plastic bags for patients on an acute mental health ward, particularly Alice, should have been a previous admission to Hepworth Ward the year before, Alice tried to harm herself using plastic bags on at least three occasions. In November 2015, sensing there was more to uncover, the couple holed themselves up in a hotel in Lindisfarne, off the Northumbria coast, and started piecing together their suspicions."We went very quickly into actually writing our own report and sending it to all the authorities that we knew of," says used their insiders' knowledge from working in the health service, to get their report in front of senior NHS people and regulators. They wrote to Sir Bernard Hogan-Howe, then head of London's Metropolitan wrote back and a police investigation into what happened to Alice was launched. The Nursing and Midwifery Council launched inquiries into several of the nurses involved in Alice's with the police involved, the Figueiredos kept digging, getting hold of as much documentation as they possibly could. When they weren't able to get documents through official routes, they'd find other ways to get them, working like seasoned they had them, they'd analyse them and produce detailed reports that they sent to the police and regulators."If I could discover something that would be helpful to their investigation. I would try to do that. We were a parallel investigation," says Jane. All this digging came at a financial cost."We were in our 50s, we both stopped working and actually sold our house and lived off that to be able to do this," says emotional price was even higher. "You can't underestimate or even find the words to say, the toll that that takes on you. It's profoundly re-traumatising," she were further shocks to come in Alice's medical notes, which showed gaps in the hospital's official SI report. They had been told Alice had attempted to self-harm with plastic bags on 13 occasions, in fact it happened at least 18 of these incidents weren't recorded in logs as they should have been."It still shocks us to the core today," says the unit, plastic bags were not used in the bins in patient bedrooms for safety reasons, but they were in a few communal locations, including a toilet that was often left unlocked. Alice used these bags to self-harm on multiple occasions, including the incident that led to her trial heard there was little evidence that ward manager Benjamin Aninakwa made any attempt to restrict access to those bin bags, despite the issue being raised with him, and it appearing in Alice's care did not appear as a witness in court but told police the toilet door was locked and he had been overruled when he tried to remove the bin bags. The court heard there were no emails or evidence in Alice's clinical notes and records to corroborate this.A Care Quality Commission inspection in April 2016, the year after Alice's death, found bin bags still being used on the unit. The bags were eventually court heard that around the time Alice was admitted to the hospital for the final time, the Trust was carrying out a "scoping exercise", which looked at removing all plastic bin bags from the hospital's wards. It was revealed a bin which didn't need a plastic liner had been considered – it would have cost just £1.26."NELFT placed more value on their rubbish bins than they did on my daughter's life," says a statement, the Trust said: "Our thoughts are with Alice's family and loved ones, who lost her at such a young age. We extend our deepest sympathy for the pain and heartbreak they have suffered this past 10 years."We will reflect on the verdict and its implications, both for the trust and mental health provision more broadly as we continue to work to develop services for the communities we serve."Jane and Max Figueiredo say they wanted to hold those at the Trust to account, but that they also wanted change for the future. But there will be no celebration at Monday's verdicts."Nothing will ever bring Alice back to us and we will never stop thinking of her and missing her," says Jane. "There's always one place empty at our table, one very special voice silent that we long to hear in our conversations." If you are suffering distress or despair, details of help and support in the UK are available at BBC Action Line.
