12 hours agoShareSaveAlison Holt,social affairs editor and James Melley,senior producerShareSaveFamily handoutWarning: This article contains upsetting details and references to serious self-harm and deathJust four months after a young woman died in a London mental health unit, another patient tried to harm herself in startlingly similar circumstances, leaked documents seen by the BBC show.Alice Figueiredo, a patient at Goodmayes Hospital, which is run by North East London Mental Health Trust (NELFT), attempted to harm herself using plastic or bin bags on 18 occasions, mostly taking them from the same shared toilet. On the 19th occasion, in July 2015, she managed to take her own life.Just four months later, in November 2015, another young woman also on Hepworth ward attempted to harm herself using a bin bag. She survived.Mental health campaigners say it suggests a worrying failure to learn from tragedies.”It’s shocking and distressing that this was still going on four months after Alice died,” says Jane Figueiredo, Alice’s mother. “The bin bags could and should definitely have been removed, but instead patients continued to be put at unnecessary risk.”NELFT says all bin bags have been removed and “it is committed to learning from every incident and continuously improving” the care it provides.NELFT and former ward manager Benjamin Aninakwa are due to be sentenced this week after an Old Bailey jury concluded they had not done enough to keep 22-year-old Alice Figueiredo safe.The BBC has spoken to former NELFT patients, families and ex-staff who have experience of the trust’s community and hospital services over the 10 years since Alice’s death.They raise concerns about poor management, record-keeping, risk assessments and staff shortages stretching over that decade.An email, which gives details of the November 2015 incident, was submitted to an internal inquiry commissioned by the trust after Alice’s parents complained about the care she had received. The inquiry’s report, which has been seen by the BBC, has never been made public.”The similarities between this young woman and [Alice Figueiredo] are startling in terms of presentation, age range, background,” the email said.It goes on to say while it appears there has been “some learning” since Alice’s death, there was “significant evidence” that not all incidents were being properly reported.The hospital used an NHS risk management system called Datix where incidents should be logged on the system to help identify risks and patterns of behaviour.The report says during the time Alice was on the ward there were 81 incidents or near misses that met the criteria for being reported via Datix, but just 14 (17.2%) were logged on the system.In the November case, there was also significant under-reporting. The report suggests that of 45 self-harm events involving the unidentified young woman, 27 do not appear on the risk management system, including the attempt to harm herself using a bin bag.The general lack of recording on the ward meant “opportunities to safely manage patients were missed”, the inquiry found.NELFT says it has removed plastic bags from wards in line with national guidance, and improved record-keeping and case management.Overall, the internal report paints a picture of a ward where there were very sick patients, staff shortages – particularly of nurses – and a poor relationship between ward manager Benjamin Aninakwa and the consultant psychiatrist.The report also says 100% of the support workers assigned to observe Alice one to one were temporary staff.Brian Dow, from the mental health charity Rethink, says the document shows the unit did not act quickly enough after Alice’s death to protect other patients.”Lessons should be learned, and you should not expect to see a repetition of the same risks and the same dangers just weeks afterwards,” he said.”You need to have a culture of openness and transparency so that you can learn from the mistakes.”Family handout”Jenny”, not her real name, was a patient on Hepworth ward at the same time as Alice. They became close friends. She says rather than an open and transparent culture on the ward, the atmosphere felt difficult and intimidating to her.She shared the statement she had made to police investigating Alice’s death with the BBC. In it she remembers how Alice helped her cope.”She used to wake me up every morning on Hepworth ward with a big hug,” she says.She describes how staff meant to be looking after them were often not doing the necessary checks or observations.”On countless occasions I witnessed Alice asking to speak to members of staff who were supposed to be doing observations on her but were instead busy on their phones,” she wrote.She also told police that observation records detailing what patients had been doing, which are important in giving clinicians a sense of how that person is coping, were often falsified.Jenny left Goodmayes Hospital before Alice died. She is now living in her own home with support in the community, although she still misses her friend.The BBC has previously highlighted repeated criticisms of the trust by coroners, with the most recent concer …
