Did Hospital Failures Persist After Alice Figueiredo's Death?

The tragic case of Alice Figueiredo highlights serious failings in mental health care, particularly within the North East London Mental Health Trust (NELFT). Just four months after Alice's death in a London mental health unit, another patient attempted self-harm in eerily similar circumstances, raising concerns about systemic issues in care and crisis management. The leaked documents reveal ongoing risks and inadequate responses, suggesting a culture that has failed to learn from past tragedies.

Last updated: 01 October 2023 (BST)

What’s happening now

The ongoing fallout from Alice Figueiredo's death continues to reverberate within NELFT, as further reports of self-harm incidents emerge. The revelation that another young woman attempted to harm herself using a bin bag just months after Alice's tragic suicide underscores a worrying pattern of negligence and a failure to implement necessary changes to patient safety protocols. NELFT is currently facing scrutiny over its management practices and care standards, with former staff and mental health advocates calling for urgent reforms.

Key takeaways

• Alice Figueiredo died in a mental health unit in July 2015, with systemic failings reported by NELFT.
• Four months later, another patient on the same ward attempted self-harm, indicating a lack of learning from past incidents.
• Concerns have been raised about record-keeping, staffing issues, and risk assessments within the trust.

Timeline: how we got here

The situation surrounding Alice Figueiredo and subsequent events at NELFT can be mapped through the following key milestones:

• July 2015: Alice Figueiredo takes her life while a patient at Goodmayes Hospital.
• November 2015: Another patient attempts self-harm using a bin bag on Hepworth ward.
• 2023: NELFT faces scrutiny for failing to learn from past incidents, highlighted by leaked internal reports.

What’s new vs what’s known

New today/this week

Recent internal documents leaked to the BBC reveal alarming patterns of under-reporting incidents of self-harm within the NELFT's mental health services. Despite a reported commitment to improve safety protocols, the documents suggest that little has changed since Alice's death, with ongoing risks to patients' safety.

What was already established

It has been well-documented that Alice Figueiredo's death raised significant questions regarding the adequacy of care provided by NELFT. Previous reports have highlighted systemic failures in risk management, record-keeping, and staff oversight, contributing to a culture of neglect and insufficient patient support.

Impact for the UK

Consumers and households

The revelations about NELFT's handling of mental health care have broader implications for consumers, particularly families with loved ones in mental health services. There is growing concern about the safety and quality of care provided, which may lead families to seek alternatives or advocate for systemic change in mental health services across the UK.

Businesses and jobs

For businesses operating within the mental health sector, these incidents reflect the need for stringent oversight and quality assurance measures. Staff shortages and inadequate training are issues that not only affect patient care but can also impact employee morale and retention, leading to potential job instability.

Policy and regulation

The ongoing scrutiny of NELFT may prompt governmental reviews of mental health policies and regulations in the UK. There is a pressing need for reform in the way mental health services are managed, with calls for more rigorous accountability and transparency in patient care practices.

Numbers that matter

• 81 incidents or near misses recorded while Alice was on the ward, but only 14 (17.2%) were logged on the risk management system.
• Of 45 self-harm events involving the second patient, 27 incidents were not recorded, including the attempt to use a bin bag.
• 100% of support workers observing Alice were temporary staff, highlighting staffing issues at the facility.

Definitions and jargon buster

• Datix: An NHS risk management system used to log incidents and identify patterns in patient care.
• NELFT: North East London Mental Health Trust, responsible for providing mental health services in the region.

How to think about the next steps

Near term (0–4 weeks)

Immediate actions are anticipated from NELFT, including a review of current patient safety protocols and staff training. Families affected by Alice's case may begin to see changes in how their loved ones are cared for if the trust takes the findings seriously.

Medium term (1–6 months)

In the coming months, NELFT may be compelled to implement new policies aimed at improving patient safety and care standards. Continued pressure from advocacy groups could result in more substantial reforms across mental health services in the UK.

Signals to watch

• Updates from NELFT regarding changes in management and staff training.
• Reports from independent reviews commissioned to assess mental health care standards within NELFT.
• Public responses from mental health advocacy groups regarding the effectiveness of measures taken by NELFT.

Practical guidance

Do

• Stay informed about the care provided to loved ones in mental health facilities.
• Advocate for transparency and accountability in mental health services.
• Engage with mental health advocacy groups for support and information.

Don’t

• Ignore signs of distress in patients; report any concerns to management.
• Assume that all necessary precautions are being taken within mental health services.

Checklist

• Review safety protocols at local mental health facilities.
• Understand the rights of patients within the mental health system.
• Reach out to mental health professionals for advice on care options.

Risks, caveats, and uncertainties

While the internal reports from NELFT provide critical insight into the failings of its mental health services, there remains uncertainty about the extent of the changes that will be implemented. The culture of accountability within the trust is questioned, and without rigorous oversight, there is a risk that similar incidents might recur. The ongoing appeal by Benjamin Aninakwa also raises questions about the legal responsibilities of staff in maintaining patient safety.

Bottom line

The tragic circumstances surrounding Alice Figueiredo's death and the subsequent incidents at NELFT highlight critical gaps in mental health care that must be urgently addressed. The call for reform is louder than ever, and the expectation for safe, compassionate care is a fundamental right for all patients. The commitment to learn from these tragedies is essential for preventing future loss of life in mental health settings.

FAQs

What happened to Alice Figueiredo?

Alice Figueiredo tragically died by suicide in July 2015 while under the care of Goodmayes Hospital, highlighting serious failures in her mental health care.

What were the findings regarding NELFT?

Reports indicate that NELFT failed to adequately manage risks, with significant under-recording of self-harm incidents and poor staff oversight.

How can families advocate for better mental health care?

Families can advocate for better care by staying informed, reporting concerns, and engaging with mental health advocacy groups for support and guidance.