Hospital failings continued after Alice Figueiredo death, leaked documents show

Tragic Death and Immediate Context

In July 2015, Alice Figueiredo took her own life at Goodmayes Hospital on the Hepworth ward. The hospital was managed by North East London Mental Health Trust (NELFT). She had previously attempted self-harm using plastic or bin bags on 18 separate occasions. Most of these incidents involved items taken from the same shared toilet on the ward. On the 19th attempt, she succeeded in ending her life.

Just four months later, in November 2015, another young woman on the same Hepworth ward attempted self-harm using a bin bag. She survived the incident. This event raised serious questions about whether lessons had been learned following the earlier tragedy. Leaked documents from an internal NELFT inquiry, seen by the BBC, revealed these concerning similarities.

The internal inquiry was commissioned after complaints from Alice's parents regarding the care provided. The resulting report was never made public. However, it highlighted patterns that pointed to ongoing issues. These included failures in basic safety measures. Such lapses contributed to repeated instances of medical negligence on the ward.

Evidence of Under-Reporting and Missed Opportunities

The leaked report pointed to significant under-reporting of incidents. During Alice Figueiredo's time on the ward, 81 incidents or near misses should have been logged on the NHS Datix system. Only 14 of them, or about 17.2%, were actually recorded. This poor recording meant important risks were not properly identified or addressed. Opportunities to manage patients more safely were therefore missed.

In the November 2015 case involving the other young woman, similar problems existed. Of 45 self-harm events linked to her, 27 were not logged on the system. This included the bin bag attempt itself. The lack of proper documentation again prevented timely interventions. These patterns demonstrated a systemic failure that amounted to medical negligence in patient risk management.

The inquiry report described a ward environment with very unwell patients. There were ongoing staff shortages, particularly among nurses. Relationships between key staff members, including the ward manager and consultant psychiatrist, were strained. All support workers assigned to observe Alice one-to-one were temporary agency staff. These factors compounded the risks present.

Continued Risks and Family Distress

Alice's mother, Jane Figueiredo, described the November incident as deeply distressing. She noted that bin bags should have been removed immediately after her daughter's death. Instead, patients continued to face unnecessary risks. The persistence of such hazards four months later highlighted a failure to act decisively. This ongoing exposure reflected broader issues of medical negligence within the service.

Mental health campaigners expressed alarm at the revelations. They emphasized the need for a culture of openness to learn from serious incidents. Without rapid changes, the same dangers could repeat. The leaked documents underscored that improvements had been too slow or incomplete.

NELFT has since stated that all bin bags have been removed from wards. This aligns with national guidance. The trust also committed to learning from every incident and improving care continuously. It has worked to enhance record-keeping and case management processes.