Alice Figueiredo: We stop our jobs, bought our dwelling twice and spent 10 years preventing the NHS

WARNING: This article incorporates upsetting particulars and reference to suicide

There did not appear to be something out of the abnormal when Jane Figueiredo spoke to her daughter that night time on the telephone.

“Alice asked me to bring her some snacks for the next time we visited,” Jane says. But that decision, at 22:15 on 6 July 2015, was the final dialog they ever had.

Around three hours later, Jane and her husband, Max, had been being pushed to hospital in a police automotive at velocity. They had been informed their daughter was gravely sick.

Alice had acquired right into a communal rest room at Goodmayes Hospital, in Ilford, east London, the place she was a psychological well being affected person, and took her personal life utilizing a bin liner. She was simply months away from her twenty third birthday.

On Monday, nearly 10 years later, the North East London NHS Foundation Trust (NELFT), which runs the hospital, and Benjamin Aninakwa, the supervisor of the ward Alice was on, have been discovered responsible of well being and security failings over her dying.

The jury determined not sufficient was completed by NELFT, or Aninakwa, to stop Alice from killing herself.

It’s taken a decade of battling by Alice’s dad and mom to uncover the reality about how the 22-year-old was in a position to take her personal life in a unit the place she was meant to be secure.

They twice needed to promote their dwelling, stop their jobs and have labored full-time on the case.

The jury deliberated for twenty-four days to succeed in all of the verdicts, after which period the Trust was cleared of the extra critical cost of company manslaughter, whereas Aninakwa, 53, of Grays, Essex, was cleared of gross negligence manslaughter.

During the seven-month trial, we sat a couple of seats away from the household. They’ve generally been overwhelmed, leaving the court docket indignant or in tears, as they felt their voices – and that of Alice – weren’t being heard.

Now, Jane hopes the verdicts will deliver main change to psychiatric care suppliers across the nation. “You need to do far, far better to stop failing those people who you have a duty of care to,” she mentioned after the decision.

Weeks earlier, in mid-March this yr, the Figueiredos had been residing in a lodge room in central London.

While folding their garments, they spoke to the BBC throughout a break within the trial, which was already operating months longer than anticipated.

They had been residing out of suitcases for the reason that finish of October, when court docket hearings started.

Even earlier than the ache of listening to proof about their daughter’s dying, they mentioned merely current like this had been an enormous problem.

For the couple, it was necessary to be on the Old Bailey each day in particular person – regardless of the fee – as a result of they felt this was their solely likelihood to see the Trust held to account for his or her daughter’s dying.

Alice was born in 1992, the second of three daughters. She was a vibrant and energetic baby, and infrequently the centre of consideration. She cherished music, poetry, studying and, particularly, artwork. Family and associates say she had an enormous persona.

“She had a really deeply thoughtful, sensitive, caring nature. She was really kind. She was really generous,” remembers Jane.

As a baby, Alice began to develop what turned an consuming dysfunction, and by 15 she was exhibiting signs of extreme melancholy and was admitted to a psychological well being unit.

In the next years she could be hospitalised on many extra events.

In 2012, then 19, she was admitted to the Hepworth Ward, at Goodmayes Hospital, for the primary time. It is an inpatient psychological well being unit for girls, run by NELFT. She was admitted there a complete of seven instances over the next 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,” provides Max, Alice’s stepfather.

Between admissions, Alice had lengthy durations when hospital remedy wasn’t wanted. She had been making use of to go to college and was planning a brighter future.

But on 13 February 2015, as her psychological well being took a critical flip for the more severe, Alice was admitted to the Hepworth Ward for what would show to be the ultimate time.

Three days later, Alice was detained on the unit underneath part three of the Mental Health Act to endure remedy for her personal security and couldn’t go away with out her marketing consultant’s permission.

Alice was placed on one of many highest commentary ranges, reserved for sufferers at most threat of harming themselves. It meant a member of employees needed to keep inside arm’s size of her 24-hours-a-day.

In a letter to employees simply 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 supervisor for Hepworth Ward on the time was Benjamin Aninakwa. The now 53-year-old had been engaged on the unit because it opened, in 2011. He was answerable for the unit throughout every of Alice’s earlier admissions, so knew her nicely.

But different issues on the ward had modified. The nurse and the marketing consultant, who had beforehand cared for Alice, had each moved on and there was a excessive stage of non permanent company employees filling long-standing gaps within the rota. Her dad and mom say Alice felt unsettled.

“I think it became clear that there was an element of chaos in the ward,” says Max.

Jane, who was a chaplain to the psychological well being belief, would go to Alice each day; Max, who labored for the NHS as an accountant, would cease by a couple of instances every week, typically with meals.

Alice informed her dad and mom that employees weren’t finishing up observations correctly. On one event, throughout the first fortnight of her admission, she mentioned an company well being care assistant who was imagined to be staying near her, was as a substitute making a telephone name.

The household later noticed an inside e mail saying Alice had been left alone whereas the care employee continued this dialog. In that point, Alice tried to hurt herself utilizing her bedding.

The similar e mail mentioned that after the care assistant returned and located Alice she slapped her. “Nothing was done about that. There was no safeguarding,” says Jane.

During the trial, the court docket heard that Alice had tried to hurt herself on no less than 39 events throughout her admission – many of those concerned plastic baggage or bin liners.

Even although they had been at midnight about many of those incidents, her dad and mom turned so involved they began elevating it with employees on the hospital, in particular person and in a number of emails.

On 16 May, three months into Alice’s keep, Jane emailed the marketing consultant for Hepworth Ward, Dr Anju Soni, about an incident of self-harm with a plastic bag by which Alice misplaced 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 wrote.

The court docket heard that many of those incidents weren’t recorded correctly by employees, nor communicated to the household.

After a number of months, Alice’s melancholy started to ease. In June, her commentary ranges had been lowered to mirror her progress, they usually had been ultimately decreased to hourly checks.

She was in a position to go away the unit for brief durations, even going to a Fleetwood Mac live performance along with her boyfriend Andrew.

But her consuming dysfunction remained a critical problem, and she or he was nonetheless underneath part. She requested to be moved to a specialist unit to assist her restoration.

On 30 June, Alice complained of chest ache and was transferred to close by King George Hospital. When she got here again to Hepworth Ward a few days later, the court docket heard she was informed she was too frail to go on deliberate go away.

Her household keep in mind intense fluctuations in her temper round this time. They say she was pissed off that her consuming dysfunction wasn’t enhancing, little progress was being made on her transferring to a different unit and she or he was getting bullied by different sufferers on the ward.

On 4 July, three days earlier than Alice died, Jane and Max went to go to her. The consuming dysfunction was taking its toll. They may see their daughter was struggling.

“She sat there almost in silence, tears were rolling down her face,” remembers Jane.

Late on the night time of 6 July, Alice and her boyfriend exchanged messages with one another, speaking about their love of Bob Dylan’s music. At 23:30 he wrote: “I can’t stop thinking about you, x.”

The court docket heard that round that point Alice had requested to talk to a care assistant she acquired on with.

The care assistant was known as away to an emergency elsewhere within the hospital. When she returned to Hepworth Ward she seemed for Alice. She ultimately discovered her slumped within the communal rest room.

Errors by two nurses on responsibility on Hepworth Ward slowed the arrival of an on-call physician and paramedics. Alice was ultimately taken to a different hospital the place 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 coping with the devastating shock of dropping their daughter, the Figueiredos set about piecing collectively what had occurred to her.

The Trust produced a Serious Incident (SI) report. These investigations are supposed to assist stop related incidents taking place.

But the Figueiredos felt it was incomplete and the Trust was avoiding accepting duty for Alice’s dying.

Whatever their issues, the report contained info that was new and troubling. It talked about 13 incidents by 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 says.

The household felt the chance of plastic baggage for sufferers on an acute psychological well being ward, notably Alice, ought to have been apparent.

During a earlier admission to Hepworth Ward the yr earlier than, Alice tried to hurt herself utilizing plastic baggage on no less than three events.

In November 2015, sensing there was extra to uncover, the couple holed themselves up in a lodge in Lindisfarne, off the Northumbria coast, and began piecing collectively their suspicions.

“We went very quickly into actually writing our own report and sending it to all the authorities that we knew of,” says Max.

They used their insiders’ data from working within the well being service, to get their report in entrance of senior NHS folks and regulators. They wrote to Sir Bernard Hogan-Howe, then head of London’s Metropolitan Police.

He wrote again and a police investigation into what occurred to Alice was launched. The Nursing and Midwifery Council launched inquiries into a number of of the nurses concerned in Alice’s care.

Even with the police concerned, the Figueiredos saved digging, getting maintain of as a lot documentation as they presumably may. When they weren’t in a position to get paperwork by official routes, they’d discover different methods to get them, working like seasoned investigators.

Once they’d them, they’d analyse them and produce detailed studies that they despatched 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 got here at a monetary price.

“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 Jane.

The emotional worth was even greater. “You can’t underestimate or even find the words to say, the toll that that takes on you. It’s profoundly re-traumatising,” she says.

There had been additional shocks to come back in Alice’s medical notes, which confirmed gaps within the hospital’s official SI report. They had been informed Alice had tried to self-harm with plastic baggage on 13 events, in truth it occurred no less than 18 instances.

Most of those incidents weren’t recorded in logs as they need to have been.

“It still shocks us to the core today,” says Max.

On the unit, plastic baggage weren’t used within the bins in affected person bedrooms for security causes, however they had been in a couple of communal places, together with a bathroom that was typically left unlocked. Alice used these baggage to self-harm on a number of events, together with the incident that led to her dying.

The trial heard there was little proof that ward supervisor Benjamin Aninakwa made any try to limit entry to these bin baggage, regardless of the difficulty being raised with him, and it showing in Alice’s care plan.

He didn’t seem as a witness in court docket however informed police the bathroom door was locked and he had been overruled when he tried to take away the bin baggage. The court docket heard there have been no emails or proof in Alice’s medical notes and data to corroborate this.

A Care Quality Commission inspection in April 2016, the yr after Alice’s dying, discovered bin baggage nonetheless getting used on the unit. The baggage had been ultimately eliminated.

The court docket heard that across the time Alice was admitted to the hospital for the ultimate time, the Trust was finishing up a “scoping exercise”, which checked out eradicating all plastic bin baggage from the hospital’s wards. It was revealed a bin which did not want a plastic liner had been thought of – it will have price simply £1.26.

“NELFT placed more value on their rubbish bins than they did on my daughter’s life,” says Jane.

In a press release, the Trust mentioned: “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 mirror on the decision and its implications, each for the belief and psychological well being provision extra broadly as we proceed to work to develop companies 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 deliver Alice again to us and we’ll by no means cease pondering of her and lacking her,” says Jane. “There’s all the time one place empty at our desk, one very particular voice silent that we lengthy to listen to in our conversations.”

If you might be struggling misery or despair, particulars of assist and help within the UK can be found at BBC Action Line.