A charity operating a psychiatric facility where a teenager was found hanged when it launched a programme of fitness and wellbeing is being investigated by the Charity Commission.
Sophie Bennett, 19, took her life in Lancaster Lodge in Richmond, west London, in May 2016, just over a year after she was admitted.
She told her mother before her death it was being run like a “boot camp” with strict rules and mandatory exercise with reduced levels of psychotherapy.
The Richmond Psychosocial Foundation International (RPFI), the charity in control of the home, is now the subject of a statutory inquiry by the Charity Commission after an inquest found its leadership and oversight was “grossly inadequate”.
During the inquest, West London Coroner’s Court heard controversial figure Elly Jansen had been acting as a consultant to the charity’s board and allegedly pressured experience figures to resign.
It emerged that Ms Jansen was forced to step away from her own psychiatric charity in the 1980s due to allegations of financial mismanagement and misappropriated funds.
Ben Bennett, Ms Bennett’s father, also raised concerns about Elly Jansen, and described Ms Jansen as possessing an “extraordinary approach to management”, which was “like something out of the 19th century”.
Lawyers for the Bennett family alleged that Ms Jansen was effectively the “shadow director” of RPFI and “the controlling mind”, making decisions on staffing and management at Lancaster Lodge.
The inquiry will look at trustees’ compliance with their responsibilities under charity law, such as their oversight and governance of safeguarding arrangements.
It will also look at the trustees’ response to Ms Bennett’s death and the changes that need to be made as a result.
Shortly before Ms Bennett died, the Care Quality Commission criticised the facility as inadequate in a number of areas – a rapid decline, as it had been rated good just six months earlier.
The home had seen a number of staff changes and was in the hands of interim manager Duncan Lawrence after the previous manager Vincent Hill resigned over fears of cuts to therapy.
The inquest heard Mr Lawrence did not have a legitimate medical doctorate, and had instead obtained a certificate from a “degree mill” in Denmark.
Mr Lawrence failed to attend the inquest despite being summonsed.
It also emerged that Ms Bennett had self-harmed in April 2016 and said she was experiencing suicidal thoughts, but staff had ignored advice to admit her straight to hospital for an assessment.
Instead, they decided to keep her in the home under close observation, but allowed her to close the bathroom door on the day she was found hanged.
A report by a Care Quality Commission inspector in March 2016 found care at the home had deteriorated rapidly in the space of six months and raised numerous concerns such as kitchen items not being locked away and poorly qualified junior staff.
The inquest revealed several other residents at Lancaster Lodge became “very ill” amid the disruptions in 2016 and “at least one” attempted suicide .
Friend and fellow patient Clarissa Jeffrey said the changes in 2016 “made it feel like the residents were running the house”.
Michelle Russell, director of investigations, monitoring and enforcement at the Charity Commission, said the coroner’s report into Ms Bennett’s death “made for highly distressing reading”.
She added: “The coroner found that governance failings at the charity directly contributed to Sophie’s death. We want to see the charity address those failings as a matter of urgency.
“The opening of this inquiry reflects the seriousness of the coroner’s findings and our concerns.”
The Bennett family welcomed the inquiry but expressed their anger that it had taken so long for Elly Jansen to be investigated by the Charity Commission.
They said: “In the aftermath of Sophie’s death it also became apparent that the Charity Commission, as long ago as 1992, inquired into the activities of the founder Elly Jansen.
“That inquiry catalogued a long list of serious failings in the way she operated charities that she had personal financial interests in.
“However Elly Jansen was then able to establish RPFI in 2006 and she continued to flout the Commission’s rules from a position as a shadow director.
“This information was brought to the Commission’s attention again in 2015 and yet it took no action.”
They added: “We believe that it is only due to our persistence that it is finally launching this formal inquiry.”