The Old Bailey
29 October 2024 – 9 June 2025
In a historic trial, an NHS Trust and former ward manager have today been found guilty of failing to ensure the health and safety of mental health patients.
A London NHS Trust and the former ward manager have been found guilty of breaching the Health and Safety Act, following the death of 22 year old Alice Figueiredo in one of its hospitals in 2015.
The NHS Trust was acquitted of corporate manslaughter whilst the former ward manager was acquitted of gross negligence manslaughter following the joint-longest jury deliberation in English legal history.
Alice died a self-inflicted death on 7 July 2015 whilst a mental health inpatient at Goodmayes Hospital, run by North East London NHS Foundation Trust (NELFT).
Alice was a much loved daughter, sister, partner and friend to many. Her family describe her as having a ‘luminous, kind, thoughtful, generous, warm, humorous and deeply loving presence’ and a bright future ahead of her.
Alice was a very creative young woman who loved the arts. She was passionate about art, music, being a member of numerous choirs and orchestras; she loved literature, writing, poetry, acting, and cooking, especially baking. She always stood up for what she believed in and tried to help and support those in need around her. She had been head girl at her school, a member of the UK Youth Parliament, Chair of the Havering Youth Council and worked with local police to improve relations between the youth community and police. She was an impressive public speaker and also a strong advocate for the mental health community.
Alice had a diagnosis of bipolar disorder and an eating disorder. She had a history of hospitalisation and self-harm. Prior to February 2015 she also had periods where she lived a very full, motivated and enthusiastic life in the community.
Alice was admitted to Goodmayes Hospital in February 2015, where she was sectioned under the Mental Health Act.
Between February and July that year, she tried to harm herself with plastic bin liners and bags on 18 occasions prior to the fatal incident. Despite this, they were not removed from the ward, nor was she prevented from accessing them.
On 7 July, Alice was able to access the communal toilet on the ward and ligatured using a bin liner. She died shortly after.
NELFT has been convicted for breaching Sections 3(1) and 33(1)(a) of the Health and Safety Act for failing to ensure the safety of non-employees. (In addition) The former ward manager has been convicted for breaching Sections 7(1) and 33(1) of the Health and Safety Act for failing to take reasonable care for health and safety.
The charges were announced by the Crown Prosecution Service (CPS) in September 2023 following a Metropolitan police investigation into Alice’s death.
NELFT was charged with corporate manslaughter as well as a health and safety breach. The ward manager at the time of Alice’s death, was charged with manslaughter by gross negligence and a health and safety breach.
Jane Figueiredo, Alice’s mother, speaking after the verdict said: “We will always believe that Alice was killed due to a level of reckless negligence which was very easily preventable, after 19 incidents with likely the same or very similar risk item – provided by the ward itself. Such a level of complacency was reckless and indefensible.
The evidence we have experienced and seen was that the ethos on this ward in 2015, was characterised by complacency, collusion, cover-up and chaos, for which Alice at the age of 22, paid the price with her precious life, which was treated both as “worthless and worth less”.
The fact is this: NELFT placed more value on their rubbish bins than they did on my daughter’s life. She was treated as more disposable and less valued than the contents of those waste bins. The repeated complacent failings were as inhumane as they were atrocious.”
Read Jane Figeuiredo's full statement.
Max Figueiredo, Alice’s stepfather, speaking after the verdict said: “During these last six months, we have had to painfully endure listening to both defence teams’ characterisation of Alice as a hopeless case with a long-term prognosis that was terminal and that her life would be inevitably short. Nothing could have been further from the truth.
Alice died because of negligence and indifference from a number of the staff at NELFT who failed to keep her safe. There is scant consolation for me in this verdict because nobody can give us Alice back.
But it is our deepest hope that this prosecution will lead to safe and respectful care for all those vulnerable mental health patients who are placed in hospitals and also that we get meaningful change so that another father does not have to experience such a heart-breaking loss.”
Read Max Figueiredo's full statement.
Deborah Coles, Director at INQUEST, said: “When someone you love is taken into the care of mental health services, you expect them to be looked after, supported and kept safe. Yet this trial has exposed how far that is from the truth.
Alice’s death is the result of repeated failings within NELFT and a culture of neglect and complacency at management level that continues to endanger lives. This was a death forewarned by her mother.
This is also about the systemic failures that pervade our mental health services across the country and the lack of consequences for those in charge.
The real victory will be when we see NHS Trusts act with candour and focus on learning and change rather than protecting their reputations and victim blaming.
This ruling must be the catalyst for true systemic change in our mental health services: they must become places of care and healing, where failures are addressed, and untimely deaths prevented.”
ENDS
NOTES TO EDITORS
For further information, interview requests and to note your interest, please contact Leila Hagmann on leilahagmann@inquest.org.uk.
The family are supported by INQUEST senior caseworker, Selen Cavcav.
Journalists should refer to the Samaritans Media Guidelines for reporting suicide and self-harm and guidance for reporting on inquests.
CRIMINAL PROSECUTIONS OF MENTAL HEALTH HOSPITALS FOLLOWING DEATHS
This is the first time an NHS Trust has been charged with corporate manslaughter over a self-inflicted death in a mental health unit.
There have been a number of successful prosecutions brought by the Care Quality Commission (CQC) and Health and Safety Executive (HSE) against NHS trusts and private hospitals in relation to deaths of patients in their care. These include:
Matthew Caseby, 23, died a self-inflicted death after absconding from the Woodbourne Priory hospital in Birmingham in 2020 where he was an NHS inpatient. In March 2024, Priory Healthcare Ltd was fined £650,000 after admitting to criminal failures for exposing Matthew to serious risk of harm. Media release.
Connor Sparrowhawk, 18, died after drowning whilst in an NHS care unit in Oxford on 4 July 2013. Teresa Colvin, 45, died in Hampshire in 2012. Southern Health NHS Trust was fined £1million and £950,000 after pleading guilty to breaching health and safety laws over their respective deaths. The trust was prosecuted by HSE. Media coverage.
Amy El-Keria, 14, died a self-inflicted death whilst an NHS funded patient in a private mental health hospital in East Sussex run by the Priory Group. The Priory Group were fined £300,000 over breaches of health and safety law in relation to Amy’s death in April 2019. The charges were brought by HSE. Media release.
NHS North Essex Partnership Trust was prosecuted by HSE and fined £1.5million in 2021 for safety failings over the deaths of 11 patients. Media coverage.
Alice Figueiredo
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The Old Bailey
29 October 2024 – 9 June 2025
In a historic trial, an NHS Trust and former ward manager have today been found guilty of failing to ensure the health and safety of mental health patients.
A London NHS Trust and the former ward manager have been found guilty of breaching the Health and Safety Act, following the death of 22 year old Alice Figueiredo in one of its hospitals in 2015.
The NHS Trust was acquitted of corporate manslaughter whilst the former ward manager was acquitted of gross negligence manslaughter following the joint-longest jury deliberation in English legal history.
Alice died a self-inflicted death on 7 July 2015 whilst a mental health inpatient at Goodmayes Hospital, run by North East London NHS Foundation Trust (NELFT).
Alice was a much loved daughter, sister, partner and friend to many. Her family describe her as having a ‘luminous, kind, thoughtful, generous, warm, humorous and deeply loving presence’ and a bright future ahead of her.
Alice was a very creative young woman who loved the arts. She was passionate about art, music, being a member of numerous choirs and orchestras; she loved literature, writing, poetry, acting, and cooking, especially baking. She always stood up for what she believed in and tried to help and support those in need around her. She had been head girl at her school, a member of the UK Youth Parliament, Chair of the Havering Youth Council and worked with local police to improve relations between the youth community and police. She was an impressive public speaker and also a strong advocate for the mental health community.
Alice had a diagnosis of bipolar disorder and an eating disorder. She had a history of hospitalisation and self-harm. Prior to February 2015 she also had periods where she lived a very full, motivated and enthusiastic life in the community.
Alice was admitted to Goodmayes Hospital in February 2015, where she was sectioned under the Mental Health Act.
Between February and July that year, she tried to harm herself with plastic bin liners and bags on 18 occasions prior to the fatal incident. Despite this, they were not removed from the ward, nor was she prevented from accessing them.
On 7 July, Alice was able to access the communal toilet on the ward and ligatured using a bin liner. She died shortly after.
NELFT has been convicted for breaching Sections 3(1) and 33(1)(a) of the Health and Safety Act for failing to ensure the safety of non-employees. (In addition) The former ward manager has been convicted for breaching Sections 7(1) and 33(1) of the Health and Safety Act for failing to take reasonable care for health and safety.
The charges were announced by the Crown Prosecution Service (CPS) in September 2023 following a Metropolitan police investigation into Alice’s death.
NELFT was charged with corporate manslaughter as well as a health and safety breach. The ward manager at the time of Alice’s death, was charged with manslaughter by gross negligence and a health and safety breach.
Jane Figueiredo, Alice’s mother, speaking after the verdict said: “We will always believe that Alice was killed due to a level of reckless negligence which was very easily preventable, after 19 incidents with likely the same or very similar risk item – provided by the ward itself. Such a level of complacency was reckless and indefensible.
The evidence we have experienced and seen was that the ethos on this ward in 2015, was characterised by complacency, collusion, cover-up and chaos, for which Alice at the age of 22, paid the price with her precious life, which was treated both as “worthless and worth less”.
The fact is this: NELFT placed more value on their rubbish bins than they did on my daughter’s life. She was treated as more disposable and less valued than the contents of those waste bins. The repeated complacent failings were as inhumane as they were atrocious.”
Read Jane Figeuiredo's full statement.
Max Figueiredo, Alice’s stepfather, speaking after the verdict said: “During these last six months, we have had to painfully endure listening to both defence teams’ characterisation of Alice as a hopeless case with a long-term prognosis that was terminal and that her life would be inevitably short. Nothing could have been further from the truth.
Alice died because of negligence and indifference from a number of the staff at NELFT who failed to keep her safe. There is scant consolation for me in this verdict because nobody can give us Alice back.
But it is our deepest hope that this prosecution will lead to safe and respectful care for all those vulnerable mental health patients who are placed in hospitals and also that we get meaningful change so that another father does not have to experience such a heart-breaking loss.”
Read Max Figueiredo's full statement.
Deborah Coles, Director at INQUEST, said: “When someone you love is taken into the care of mental health services, you expect them to be looked after, supported and kept safe. Yet this trial has exposed how far that is from the truth.
Alice’s death is the result of repeated failings within NELFT and a culture of neglect and complacency at management level that continues to endanger lives. This was a death forewarned by her mother.
This is also about the systemic failures that pervade our mental health services across the country and the lack of consequences for those in charge.
The real victory will be when we see NHS Trusts act with candour and focus on learning and change rather than protecting their reputations and victim blaming.
This ruling must be the catalyst for true systemic change in our mental health services: they must become places of care and healing, where failures are addressed, and untimely deaths prevented.”
ENDS
NOTES TO EDITORS
For further information, interview requests and to note your interest, please contact Leila Hagmann on leilahagmann@inquest.org.uk.
The family are supported by INQUEST senior caseworker, Selen Cavcav.
Journalists should refer to the Samaritans Media Guidelines for reporting suicide and self-harm and guidance for reporting on inquests.
CRIMINAL PROSECUTIONS OF MENTAL HEALTH HOSPITALS FOLLOWING DEATHS
This is the first time an NHS Trust has been charged with corporate manslaughter over a self-inflicted death in a mental health unit.
There have been a number of successful prosecutions brought by the Care Quality Commission (CQC) and Health and Safety Executive (HSE) against NHS trusts and private hospitals in relation to deaths of patients in their care. These include:
Matthew Caseby, 23, died a self-inflicted death after absconding from the Woodbourne Priory hospital in Birmingham in 2020 where he was an NHS inpatient. In March 2024, Priory Healthcare Ltd was fined £650,000 after admitting to criminal failures for exposing Matthew to serious risk of harm. Media release.
Connor Sparrowhawk, 18, died after drowning whilst in an NHS care unit in Oxford on 4 July 2013. Teresa Colvin, 45, died in Hampshire in 2012. Southern Health NHS Trust was fined £1million and £950,000 after pleading guilty to breaching health and safety laws over their respective deaths. The trust was prosecuted by HSE. Media coverage.
Amy El-Keria, 14, died a self-inflicted death whilst an NHS funded patient in a private mental health hospital in East Sussex run by the Priory Group. The Priory Group were fined £300,000 over breaches of health and safety law in relation to Amy’s death in April 2019. The charges were brought by HSE. Media release.
NHS North Essex Partnership Trust was prosecuted by HSE and fined £1.5million in 2021 for safety failings over the deaths of 11 patients. Media coverage.
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