The Charity Commission has strongly criticised the former trustees of a mental health charity in whose care a young woman tragically took her own life in 2016.
In an official inquiry report published today, the regulator makes findings of misconduct and mismanagement against three of RPFI’s former trustees, concluding that they exposed residents to significant avoidable harm. Two of the former trustees have now undertaken not to act as charity trustees or senior managers; the third died in 2019.
RPFI ran Lancaster Lodge, a residential home in Richmond, South London, that provided care for adults recovering from mental health issues and adolescents with complex emotional needs. In May 2016, a resident of the home, Sophie Bennett, took her own life.
A coroner’s report, published in February 2019, found that the then trustees oversaw abrupt changes at Lancaster Lodge during 2016, which included replacing experienced, qualified staff with unqualified staff, and removing residents’ access to external therapies. These changes were chaotic and resulted in a deterioration in care for residents.
In March 2021, the charity and Lancaster Lodge’s former registered manager were ordered to pay substantial fines and costs, having pleaded guilty to two separate charges under the Health and Social Care Act, following a prosecution brought by the Care Quality Commission.
The Commission’s own inquiry was opened in April 2019, following the coroner’s inquest, specifically to examine the role of the charity’s former trustees. Its investigation set out to determine whether the former trustees had complied with their governance duties and responsibilities under charity law, and to examine the trustees’ response to the coroner’s findings and what steps they were taking to address the serious failings identified in his report.
The investigation also considered the role of the charity’s founder, who acted as consultant to the board, and whether she was a de-facto trustee.
Today’s report finds that the former trustees were responsible for misconduct and mismanagement, and that they:
- failed in their duty to provide leadership and oversight of the charity
- failed to comply with the law such that the charity’s beneficiaries were exposed to “significant avoidable harm”, contributing to Sophie’s death
- were over-reliant on the former Chair (since deceased) who acted in breach of good governance requirements.
- took advice from the charity’s founder which was, according to the Coroner, “followed by RPFI staff without [the founder – Charity Commission clarification] ever meeting or having knowledge of the residents”.
The report also finds that the former trustees failed to properly manage the charity’s resources, including by failing to file annual accounts on time, and concerns about the management of the charity’s banking services, which potentially placed the charity’s funds at undue risk.
Two of the former trustees have signed undertakings to not act as charity trustees, or to be involved in any charity’s senior management.
A new board of trustees is in place at the charity. The new trustees have demonstrated to the Commission that they have carried out actions to significantly strengthen governance processes at the charity to ensure safeguarding policies and processes are followed and its beneficiaries are protected. Lancaster Lodge closed in 2017, but RPFI continues to run another home.
Helen Stephenson, chief executive of the Charity Commission, said:
Sophie Bennett’s death is a tragedy and the circumstances surrounding it remain deeply distressing.
Our findings are serious, and sobering: the former trustees of RPFI presided over decisions that, in a matter of months, turned a home rated ‘good’ by CQC into one in which residents were unsafe.
No official inquiry can turn back the clock and change what happened in 2016. But we can and must ensure lessons are learnt from this case. We urge trustees of charities that care for vulnerable people, like Sophie, to consider the findings of this inquiry, and to examine their own systems, structures, and indeed the expertise and competence of their board collectively to ensure they meet their legal duties.