Hospital failings continued after Alice Figueiredo death, leaked documents show

Warning: This article contains distressing details and references to serious self-harm and death.

Just four months after the death of a young woman in a London mental health unit, another patient tried to harm herself under strikingly similar circumstances, leaked documents seen on the BBC program have revealed.

Alice Figueiredo, a patient at Goodmayes Hospital, run by the North East London Mental Health Foundation (NELFT), attempted to harm herself using plastic or bin bags on 18 occasions, mostly by taking them from the same public toilet. In the 19th incident in July 2015, he managed to commit suicide.

Just four months later, in November 2015, another young woman, also on Hepworth ward, tried to harm herself using a bin bag. He survived.

Mental health campaigners say this points to a worrying failure to learn from tragedies.

“It’s shocking and sad that this is still going on four months after Alice’s death,” said Jane Figueiredo, Alice’s mother. “The rubbish bags could and should certainly have been removed, but instead patients continued to be put at unnecessary risk.”

NELFT says all bin bags have been removed and is “committed to learning from each incident and continually improving the care it provides”.

NELFT and former ward warden Benjamin Aninakwa expected to be sentenced this week Old Bailey jury found they did not do enough to keep 22-year-old Alice Figueiredo safe.

The BBC spoke to former NELFT patients, families and former staff who had experience of the Trust’s community and hospital services over the decade since Alice’s death.

They raise concerns about poor management, record keeping, risk assessments and staff shortages that have persisted throughout this decade.

An email containing details of the incident in November 2015 was sent to an internal investigation commissioned by the trust after Alice’s parents complained about the care Alice received.

The report of the investigation, which was reviewed by the BBC, was never made public.

“Similarities with this young woman [Alice Figueiredo] Astonishing in terms of presentation, age range and background,” the email said.

He also notes that although “some things appear to have been learned” since Alice’s death, there is “significant evidence” that not all incidents were properly reported.

The hospital used an NHS risk management system called Datix, where events were required to be logged into the system to help identify risks and patterns of behaviour.

The report says that during Alice’s time on the ward there were 81 incidents or near misses that met the criteria to be reported through Datix, but only 14 (17.2%) were recorded on the system.

There was also significant underreporting in the November case. The report suggests that 27 of 45 self-harm incidents involving the unidentified young woman did not show up in the risk management system, including an attempt to harm herself using a bin bag.

The investigation found that a lack of public records on the ward meant “opportunities to manage patients safely were missed”.

NELFT says it has removed plastic bags from wards and improved record keeping and case management in line with national guidelines.

Overall, the internal report paints a picture of a ward with very sick patients, staff shortages (particularly nurses) and a poor relationship between the ward manager, Benjamin Aninakwa, and the consultant psychiatrist.

The report also states that 100% of the support workers assigned to monitor Alice one-on-one were temporary staff.

Brian Dow, of mental health charity Rethink, says the document shows the unit did not act quickly enough to protect other patients after Alice’s death.

“Lessons must be learned and you should not expect to see a repeat of the same risks and the same dangers a few weeks later,” he said.

“You need to have a culture of openness and transparency so you can learn from mistakes.”

“Jenny”, not her real name, was a patient on the Hepworth ward at the same time as Alice. They became close friends. He says that the atmosphere in the ward seems difficult and scary to him, rather than the open and transparent culture.

He shared his statement to the police investigating Alice’s death with the BBC. In it, he remembers how Alice helped him cope with the situation.

“He would wake me up every morning in Hepworth ward with a big hug,” she says.

He explains that the staff should take care of themselves and often do not make the necessary checks or observations.

“I witnessed Alice countless times asking to talk to staff who were supposed to be monitoring her but were busy on their phones,” he wrote.

He also told police that observation records, which detail what patients were doing and are important to give clinicians insight into how that person is coping, are often forged.

Jenny left Goodmayes Hospital before Alice died. Although he still misses his friend, he now lives in his own home with the support of the community.

The BBC has previously highlighted repeated criticism of coroners’ trust.The latest concerns were raised in May 2025 following the death of a 37-year-old man under the care of NELFT’s community-based team.

The most common criticisms relate to the poor quality of record keeping, risk assessments, risk management and care planning. Staff shortages and poor communication have also been highlighted in a number of reports over the last decade.

Former staff members speaking to the BBC expressed similar concerns.

Mark New was a senior support worker in the trust’s community mental health team. He said it was a good place to work for most of the 15 years he was there, but things got so bad that he resigned earlier this year.

He said mandatory medical and care management reviews did not always take place, some patients’ conditions remained untreated and some “languished in crisis for weeks, months”.

“All of this was being passed on to the responsible staff, but it wasn’t actually acknowledged,” he says.

The trust ran a traffic light system on patient charts to indicate patients’ levels of need and the risks they posed to themselves or others. Mr New says these files, including risk assessments, are often not completed correctly or updated properly.

Mr. New recalls one client who was flagged as green, or low risk. He later discovered that they had recently been captured by the police following allegations of “assault with a sharp weapon and hostage-taking”.

The trust says it is sorry if any staff felt unsupported or unsafe and acknowledges that “workforce pressures have historically affected the quality of care across the NHS”. It says it has made significant investments in the recruitment and retention of staff.

“We need a healthcare system that prevents people from falling into crisis,” says Brian Dow of Rethink. “Too often we hear stories of people climbing unnecessarily.”

Alice Figueiredo’s mother, Jane, and stepfather, Max, have spent the last decade seeking justice and transparency about what happened to her.

“We should be able to expect safe, compassionate and caring care for some of the most vulnerable people in society,” says Jane. “Urgent action is needed not just at NELFT but in all mental health hospitals, wards and services across the country.”

NELFT said it was saddened by Alice’s death and was “committed to ensuring Alice’s memory continues to inspire positive change” and “will continue to work tirelessly to deliver safer, more compassionate care to the communities we serve.”

The BBC understands that Benjamin Aninakwa, currently employed by NELFT, is appealing his conviction on the grounds that he failed to take reasonable care for the health and safety of others affected by acts or omissions at work. He was acquitted of manslaughter by gross negligence.

If you are experiencing distress or despair, details of help and support in the UK can be found at: BBC Action Line.