Hospital failures continue after Figue’s death?

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

Four months after a young woman died in a mental health unit in London, another patient tried to harm himself in very similar circumstances, leaked documents seen on the BBC show.

Alice Figeireo, a patient at the Good Hospital, run by the North East Health Trust Enter (Nelft), tried to harm herself with a pair of toilet bowls. On the 19th occasion, in July 2015, he managed to take his own life.

Four months later, in November 2015, another young woman also in Hepworth Ward tried to harm herself with a bin bag. He survived.

Mental health campaigners say it suggests a worrying failure to learn from tragedies.

“It’s shocking and heartbreaking that this is still going on four months after Alice died,” said Jane Figueireo, Alice’s mother. “Garbage bags could and should have been removed, but instead patients continue to be put at unnecessary risk.”

Nelft said all bin bags have been eliminated and “it is committed to learning from each incident and continually improving” the care it provides.

Nelft and Former Ward Manager Benjamin Aninakwa are due to be indicted this week An elderly Bailey Jury concluded they did not do enough to keep 22-year-old Alice Figeireo safe.

The BBC spoke to former Nelft patients, family and ex-staff who had experience of the Trust’s community and hospital services when Alice died.

They raised concerns about poor management, record keeping, risk assessments and staff shortages that spanned that decade.

An email, giving details of the November 2015 incident, was submitted to an internal inquiry commissioned by the trust after Alice complained she had received it.

The inquiry’s report, seen by the BBC, has not yet been made public.

“The similarities between the young woman and [Alice Figueiredo] Surprising in terms of presentation, age, background,” the email said.

It went on to say that while it appeared that there was “some learning” because of Alice’s death, there was “significant evidence” that not all incidents were reported correctly.

The hospital uses an NHS risk management system called Datix where incidents must be logged into the system to help identify risks and patterns of behaviour.

The report said during the time Alice was in the ward there were 81 incidents or near misses that met the standards reported by the data, but only 14.2%) were logged into the system.

In the case of November, there was also significant under-reporting. The report suggests that of the 45 incidents of self-harm involving an unidentified young woman, 27 were not visible in the risk management system, including an attempt to harm herself with a bag bag.

The general lack of ward recording means “opportunities to safely manage patients are being lost”, the inquiry found.

Nelft said it removed plastic bags from wards in line with national guidelines, and improved record-keeping and case management.

Overall, the internal report paints a picture of a ward where there are sick patients, staff shortages – and a poor relationship between Ward Manager Benjamin Aninakwa and the ward’s psychiatrist.

The report also says 100% of support workers are assigned to follow one-on-one temporary staff.

Brian Dow, from mental health charity Mental Health, said the document showed the unit was quick to act after Alice’s death to protect other patients.

“Lessons must be learned, and you should not expect to see a repetition of the same risks and the same dangers weeks after,” 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 said instead of an open and transparent culture in the ward, the situation felt difficult and scared him.

He shared the statement he made to the police investigating Alice’s death with the BBC. In this he remembers how compassion helped him cope.

“He used to give me a big hug every morning on the Hepworth ward,” she said.

He described how the staff meant to watch them regularly without doing the necessary checks or observations.

“On countless occasions I witnessed Alice asking to speak to staff members who were supposed to be making observations of her but instead were busy on their phones,” he wrote.

He also told the police that observation records detailing what patients were doing, which is important to give clinics a sense, were often tampered with.

Jenny left a good hospital before Alice died. He now lives in his own home with community support, although he still misses his friend.

The BBC has previously highlighted repeated criticism of coroners’ trustwith the most recent concerns being raised in May 2025 following the death of a 37-year-old man under the care of the Nelf Community-based team.

The most common criticisms are about poor quality record keeping, risk assessment, risk management and care planning. Staff shortages and poor communication have also been highlighted in many reports over the past decade.

Former staff who spoke to the BBC raised similar concerns.

Mark New is a senior community support advisor at Bath Mental Health. He said it was a great place to work for most of the 15 years he was there, but things got so bad that he left earlier this year.

He said that the mandatory Medical and Care Management Reviews are not always happening, leaving the conditions of some still unknown, and others fighting the crisis for weeks … for months.

“It’s all fed back to the staff in charge, but it’s never acknowledged,” he said.

The trust operates a traffic light system on file patients to indicate their level of need and the risk they pose to themselves or others. New says these files are often not filled out accurately or updated properly, including risk assessments.

Mr. New recalled a client flagged as green or low risk. He later learned that they had recently been picked by the police following allegations of “assault and hostage-taking with a bladed weapon”.

The trust said any staff member felt unsupported or unsafe, and acknowledged that “workplace pressures are affecting the quality of care in the NHS.” It says it has made significant investments in recruiting and retaining staff.

“We need a health system that prevents people from ending up in crisis,” said Brian Dow from Rethink. “We always hear stories of people growing up.”

Alice Faraireo’s mother, Jane, and Emajama, Max, have spent the last decade seeking justice and transparency in what happened to her.

“We should expect safe, compassionate and diligent care for some of society’s most vulnerable people,” Jane said. “Urgent action is needed, not only in nelft, but in all mental health hospitals, wards and services across the country.”

Nelft said that Alice’s death and that it remains “dedicated to ensuring that Alice’s memory continues to deliver positive change” and “will continue to work in poor care in the communities we serve”.

The BBC understands that Benjamin Aninakwa, who still works at NELFT, is interesting against his conviction for failing to take care of the health and safety of others affected by the acts or elimination of work. He got away with gross human negligence.

If you are suffering from distress or despair, details of help and support in the UK are available at BBC action line.