Numerous suicide attempts by an inpatient at an east London hospital were not properly recorded, a court has heard.
During her five-month detainment in an acute psychiatric unit at Goodmayes Hospital, Alice Figueiredo, 22, attempted to harm herself on 39 occasions.
Alice died on July 7, 2015 after she was able to access a plastic bag in a communal toilet on the Hepworth ward, a jury at the Old Bailey was told.
North East London NHS Foundation Trust (NELFT), which oversees mental health care across Barking and Dagenham, Havering, Redbridge and Waltham Forest, denies corporate manslaughter and charge of failing to ensure the safety of non-employees.
Benjamin Aninakwa, of St Francis Way in Grays, who was ward manager at the time of Alice’s death, pleaded not guilty to manslaughter by gross negligence and failing to take reasonable care for the health and safety of patients on the ward.
Eighteen of Alice’s attempts involved bin bags but incidents were not consistently recorded on the NHS Datix system, which is used by staff to log incidents and risks involving patients, it is alleged.
Only one of six incidents in February 2015 were recorded via Datix and not all were logged on the Rio system, which the NHS uses for patient health records, according to the prosecution.
The following month, Alice attempted self-harm or prepared to self-harm 13 separate times but only one incident was recorded via Datix, jurors heard. She had used plastic bags on eight occasions.
Duncan Atkinson KC, prosecuting, said: “The reality is that each of them should have been recorded in that way.”
He added: “The one Datix that was made and provided to senior managers, despite flagging up issues already raised in February, did not generate a response or any action.”
Though there were no bin bags in her room, the court heard they were present in communal areas and toilets, which patients had access to.
Jurors were also told there was “no evidence” the “emerging pattern was identified either at ward level or a more senior level”.
Alice’s mother, Jane Figueiredo, had written to the hospital after an incident in May involving a plastic bag that left Alice “very distressed and shaken up”.
In the letter, read out to the jury by the prosecution, she said “there have been numerous occasions during this admission – probably more than 15 – when Alice has been out of sight and hearing long enough” to cause herself harm.
Jane was quoted as saying: “If staff are complacent or careless in this way and don’t carry out level-three observations of a suicidal patient with diligence, it’s only a matter of time before there will be a fatality on the ward.”
Patients under level-three observation must be “continuously within eyesight,” according to NHS guidance.
The email had been forwarded to Aninakwa, the court was told, but “there was no record of any investigation by him as a result, and no action in relation to the lack of a Datix record”.
Jane Figueiredo was present for the hearing on Tuesday, November 5, alongside Alice’s sister and stepfather.
Alice had first been admitted to the Hepworth ward in 2012, having been diagnosed with bipolar affective disorder and a non-specific eating disorder.
The 22-year-old was described as someone loved for her “warmth, kindness and joyful character”. She had been head girl at school and set up a support group for her fellow students.
The trial is expected to last until January.
Whatever you’re going through, Samaritans are available to talk to 24 hours a day, 365 days a year – call 116 123 for free.
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