Sophie Bennett was ‘upset at prospect of leaving facility’, which was criticised by CQC

A teenager took her own life at a mental health care home after the charity in charge laid off external therapists, employed unqualified staff and turned it into a “boot camp”, an inquest has heard.

In May 2016 Sophie Bennett, 19, from Tooting, south-west London, killed herself in a bathroom at Lancaster Lodge in Richmond, west London, a facility that helps people with mental illnesses transition back to normal life, an inquest jury at West London coroner’s court was told.

The home was run by Richmond Psychosocial Foundation International, a charity set up by Elly Jansen, a leading figure in mental health care.

In the first months of 2016, an abrupt change in management led to a deterioration in care, the inquest heard. After an inspection by the Care Quality Commission discovered problems, including about the administration of drugs, some of the 12 residents were told they would need to move out.

Sophie was so upset by the prospect of leaving that she was placed on a regular five-minute inspection to ensure she did not harm herself. She was found unconscious in a bathroom minutes after one such check and died two days later in hospital. Another resident also attempted suicide.

Before the changes, things looked like they were working out well for Sophie, her mother, Nickie Bennett, told the first day of the inquest, but later she became “very distressed”.

Sophie’s father, Ben Bennett, said he felt no one at Wandsworth council’s social services department gave any consideration to her safety.

The teenager, a former county level swimmer described by her family as “a bright, loving and caring person who loved sport and art and was talented at music”, had been diagnosed with autism, bipolar and social anxiety disorders. She had twice previously taken overdoses and lived in an institution in Northamptonshire before moving to Lancaster Lodge.

In late 2015 and early 2016, she had taken part in a Prince’s Trust programme and worked in a charity shop, and the family hoped she might attend university. That unravelled when the care home manager, Vincent Hill, who she liked, was removed and “marched out of the building in front of the residents”, Nickie Bennett said. Sophie’s external therapist was also removed and her key worker dismissed.

“They didn’t respond very well to [the new manager],” said Sophie’s mother. “They felt he didn’t have the necessary qualifications. He wanted to run the place in a different way. Sophie described it that he wanted to run it as a boot camp.”

Clarissa Jeffrey, a fellow resident and friend of Sophie’s said in a statement: “The changes felt as though they were fuelled by wanting to make money or save money. It eventually felt like we the residents were running the place.”

At one point some of them had to restrain a 17-year-old because “noone else would and she would have hurt herself,” Jeffrey said.

Richard Malado, a support worker interviewed by Jansen for a job after the original staff had left, said he had no qualification or experience in mental health work and said the post was “a baptism of fire”. In a statement he said he was aware of “safeguarding concerns” and it was “a fragile environment”.

The CQC had carried out an inspection in March 2016 prompted by concerns about the handling of medicines, and by 7 April Sophie was told by her social worker that she would have to move, which left her “very distressed” and “very unstable”, the inquest heard.

“She was absolutely desperate for us to say she could come home,” said her mother, who told the coroner, John Taylor, it was not possibile. “We would have needed absolutely full-time care.”

On 2 May 2016, Sophie was found dead.

Taylor told the jury that they would need to consider “did the changes [at Lancaster Lodge] cause or contribute to her death”.

“I don’t believe she wanted to die,” her mother said. “She just wanted some help.”

The inquest continues.