Slow Newscast

A death at Lancaster Lodge

A death at Lancaster Lodge

Sophie Bennett took her own life in a care facility that was crumbling around her. Paul Caruana Galizia and Chris Cook investigate what went wrong at a charity led by a famous mental health pioneer


Transcript

Before we begin, I just need to warn you this is a hard listen at times. It deals with self-harm and suicide, and you might feel this is not for you. If you are affected at all, please ask for help at Samaritans.org.

It’s late 2015, and Sophie Bennett is 19-years-old.

Sophie’s a kind and gentle soul. She puts everyone before her, even though she’s deeply unwell. 

She has bipolar disorder, social anxiety, and atypical autism. She’s suffered serious bouts of mental illness ever since she was 14, when she was sectioned for the first time. 

She’s spent most of her teenage years in a cycle of hospitalisation.

It was just hideous. There were times when you’re quite hopeful, every time she came home, it was just dreadful. We ended up with all sorts of really unpleasant incidents. I remember physically stopping her drinking bleach, you know. She had these terrible instances of rages and kind of depressions and manic – but then, you know, she could hold it together. You could have met her and thought, well, she’s just a nice shy girl.”

Ben Bennett

But she’s now living in a small adult mental health facility in Richmond, in south west London

“I think ultimately she was excited. I think she felt that there was real potential for change.”

Vincent Hill

It’s called Lancaster Lodge and it’s a therapeutic community, a place where people who are mentally unwell spend time and do therapy together in preparation for outside society.

So as 2015 draws to a close, Sophie is doing much better. After many difficult years she seems to have finally turned a corner. 

“Towards the end point of 2015 she had changed dramatically. She ultimately, for me, was in the beginning of that upward recovery process. She was stronger, she was happier. She was having much better relations with her parents. Her talk about suicidal ideation virtually stopped. Her self-harm stopped dramatically. We saw a lot of positive indicators and she smiled a lot more and she laughed and she integrated socially much better. All of the indicators were very positive for her.”

Vincent

But just over 4 months later, Sophie is found unconscious in a bathroom at Lancaster Lodge. 

She dies in hospital two days later.

At the inquest – an official investigation to determine how someone died – the jury concludes that neglect by the charity which cared for her contributed to her death. 

This week I’m going to tell you the story of Sophie’s last months, and how the tragedy of her suicide could have been prevented. 

It’s a story about how we came to rely on charities for the care of society’s most vulnerable people, and how we have failed to control these charities – in Sophie’s case, with fatal results.

Because at the beginning of 2016 things started to change at Lancaster Lodge and Sophie’s home became dangerous. Not just for her, but for all the residents. 

But Sophie wasn’t just let down by staff who didn’t call an ambulance, and who didn’t keep her under observation. 

Her story reaches far beyond this one solitary case. There are around 1800 homes like Lancaster Lodge in England. Much of the care they provide is publicly funded, but delivered by charities.

They’re regulated by the Charity Commission, which exists to make sure charities are well managed and spending resources appropriately, and by the Care Quality Commission, which is responsible for standards in healthcare. 

In Sophie’s case, both institutions – but the charity commission, in particular – have questions to answer.

There were red flags everywhere that ought to have been acted upon. 

She might still be alive but for the catastrophic failure of the bodies that were entrusted with making sure that the rules were being followed – and keeping her safe. 

I’m Paul Caruana Galizia, a reporter at Tortoise, and you’re listening to the Slow Newscast. 

Clarissa Jeffery: I think it was the first place I actually felt safe from like I guess the outside world. I don’t know, there was just something about it, everyone there loved what they did.

This is Clarissa Jeffery, she was a resident at Lancaster Lodge at the same time as Sophie Bennett and she’s telling me what it was like before the changes of 2016. 

Clarissa: The first two years I was there, it was the best place I’ve been. It was just incredibly supportive, there was no power like hierarchy. You actually were treated like human beings and like you were actually human for the first time in years.

Hosannah Kirton was there too: 

Hosannah Kirton: I felt like I was listened to and I felt comfortable. And I could see myself living there. And I liked the fact that I could voice an opinion and not get completely shut down for it.

The Lodge is on a leafy street in Richmond, not far from the River Thames. It’s run by RPFI, the Richmond Psychosocial Foundation International, as a therapeutic community. Its slogan is “Quality care to transform lives.” Its declared mission is “to the most vulnerable.”

Its residents suffered from a range of disorders: bipolar disorder, borderline personality disorder, psychotic episodes, depression, eating disorders, post-traumatic stress disorder, autism, anxiety. 

Many had a history of being sectioned, and it was in psychiatric wards that they – the lucky ones – were referred to Lancaster Lodge after being assessed and securing funding.

A referral was their last chance to break out of a cycle of hospitalisation, and work towards an independent life. 

As residents, they had to do their fair share of chores and to help with the cooking

Hosannah: I think I did my first meal, like cooked meal, for everyone maybe two weeks in. I was really, really nervous. 

Paul: What did you make Hosannah?

Hosannah: I made like Caribbean chicken and rice. 

Paul: Oh, nice! 

Hosannah: And I had my grandma on the phone and I was like, okay, what do I need? What ingredients? But the staff helped you out though.

The girls paint a picture of a warm, supportive place. A home of nine residents. One of four homes that RPFI ran.

Key to their treatment there were regular sessions with a therapist. 

Many of them had spent several years in and out of hospitals and psychiatric units, missing out on much of their education, on life. The way they tell it, they felt lucky to get a place at all. 

Clarissa: It took you to almost die many times for them to realise that something different needed to change. So it was not easy at all to get any kind of help and we were, you know, for the few years that we had before, we were very fortunate to have been able to go there.

There’s a clear sense of before and after in this story. 

When Clarissa says ‘before’ she means before their access to therapy was suddenly stopped. 

Before the emphasis shifted, from psychotherapy to… pilates.

Clarissa: It just went from being like the safest place that we’ve sort of felt, in a matter of almost days, weeks, to like being right on the edge again, and just being completely overridden with fear basically. 

And before a man called Vincent Hill abruptly left. 

Vincent Hill was the widely admired care manager at Lancaster Lodge. He oversaw everything. 

Vincent: They would have the first group process meeting in the morning, they might have their own individual therapy during the days, one-on-one with a psychotherapist. Depending on the day, they would either do one-on-one art therapy or group art therapy.

To activities and food shopping. 

Vincent: There’d be a lot of music, playing the piano, singing guitar, etc. and helping to cook and, you know, lay the table. And it was fundamentally all to be part of how to establish the running of a community, right the way from its practical nature of living, cooking, feeding, etc, right the way up to making sure that their rooms were clean and tidy. 

He knew what to do when there was a crisis.

Vincent: If any of the residents were particularly unwell or maybe having suicidal ideation, then they would be on the careful watch and have regular check-ins through the night and through the day. So it was always this ebb and flow of what needed to happen. You had to be very reflexive to each situation.

But in January 2016 that ebb and flow; those routines of therapy and domesticity -– suddenly stopped. 

Vincent: I came back on the Monday of the beginning of Jan to an email that basically had asked me to sack my clinical supervisor, all of the psychotherapists that were supporting the residents, all of the art therapists who were on placement at Roehampton uni. It was as though everything that we’d worked towards had just completely been annihilated. Every plan, every route, every routine, and things that contained and held the residents had suddenly been taken away.

For Vincent it was the final straw, coming after weeks of hostility from bosses – and other staff members.

And he left. 

He was only allowed to return to collect his things – so the first Sophie, Clarissa and Hosannah knew of his departure was when he appeared in the house one Monday to say he wasn’t coming back. 

Vincent: I remember one of the girls just slipping down on the floor, if you know what I mean. Just standing up like that, with her back against the wall and just slumping to the floor. It was incredibly emotional. I’d known these people, they’re not my friends, but they’re people that I’ve worked with and eaten with and played music with and stopped killing themselves, as well as helped them if you see what I mean. I knew them in so many different contexts. And I think there was a mutual respect amongst everybody who worked there and who was a resident there that we would do – that we were there to really support and keep them safe. 

We know now, that fewer than four months after Vincent was forced out – Sophie takes her own life. 

From our vantage point, 5 years on and after the inquest into her death, it seems blindingly obvious that suddenly stopping access to therapy and offering yoga instead, isn’t going to help.

That it is, in fact, dangerous.  

If the so-called “parity of esteem” between physical and mental health care existed, which it should by law, this would be like replacing surgeons with yogis.

But what’s extraordinary is how clear-sighted the residents were at the time, about the disaster that was coming their way. 

And I don’t have to rely on hindsight here – because back in early 2016, some residents were so concerned about the changes at Lancaster Lodge –  that they started secretly recording meetings. They’ve allowed us access to the tapes. 

In many ways the tapes are distressing to listen to because we know what’s coming. 

But also because it’s clear the women know that abruptly removing their access to therapy isn’t just detrimental to their recovery, but dangerous too. 

In the first meeting Sophie herself speaks up.

Sophie: I was at a therapeutic community before this and we didn’t have any external therapy. And like, I was unstable there. And like being here, having people coming in has really helped me.  

The person whose voice dominates the tape, and who responds to Sophie, is Peggy Jhugroo. 

She worked for RPFI, the charity that ran Lancaster Lodge and oversaw its homes, as well as being a youth worker for Wandsworth Council. 

Later she tells the women she’s a practitioner of Reiki, a form of faith healing. 

She defends the decision to cut therapy and tries to outline the new regime that’s starting at Lancaster Lodge 

Peggy Jhugroo: Now I’ve studied a lot about the therapeutic community, I’ve read a few books on it, I’ve visited a few places. Now we’re selling a product to commissioners and to providers that pay for you lot, but we’re telling them we’re a therapeutic community. And yet we are parachuting in people to deal with your therapy. 

Clarissa: Because we need specialists.

Hosannah: I wouldn’t call it parachuting them in. They’re needed as part of our care plans.

Peggy: Okay, so therapeutic communities, the way they were designed was that the therapy starts from the minute you open that door, you enter, the way that you work – that is what a therapeutic community is. That’s what makes people well.

Unknown voice: Why take away the external therapy?

Peggy: Because we’re not a community of therapies. We’re a therapeutic community. 

Listening in, it’s hard not to draw the conclusion that the charity was trying to change Lancaster Lodge – from a residence for people with severe mental health needs, to a facility for people who weren’t as unwell.

That was Vincent’s view, too. 

And what one of the trustees told him was happening when he tried to resist this change in direction. 

But the shift the trustees signed off on meant cutting care, while Sophie, Clarissa, Hosannah, and other residents were still there.

The focus shifts to the community, and not treatment. 

She tells the residents about the importance of getting out of bed in good time.

Peggy: We stay in bed till late in the afternoon, some people. Not having exercise, not seeing more increased improvement. All these things, they’d been happening for a long time and I want to see a further increase. And I don’t think staying in bed till after – is it 10 o’clock or 11 o’clock? What time do you averagely get out of bed? 

Hosannah: It depends how much meds I’ve had the day before. And what kind of day I’ve had. 

Peggy: So what about you Clarissa? Because you go to uni and things. 

Clarissa: Well, when I get to uni I have to wake up at half seven. But it’s virtually impossible, I struggle so much to get up in the morning, yeah, like it’s incredibly difficult. 

Peggy: There have been improvements, but we want to see even increased improvements. A real therapeutic community should be awake at nine o’clock in the morning.

And you can tell Peggy’s attitude to the residents does not go down well. At one stage, she compares the women’s terror at losing their therapy to “taking their toys away”. 

Then she tries to tell them that they shouldn’t get involved in discussions about overnight staffing levels: 

Peggy: If you look at the staff team as your parents and that you’re children, I know that’s not the best analogy because you’re all adults, but putting it in that place, and they tell you all the wrangles, the arguments that go on with mummy and daddy and auntie, and they’re bringing it to the children, the children’s expressing about it.

In contrast – it’s clear that the residents in the room have a very clear idea of their needs.

And they instinctively focus on the details that matter. 

That concern about overnight staffing levels was born from experience, as the women tell a story that should have set alarm bells ringing at the charity. 

Clarissa: Things like staying up until like one, two in the morning, last night –  

Here Clarissa mentions another of the residents

Clarissa: Restraining her, me and Hosannah.

Peggy: Why were you holding her down?

Clarissa: Because there wasn’t enough staff here and this is the problem.

Peggy: So I wasn’t aware of this. 

Clarissa: Were you not? Because, shall I explain what happened? So Hosannah and Sophie were here with her for the first couple of hours. 

Hosannah: About six hours I stayed with her.

Peggy: From what time? 

Hosannah: From around 7:30 or 8:00.

Peggy: Why didn’t you call the staff? 

Hosannah: The problem was even if I’d called the staff, so that’s practically one person, they can’t stop her from harming herself, just one person. And they can’t control the situation and get meds. 

It appears the basic safety of the facility was collapsing, and the residents knew it.

Hosannah: There was one point, I think Clarissa, I think you said to Peggy, what if one of us dies? Like it was that serious. Like she said, what if one of us dies, I think that’s when Peggy said, “oh well, I’d be in jail” or whatever. And it was like, we were trying to explain how detrimental this could be. This could be so bad.

Back in the meeting Peggy Jhugroo makes a great deal of the appointment of a new colleague, Lancaster Lodge’s new clinical lead. 

Once again, the women zero in on the details. 

Peggy: Duncan’s quite high up, you know, but he’s quite hands on. He’s quite a modest person, so he won’t pretend to be anything big, but his name is Dr. Duncan Lawrence. He is proper qualified. Duncan he actually is the clinical operational lead for the whole of the service. It’s four houses that we have. Right, so he’s the clinical – that means he’s clinically trained to do different types of therapies. He trains at degree level, he trains students in counselling and therapy. 

Unknown voice: Does that mean that you’ve got any medical qualifications?

Duncan Lawrence: Yeah, I worked in the medical field as well. 

Unknown voice: So can you administer drugs and things? 

Duncan: I was hired more for a quality assurance role. 

Unknown voice: But what I’m saying is are you actually qualified to do that in the event of anything?

Duncan: Not now, but I wouldn’t take the medication training. 

And the women were right to quiz Duncan Lawrence over his suitability for the job and his training. 

Because Duncan Lawrence was not a medically trained doctor.

In fact, Lawrence wasn’t any sort of doctor. He purchased his degree in administration from Knightsbridge University – a degree mill based in Denmark, incorporated in Antigua and Barbuda, that received its mail in Scotland.

Lawrence was certainly no “doctor of psychotherapy”, as Jhugroo had told residents.

But something else came up in this meeting too. Something which the residents had no way of knowing was a warning sign. 

Peggy: Duncan was actually trained in a therapeutic community at Richmond fellowship by Elly Jansen’s first findings.

That name, Elly Jansen. That’s the warning sign. 

But a series of decisions made by the Charity Commission, which regulates and registers charities, and by lawyers, meant there was no way any of the women could have known this. 

Duncan: This first house was the company’s first house. 

Peggy: So how many years were you with?

Duncan: Four years.

Peggy: Four years. So Duncan clearly knows what a therapeutic community should look like.

Clarissa: But that was how many years ago? 

Peggy: That was how many years ago?

Duncan: It was in the late eighties.

Peggy: Right. But principles haven’t changed. 

Clarissa: Well, they should have, because the times have changed, 

It’s a story that goes back years, but Elly Jansen is always in the background. And so is Lancaster Lodge. 

In fact, there was a good reason why Jansen had to stay in the shadows.

Elly Jansen was born in Holland in 1929, and first developed the idea of a therapeutic community in Amsterdam, while working as an assistant at a clinic for autistic children.

The clinic was understaffed so, as Elly Jansen later told an interviewer, “everything, chores and privileges, was distributed and shared under God’s watchful eye. I was God.”

She came to Britain to study theology in 1954, just as the Queen appointed a high-level inquiry into the provision of mental health care.

Five years later, the inquiry’s findings were passed into law by parliament, and Elly Jansen was actually there, watching from the strangers’ gallery in the House of Lords.

Until then, mental health care had been provided by hospitals. But the new law changed who had access, and where. It meant that privately run residential homes could take in NHS patients, and local councils could fund their treatment there.

Jansen seized the opportunity. She begged, borrowed, and worked to rent a large derelict house in Richmond.

She named it Lancaster Lodge.

Jansen called two psychiatric hospitals, and persuaded them to send their discharged patients to her. She was soon inundated. Using local government grants, she rented and bought more homes to cope with demand.

The Richmond Fellowship, Jansen’s charity, was in business. 

By the early 1980s, the Richmond Fellowship ran 45 homes in Britain. Jansen opened residences around the world, running the charity like a franchise.

There were 24 in Australia and 16 in the US. There were residences in New Zealand, Austria, Hong Kong, and India. There were plans for Malta, Zimbabwe, and many other countries. 

By this point, it was already one of the largest mental health care charities in the world.

And Jansen, who was honoured with an OBE, ran it, one person said, as a “family business.”

Jansen and her husband bought a number of the homes, including Lancaster Lodge, and leased them to another of their charities that sub-leased them to the Richmond Fellowship. 

Each year, the charity paid or owed them hundreds of thousands of pounds – all the while Jansen drew a substantial salary as director and charged personal expenses to its central account.

It was this mismanagement that got Jansen forced out of her own charities in the 1990s. And it was then widely assumed that Jansen had retired.

The second secretly recorded meeting at Lancaster Lodge takes place in March 2016. 

The home is now in crisis and the residents know this because they’ve alerted the Care Quality Commission, which inspects and regulates care services.

Peggy: I don’t know if you’ve all spoken to safeguarding. 

Unknown voice: No. 

Peggy: Well, they will be back. 

Unknown voice: Why? 

Peggy: Because there was an alert from somebody and basically it was alerted that the house is so unsafe that they have to come down. So they’ve got to speak to all of you. See how you feel about the place. 

The CQC’s senior inspector would say that he’d never experienced so many safety concerns being raised within such a short period. 

His report, which wasn’t published until June 2016, three months after this meeting, is a parade of red flags.

It said: Lancaster Lodge didn’t have a registered manager. Key documents were missing and records weren’t kept up to date. The new staff were inexperienced and unqualified. They mixed up residents’ medicines. They weren’t even making sure that residents were eating and drinking properly. And they weren’t safeguarding them from abuse.

In all, the inspector found seven breaches of the Health and Social Care Act and CQC Regulations.

But the CQC did not act quickly enough.

Quite soon the decline was so complete that most of the women, including Hosannah and Clarissa, were no longer there. They’d been sectioned and removed to hospital, and when they were discharged they were sent elsewhere. 

Clarissa: I just can’t describe how guilty I feel for us being removed. And she was left there. We had, four out of six of us had gone, I think that was the right number, it was a large proportion, had been removed from that situation. And that wasn’t our choice. We didn’t say, oh, we need to get out of here and someone lifted us out. You know, we were sectioned. 

But Sophie Bennett remained. 

Clarissa: We were put into a hospital with no say in it, but the guilt that I still feel for getting saved, and she was left behind. 

And her father Ben believes that a conscious decision was made, not to allow Sophie to go to hospital, to be sectioned

Ben: They got to the stage at Lancaster Lodge, where if that happened, then the commissioning authority would not put them back there. So Clarissa left and didn’t come back and then the other woman left and didn’t come back. I think they wanted to keep Sophie. As soon as Sophie steps in an ambulance she’s not coming back here. 

Sophie should have been put into an ambulance to A&E on 28 April 2016. We know this because during the inquest the jury was given a transcript of a call between Lancaster Lodge and a crisis line, in which the advice was unequivocal. Call an ambulance. Get her to hospital. 

And I have to warn you here, what I’m about to talk through is distressing. 

Earlier that morning Sophie had been seen crying, and she told a staff member she was feeling suicidal. Broken cups, a razor, tweezers, a metal rod and scissors were all found in her room.  

Staff found she had cut herself and saw a mark on her body that was consistent with a unnoticed suicide attempt she had made previously. 

She was placed under close observation and when a staff member called that crisis line, she was told: 

Katie Gunning: “We cannot just assume that she’s not going to do anything. So, when you’ve taken her to A&E they’ll do that assessment and see whether she should be referred to in-patient, or go back, whatever they decide, we take it from there.” 

But the charity didn’t call an ambulance – or take her to A&E. 

On 2 May, four days after they were told to take her to hospital, Sophie was refusing to talk and pacing around.

A note in the staff communication book reads:  “[Sophie] had a better morning today but has not been in a good place this afternoon – suicide + self harm ideation at 5. Keep [under] close obs[ervation]… I feel that her impulse levels are high…” 

That afternoon, despite this instruction to keep her under observation, she was allowed to take a bath in a room behind a closed door. 

The evidence suggests she was not checked for 15 minutes. 

She was found unconscious after making an attempt on her own life. 

Ben: On the Monday, the bank holiday Monday when my wife had just come home, we were just having something to eat. And then suddenly the police turned up with a blue light outside our house. And we went in a police car and blue light to Kingston hospital, really, really quickly, I mean and I think, we just knew this was bad news… 

She died, two days later, in Kingston Hospital.

“Today an inquest found neglect by the charity running Lancaster Lodge contributed to Sophie’s death. They picked out multiple failures including staff without relevant qualifications…”

ITV news clips about Sophie’s inquest

The inquest into Sophie’s death, held in February 2019 at the West London Coroner’s Court, was damning about her care at the hands of the RPFI charity and Lancaster Lodge. 

“The jury tonight delivered 16 different points of failure in Sophie’s care: inadequate training of the staff, changes made at the lodge which didn’t need to be made…

Channel 4 news clips about Sophie’s inquest

But it also revealed something else that was shocking. 

While the residents and their families knew the names of the staff at Lancaster Lodge, and they knew who the trustees of the charity were, none of them knew who, in truth, was making the decisions that had led to this disaster.

Ben: It began to dawn on me that Elly, this elderly woman, was controlling that place absolutely.

It was Elly Jansen, the now 91-year old we met earlier, whose influence drove Vincent Hill out of the charity. 

Vincent: It became a bullying dictatorship. And I know that the number of the other senior directors who were there equally felt bullied and dictated to by Elly and that’s why they left very quickly. She was everywhere. The threads were there that ultimately anything that went on there had to be sanctioned by Elly.

Jansen, who was cast out of her charities in the early 90s, was controlling RPFI – and few people realised the extent of her influence, because she was neither a trustee nor employee. 

Outsiders would have no means of seeing her grip on the charity.

For a while she was kept in check by her board of trustees, but eventually, they too were forced to resign, and the changes that led to Sophie’s death were set in motion. 

Resigning from the charity is a decision that still haunts Lyn Dade. She was chair of the trustees up until the middle of 2015. Before she left she wanted to make sure that the charity was able to continue its valuable work at Lancaster Lodge. 

Lyn Dade: So that’s what all our efforts were about. Mostly they were about preserving Lancaster Lodge and the wonderful work that was going on there. Which makes it even more ironic that, you know, Vincent was marched out the building and the whole thing resulted in the suicide of a beautiful, but very vulnerable young woman who frankly deserved so much better.

We’re putting Elly Jansen in the firing line here.

And yet she’s very elderly and in poor health. She has a long track record of mental health provision behind her. Perhaps this seems unfair. 

Not least because her name never appears on the paperwork.

And there’s a reason for that. It’s why this story tells us so much more than just a single, tragic case – it’s about a system that cares for vulnerable people, and that has gone wrong. 

In 1988, the Charity Commission – that’s the government body that regulates and inspects charities – received allegations of mismanagement at Elly Jansen’s charities. The allegations pointed to Jansen’s role and influence at the charities.

And here’s where it gets complicated, because Jansen was a director or a trustee of a host of charities with all vaguely similar names. 

There’s the Richmond Fellowship, the Fellowship Charitable Foundation, the Richmond Fellowship International. Later there’s also the Richmond Fellowship Foundation International. Which becomes Richmond Psychosocial Foundation International, or RPFI. 

Confused yet? 

It’s possible that is the intention. Certainly, the Charity Commission was confused by the flow of money between the charities and the Jansen family.

Its findings managed to force Elly Jansen out of her original charity, the Richmond Fellowship. 

When you hear about any English charity scandals, be it Kids Company, Oxfam, Save the Children, or the Cup Trust, the Charity Commission is usually not involved until things have run their course. 

So, true to its timid form, back then it only “invited” her to resign her trusteeship of a second charity. 

And she simply chose not to. 

Lyn Dade: You know, the basic question is why after the revelations about Elly and Richmond Fellowship, the Charity Commission allowed her to set up other charities. Why? How could that possibly happen?

That’s Lyn Dade again, a former trustee. When she began volunteering at RPFI in 2014 she didn’t know any of this, nor when she took over as Chair soon after. 

Lyn Dade: She is very charming and she is also a very powerful woman. I mean, she walks into a room and there’s an aura around her, you know, you can feel it. 

Lyn set out to get to know the charity better.

Lyn: The first thing that I wanted to do as chair was to go round to each of the four houses and meet the staff and get a feeling for, you know, what was going on and how things were and so on and so forth. Elly did not like that at all. She didn’t want me to go. “Why do you want to do that?” And I said, well, look, I’m chair of the board. I need to understand, I need to meet these people. They need to meet me. And I need to understand if there are any issues or problems

Lyn found one house which was hardly being used. Another had staff members in conflict. There was one bright spot.

Lyn: Lancaster lodge was the jewel in the crown and I mean, Vincent did the most, oh gosh, I mean, it was just so impressive as a therapeutic community. It’s incredible, incredible what he was able to offer mainly troubled young people, you know, like lovely Sophie. Vincent was amazing. And he had a great team around him. It was deeply impressive. 

But there was an issue.

Lyn: It quite soon became clear that Elly didn’t actually want me to do anything, but endorse her decisions. That was my job. 

It’s around this time that Lyn chats to a fellow volunteer, and learns for the first time about what she calls “the Guardian file”. 

Now these are articles she would never have found herself. They are inaccessible to anyone without paid-access to archives, or the time to look them up in a library.

You won’t stumble across them because of a legal settlement from 1995, and I’ll come back to that. 

But first we need to meet David Brindle. He was the Guardian newspaper’s social affairs correspondent between 1988 and 2020. It was Brindle who had reported the stories that Lyn found in “the Guardian file” but whose byline never appeared on another piece about Jansen or her charities. 

When I tracked him down for this story, Brindle said: “I’ve been waiting for someone like you to come along for 30 years”.

David Brindle: There had been an initial article about Elly in the Sunday Times. Then a year later managers within the Fellowship Charitable Foundation, which was one of her charities, approached me with concerns about the way it was being run. Their concerns were raised with the charity commission, which reported in 1992, expressing the view that while there was no evidence that charitable funds had been diverted for private use, nonetheless, she had failed to separate her own personal financial affairs from those of the charities with which she was then involved.

David writes his first article on Elly Jansen and her charities on the back of that 1992 Charity Commission report. 

David: She had flatly refused to resign, and within weeks of that first Charity Commission report in 1992, her lawyer, Arnold Goodman and David Astor, her champion, and former editor, famous editor of the Observer, wrote a letter to the Guardian in which they said she will not be resigning.

Looking back on this now it seems an odd way for the Charity Commission to have gone about its regulatory business, to have invited somebody in this position to step down rather than to direct it. And of course if the person then flatly refuses and says, “I don’t accept your inquiry findings”, they had nowhere else to turn at that point.

So managers who were continuing to see the same patterns of behaviour on her part in terms of the intermingling of her personal financial affairs with those of the charities: shopping, driving lessons, insurance, travel, all being paid for from the charities bank account. They continued to raise their concerns through me.

David Brindle then wrote a flurry of articles between April and July 1993, outlining concerns that all eight managers of homes run by the Fellowship Charitable Foundation had complained to the Charity Commission about financial mismanagement by Jansen and her undue control over staff and decision-making. 

Elly Jansen was finally publicly pressured into resigning her trusteeship of the charity. 

And then she sued the Guardian and David Brindle for libel; because their reporting alleged she had stolen money from her charity. She argued that David: 

David: Had neglected to point out that, in her view, she was owed at any one time much more by way of money she had said she had loaned to the charity than she was drawing in any expenses. 

A criminal barrister told the Guardian that the material available to the newspaper presented a clear case of theft and of false accounting. He also suspected Jansen guilty of a conspiracy to defraud and to steal. But… 

David: It turned out not to be the view of our counsel we retained. George Carmen QC, who was perhaps the most famous barrister of his age and his view was that we would struggle to prove that Elly Jansen had stolen money, partly because of the very complexity of the network of charities.

So, on Carman’s advice, the case never went to trial: the Guardian reached an out-of-court settlement with Jansen. The newspaper paid her damages and legal costs, made a donation to charity and printed an apology. 

It was a decision that would cast a long shadow.

David: I think that settlement basically put a cap on, certainly the Guardian’s investigation of Elly Jansen’s affairs. And I imagine it also sent a clear warning to other media organisations about what would happen to them if they pursued similar avenues of inquiry.

The reporting stopped; what was published was lost in pre-Internet archives. 

And that 1992 Charity Commission report? 

That’s disappeared too. The Charity Commission lost its own files on its investigations. 

And so, when everything began going catastrophically wrong in 2015, there was no way of knowing what had gone before.

Elly Jansen’s name doesn’t reappear in the public domain until Sophie Bennett’s inquest.

But if you scour the records at Companies House her name does appear. In 2006. This time on the incorporation of a charity called Richmond Fellowship Foundation International. 

After being forced out of her charities in the early 90s, and then laying low for a decade, Jansen was back. 

It’s this charity which becomes RPFI, the outfit running Lancaster Lodge. 

And the same organisation which in 2015 the chair of trustees Lyn Dade has just discovered is in terrible shape. 

It is close to insolvent, has no real assets and it’s finances are closely bound up with that of the Jansen family. 

Not only that – now Lyn Dade knows the backstory. 

She’s found a set of minutes that’s been altered between board meetings to allow a payment to Elly Jansen of £100,000. 

Now she’s concerned the charity could face allegations of theft. So she goes to the Charity Commission for advice 

Lyn Dade: And basically we were sent off with a flea in our ear. We can’t help you. And I mean, we were devastated because we’d always thought that we had the Charity Commission’s support, if you like, in our back pocket.

The Charity Commission was meant to be Lyn’s nuclear option. She hoped they’d come in and take over. 

Because this is a charity working in mental health. The stakes are high, it matters, right? 

Yet the Charity Commission doesn’t help. Back in the 90s it simply “invited” Elly Jansen to resign. 

Decades later, it chooses to do… nothing. 

Lyn: We basically saw the writing on the wall. And in the end it was the solicitor who said, look, why don’t you just resign? Resign as a board, let Elly have the charity and just walk, because you’re between a rock and a hard place. She won’t work with you. You’re responsible, but you’re not in control. So we did, we got the accounts filed first up to March 2014 because that was important. But then we walked. 

And without the trustees who would keep Lancaster Lodge safe? Jansen had her way.

RPFI hired Duncan Lawrence, who had worked for her before. It also hired Peggy Jhugroo.

There’s a clear path from that fight with trustees over financial mismanagement to the disaster of 2016. The organisation with the power to intervene is the Charity Commission. 

It’s own guidance says, basically, the more important a charity is to its clients, the more important it is that it is run carefully and sustainably. 

Lancaster Lodge literally kept its residents alive.

It ought to have been a high priority for the regulator. RPFI was bringing in more than a million pounds a year. So in income terms it was in the top 3 per cent of institutions.  

It served very vulnerable people. 

And the complaint came not from a member of the public but from the chair of the trustees. 

Yet it did nothing.

The Charity Commission has the power to demand sweeping changes to charities and ban people from charity leadership. But it rarely uses them. 

It is, as one government figure put it, more of a “register” of charities than a regulator. 

In this case the Charity Commission didn’t know who Jansen was, because they’d lost their records of their investigation into her. 

That incompetence in the 1990s meant they couldn’t do their job properly in 2015. 

The charity commission told us: 

Gary Marshall: “The coroner who investigated the circumstances of Sophie’s death found that failings in the charity’s leadership and oversight were in part to blame. We opened a statutory inquiry into the charity, focused on assessing what had gone wrong, and putting it right for the future. That inquiry remains ongoing.”

The contrast with physical care is stark. When problems blow up in the NHS, we have a public inquiry and wall-to-wall press coverage. Here we had an inquest that barely made the inside news pages. 

We know no action was taken against Elly Jansen. She kept her name off the paperwork. But what of the others?

Jhugroo was fined £3,000 for her part in the mismanagement of Lancaster Lodge. The charity RPFI was fined £40,000. 

Duncan Lawrence was sentenced to four months in prison for refusing to comply with the inquest into Sophie’s death – though he has no conviction in relation to his professional conduct.

We asked for a comment from all three. 

Elly Jansen hasn’t replied. Peggy Jhugroo has a new name – Marilene Peggy Moylan – and we tracked down her number and email, but again no response. 

We hand-delivered Duncan Lawrence’s letter to his home. He told us he might give us access to all his emails and photos that would prove him to be a whistleblower, in return for what he called “an incentive”. 

When we asked if he meant cash, Lawrence said he’d reflect on his “wish list” for the documents. We declined.

What of the CQC? It noticed the decline at Lancaster Lodge but Lawrence and Jhugroo were still in post when Sophie died two months later.

The CQC told us: 

Matt Russell: “CQC visited Richmond Psychosocial International in March of 2016 rating the service ‘Inadequate’.” 

They note that RPFI was issued with two warning notices and a “notice of proposal” – the beginning of action against the charity – before Sophie died. And that they took further action afterwards – including prosecuting RPFI and Jhugroo.

And the Bennett family? Ben, Sophie’s father, says each move felt like a “battle”; the whole campaign has been an “obsession”. 

Ben: On a personal level, it’s been life changing for us, for my family. I’ve given up my career. I’d become useless at work, I wasn’t sacked or asked to go, but I needed to get out of it because I wasn’t functioning really. And then our family has been really affected. My wife and I have separated now.

He feels exhausted, broken, and defeated after five years of fighting for what was theirs, and Sophie’s, by right. 

If the measure of a state is how it treats its vulnerable, then in Sophie’s case there is complete failure.

Vincent: She was a delight. I will always remember her on that basis. As much as you see people’s distortions and how they act out etc. And I had to restrain Sophie a couple of times as she was a harm to herself and all of those things disappear because that’s just part of a person, it’s not all of who they are. And she had so many other wonderful qualities. And those were the bits that made everyone laugh and smile. 

This story was reported by me, Paul Caruana Galizia and by Chris Cook. 

It was produced by Katie Gunning, with sound design by Tim Clay. 

The editor was Basia Cummings.

Next in this file

Fatal flaws

Fatal flaws

The death of Sophie Bennett might have been prevented – were it not for a series of failures by those entrusted with her care, including the state

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