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From the file

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.

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

Sophie Bennett’s death was preventable. The tragedy of her case is that she, a London teenager who died at 19 years old in 2016, could still be alive – but for the catastrophic failure of the charity entrusted with her care.

Sophie had bipolar disorder and spent her teenage years in a cycle of hospitalisation. But she had been doing better at Lancaster Lodge, a “therapeutic community” in West London. A corner appeared to have been turned in her care. Then, suddenly, her safe residence became dangerous – and not just for her, but for all the residents of the house. 

Starting in January, just a few months before her death, established medical practices were cut back. The residents’ access to therapy was suddenly stopped. Staffing levels became a worry. Sophie’s death – a suicide – could be seen as the ultimate consequence.

She was a victim of a horrendous and sudden crisis that started that January. Over four months, the community she lived in, a residence that had kept her safe, was destroyed. It ceased to be a space where residents recovered together. 

But this sudden crisis was years in the making. The charity running Lancaster Lodge, the Richmond Psychosocial Foundation International, was not what it seemed. The names on the paperwork were not the names of the people making the decisions. Only a coroner’s inquest revealed that, in truth, someone else was secretly running Lancaster Lodge. 

The real authority in the home was someone not known to the residents nor their families. Someone whose name would have been a shock to anyone who recognised it. 

This is a story about how charities in the UK can be entrusted with the most vulnerable of people. They can be given public money to discharge crucial responsibilities. And no-one is watching closely enough to make sure that the wrong people are not running them. 

In principle, RPFI was regulated by two bodies. One, the Care Quality Commission, was there to make sure its services were safe and up to standard. The other, the Charity Commission, was there to check that the charity was managed by appropriate people and spending its resources correctly. But the two institutions – particularly the Charity Commission – do too little, too late in this story.

And the story matters even beyond the immediate tragedy of Sophie’s death: her situation was not unusual. There are 1,800 residential homes in England offering care to working age people with serious mental health conditions. 

Sophie Bennett’s death can be seen as a result of their decades-long total failure to police the charity sector.

In January 2016, a group of residents and staff met in Lancaster Lodge to discuss ongoing changes to the regimen. And, unknown to the staff, someone was secretly recording what was said. The tapes, heard by Tortoise, reveal that the residents were clear-sighted about the disaster that was coming – fewer than four months before Sophie’s death. 

Hosannah Kirton, a resident at the time, told us: “We were trying to explain how detrimental this could be. This could be so bad.”

The person whose voice dominates the tape is Peggy Jhugroo, who worked for the RPFI and oversaw its homes. She is there to explain the changes that were being made to the facility. The residents were uneasy – not least since the widely admired care manager of the facility, Vincent Hill, had suddenly just resigned over changes being made to the charity. 

Hill had been diligent – and respected. For the young women who lived there, who had often spent years falling in and out of acute wards in psychiatric hospitals, he created a home where they could remember how to live for themselves. He told Tortoise that he put focus on “the practical nature of living, cooking, feeding… All the way up to making sure that their rooms were clean.”

The community aspect helped with this. Cooking and shopping, for example, were important communal activities. Kirton said: “I think I did my first meal – like, cooked a meal for everyone – maybe two weeks in… I made Caribbean chicken and rice. I rang my grandma and I was like, ‘Okay, what do I need? What ingredients?’” 

“But the staff helped you out… it’s like getting back into the swing of normal life outside of the hospital, kind of reintegrating… The staff and everyone in the house was just so supportive and just normalised these things that we’d sort of worked up in our heads were impossible or never going to do again.”

But central to the Lodge’s success was a regimen of therapy on top of this collective home life. The residents were monitored weekly. Hill told Tortoise they reviewed “their progress, what they needed to do if they had any visits or had to go and see their psychiatrists… It was a continual ebb and flow of information.” He wanted to “create the best sort of safe home environment. And, at the same time, quite a strong therapeutic overview.”

When Hill speaks about Lancaster Lodge, his language is thick with references to strategies and ideas in psychotherapy. Jhugroo, by contrast, was a youth services worker at Wandsworth Council. She also revealed to the group that she was a Reiki practitioner – a form of faith healing.

Peggy Jhugroo arriving at Uxbridge Magistrates’ Court to be sentenced over the death of Sophie Bennett

The change in regime she outlined was alarming to the residents. Their concerns were very clear and well articulated: Lancaster Lodge’s residents were suddenly being cut off from therapists recruited from outside to offer specialist support. 

Hill told Tortoise: “It was as though everything that we’d worked towards, it had just completely been isolated, every plan, every route, every routine… had suddenly been taken away… None of us were consulted on a clinical basis as to how this might affect the residents.”

He left.

In the meeting, the residents were unnerved. Sophie herself speaks up: “I was at a therapeutic community before this and we didn’t have any external therapy…. I was unstable there. And like being here; having people coming in has really helped me.”

But Jughroo defended the decision to cut therapy, noting that if they still needed the support, the therapy was not working. One resident pointed out that she has only had a short spell of therapy: “I’m coming to the crux of my work, because I came out of hospital a year ago, done a lot of work and we’re getting to the point where I can go deeper. It’s just all being taken away from me.”

The meeting raised other issues that should have set alarm bells ringing: Clarissa Jeffery, another resident, told Jughroo that she had been “up until like one, two in the morning, last night with [another resident] restraining her. Me and Hosannah holding her because there wasn’t enough staff here.” A resident had tried to hurt herself the night before, but the staffing levels had been allowed to drop such that the residents themselves were forced to try to stop her. 

Jeffery said there was “one agency staff and there’s one new member of staff. The agency staff… had no idea what to do at all. In fact, she was adding stress. She was adding fuel to the fire, basically.” In addition to removing the therapy, the basic safety of the facility had collapsed. 

This appears to have been the result of a deliberate strategy. Before he resigned over the changes to Lancaster Lodge, Hill had taken his concerns about cutting the therapy to the charity’s trustees, one of whom told him that they would need “different clients in there”. (RPFI, which still exists, has declined to comment.)

Lancaster Lodge was being changed – from a residence for people with very severe mental health needs to a facility for people with much more moderate needs. The shift the trustees signed off on, though, would mean cutting care with the current residents still there.

At the meeting with residents, though, Jhugroo did not say this. She justified it as being about the Lodge’s “school of thought”. She told the residents’ meeting that the atmosphere of Lancaster Lodge was the intended therapy: “everything from making your bed to making a cup of tea…. We’re not a community of therapies. We’re a therapeutic community.” 

Jhugroo’s attitude did not endear herself to the residents. On the tape, she compared the relationship between the care managers and residents to that of children and their parents. She compares the residents’ terror at losing their therapy to “taking all the toys away”. 

She places great emphasis on physical exercise and getting residents out of bed early – something which the residents noted is often very difficult, thanks to their sometimes-heavy drug regimens. 

Kirton told Tortoise: “I think they thought that we were kind of really, like, loopy and, you know, not unaware of what was going on. And they were very surprised that we would be so proactive.”

The new direction envisaged more sport and other activities. But the people present were appalled. One of the residents’ mothers sat in on the meeting: “Individual therapies, they’re hugely important. Hugely important. I know I’m going to fight for [my daughter] to keep her therapist. It’s taken a year to get to this point. I don’t care whether they put the funding in Tai Chi. If Hosannah doesn’t want Tai Chi and wants her therapist, give her the therapist.”

Clarissa said: “They just saw us as mentally ill patients that had no voice, no capacity to actually understand a conversation…. They just thought, well, we would accept it. We were not going to accept it at all.”

Jhugroo also made a great deal out of the appointment of a new colleague – Lancaster Lodge’s new clinical lead. Speaking to the group, she said: “Duncan’s quite high up…. 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 is a clinician that’s come in… Duncan… is the clinical operational lead for the whole of the service. Four houses that we have…. He’s clinically trained to do different types of therapies…. He trains at degree level, trains students in counselling and therapy…”

“Does that mean you’ve got any medical qualifications?” one person asked.

“Yeah. That, and I worked in the medical field as well,” he replied.

“So can you administer drugs and things?… Are you actually qualified to do that in the event of anything?” she replied. 

“Not now, but I am going to take the medication training as well.”

“He is a doctor,” Jhugroo chimes in, “of psychotherapy.”

In that meeting, the residents’ questions about Lawrence’s experience would prove to be very perceptive. Their terror about the decision to cut the access to therapy was well articulated. And the problems with supervision and safety had been aired. 

In that meeting, the threads that formed the backdrop to the end of Sophie’s life had been exposed. 

Part of the tragedy of Sophie Bennett is that the decline and her death took place just as she had been turning a corner. She had spent her teenage years in a cycle of repeated hospitalisations – but she seemed to be levelling out after years of difficulty and pain. 

Her father, Ben Bennett, says that Sophie had managed to hold herself together as a young girl, but “when she went to secondary school, it didn’t work anymore. And I think the whole thing came tumbling down for her.” She had been sectioned for the first time at the age of 14. 

“I have such a clear memory of… St George’s [Hospital], but then Springfield mental health hospital… such a clear memory of accompanying her in the middle of the night to the psychiatric ward.” She spent spells, he said, in this unforgiving Victorian creation – “literally prison architecture.”

She eventually went away to a residence – Thornby Hall in Northamptonshire – where she made some progress. But as she became an adult, she needed somewhere new to live – and her mental health was fragile. Bennett said: “We ended up with all sorts of really unpleasant incidents… I remember physically stopping her drinking bleach.”

But they managed to find a place at Lancaster Lodge. Kirton recalls her arrival: “She hardly spoke. I could tell that she was quite nervous and I was trying to reassure her because of course I was new as well. I had only come like a week before and, yeah, it was just a slow climb.”

Hill had the same view: “She was very quiet. Initially, it took her time to find her voice, but I think she settled in and, as we began to sort of put forward much more positivistic affirmation of who she was and the things she could do, then she began to come out of her shell… and it took her time, as it does for most residents.”

Sophie Bennett

She took to the regimen. Hill says that, by the time he left at the end of 2015, “she had changed dramatically. She… was in that beginning of that upward recovery process, she was stronger. She was happier. She was having much better relations with her parents…. 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.”

But after Hill left, the change in the care regimen was a disaster for all the residents. The crisis at Lancaster Lodge was sudden and extraordinary. 

The Care Quality Commission, which oversees standards in care facilities, made a surprise inspection in March 2016, midway through the descent. They found “the home did not have a registered manager”. There was no-one accepting “legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.”

This initial report is a parade of red flags: “The new staff were not knowledgeable about the people they worked with. They had inappropriate experience and qualifications. In spite of their best efforts and hard work to provide care in a supportive and friendly way, they did not have appropriate experience and qualifications to. This was not successful beyond meeting daily basic needs.”

It added: “People told us that they were not given the opportunity to choose the way that their individual and group activities would be delivered. Rather they were presented with a new method of service delivery that concentrated on therapy being delivered in-house.”

At a meeting at around this time, also secretly recorded, one person reveals that a member was astonished she had been asked to take on a new set of responsibilities. She “was incredulous that she didn’t even ask to be deputy manager. She said to me, I can’t believe they asked me to be deputy manager because I’ve never experienced running… a home. I’m an art therapist.”

The inspections revealed that errors had started to be made in basic safeguarding – such as giving the residents the right medication. Kirton told Tortoise: “Sometimes they give you more meds than [your prescription]. There were like two other people at the time who had ‘H’ as [the first letter of] their name and that was their excuse.” 

The CQC issued warning letters and began regulatory action: two warnings and a “notice of proposal” – the start of regulatory action. But the home was in free fall. Their action was intended to spur a response, but it left those residents in the care of the same people.

Quite soon, Jeffery said that the decline was so complete that most of the residents had been removed from the home after being sectioned and removed to a higher level of supervision in hospital. “Four out of six of us had gone… a large proportion. We had been removed from that situation. And that wasn’t our choice. We didn’t say, oh, we need to get out of here. Someone lifted us out. You know, we were sectioned.”

Sophie, however, was not – and Jeffery feels survivor’s guilt about her death. “We were put into a hospital with no say in it, but the guilt that I still feel for getting saved. She was left behind.”

On the morning of 28 April 2016, Sophie was observed crying. She told a staff member she was “feeling suicidal” – and staff found broken cups, a razor, tweezers, a metal rod and scissors in her room. They discovered she had cut herself and had a mark on her body that was consistent with a previously unnoticed suicide attempt. They placed Sophie under close observation.

A staff member called the “crisis line” for advice on what to do. Their advice was clear: call an ambulance and get Sophie into an acute hospital ward. They were told:

“Express your concern that you think she needs to be assessed, and especially when you go to express your concern to her that we cannot just assume that she’s not going to do anything. So, when you’ve taken her to A and E they will 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 did not do what they were told. They kept Sophie under their own care. Over the following days, she continued to show signs of dangerous behaviour. On 2 May, she was refusing to talk and “pace[d] around with a blank expression.” A staff member recorded in the Staff Communication Book that “[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 on for 15 minutes. She was found unconscious at her own hand. She died, two days later, in Kingston Hospital.

At the coroner’s inquest that followed, the jury concluded that Sophie’s death was contributed to by “neglect” on the part of the charity. The “leadership and oversight of the RPFI board was grossly inadequate”.

Nickie and Ben Bennett, the parents of Sophie Bennett

As the Bennett family’s lawyers wrote in a letter to the Crown Prosecution Service:

“No witness in the inquest (including Ms Jughroo) sought to suggest anything other than that the home had become chaotic. That was triggered by the misconceived decision, without consultation, to cancel all external therapies, and thereafter the home being in the hands of Mr Lawrence.”

The jurors in court found that staff “did not hold the relevant qualifications for the roles in which they were carrying out responsibilities.” Residents felt unsafe as a result of staff being “in the deep end” and “learning on the job”. Changes at Lancaster Lodge had been implemented based on the results of a one-day audit which was “grossly inadequate”.

But the inquest also revealed something else. The residents and their families knew the names of the staff at Lancaster Lodge. They knew who the trustees of the charities were. But none of them knew who, in truth, was making the decisions that had led to this disaster. 

The RPFI and Lancaster Lodge they knew was a mirage.

If you check the charity’s filings, a single name is listed as an adviser to the trustees: Elly Jansen OBE. She was once a big name in the British charity and mental health sectors. 

But Jansen was in her mid-80s. She had founded the charity, in its latest form, in the mid-2000s, briefly serving as an employee. Ben Bennett, an accountant by training, had checked on RPFI’s accounts when Sophie first went to Lancaster Lodge and assumed this “adviser” title was an honorific for a long-retired grandee. 

At the second secretly recorded meeting, Jansen’s name is mentioned. She was, Jhugroo said, an “amazing woman”. But Jhugroo plays down her influence. “She’s just, sometimes you need an expert person, but they’re not allowed to vote [on the charity’s board], but she might bring recommendations.” One person asks if she is a silent partner – an idea that Jhugroo firmly dismisses. 

But Jansen was pivotal. As the Bennett family’s lawyers put it in a letter to the Crown Prosecution Service, Jhugroo’s “experience was in youth work and she had no experience at all of therapeutic communities or specialist mental health provision. The training she received was from Ms Jansen, delivered in Ms Jansen’s front room.” 

At the inquest, RPFI produced no evidence of any interview of Dr Lawrence, nor any attempt at reviewing his credentials. At the inquest, Jhugroo would refer from the witness box to Jansen hiring Lawrence. 

But Lawrence, it transpires, was not a medically trained doctor. Nor, indeed, any sort of doctor. He purchased his degree in administration from a degree mill – Knightsbridge University, a company based in Denmark which is not accredited to issue degrees by any reputable body. He was certainly not a recognised “doctor of psychotherapy,” as Jhugroo had claimed in that first meeting.

His real qualification, instead, was much simpler. He had worked for Jansen before. In fact, in that first ill-fated meeting, he revealed he had worked at Lancaster Lodge for Jansen in the 1980s for four years. Jhugroo boasts to the residents that he was trained by Jansen.

Duncan Lawrence at Wimbledon Magistrates’ Court for a plea hearing after he was charged with withholding evidence in relation to a coroner’s inquest

It was Jansen whose influence drove Hill out of the charity: “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 they, that’s why they left very quickly… She was everywhere. The threads were there… Ultimately, anything that went on there had to be sanctioned by Elly.” 

Jansen had, indeed, forced out trustees who stood up to her. Lyn Dade, who was the chair of RPFI’s trustees until mid-2015, stated that Jansen was actually listed as the former CEO’s line manager. In Dade’s view, this made her a “sleeping director”. Jansen drove out Dade in mid-2015 and started implementing the changes that could be said to have led to Sophie’s death.

Jansen’s name, though, never appears on the paperwork.

Indeed, Jansen had to stay in the shadows.

The sixth of nine children born to devoutly Christian parents, Jansen was ten years old when Nazis poured over the Dutch border. “For five years,” she said, “we were frightened and hungry. We children would go round the farms begging for food, or scour the woods for fuel…. And those years made me very persevering. I am not easily discouraged, I learned to take strain.”

Jansen paid her way through university in Amsterdam by working at a clinic for autistic and “other problem children”. The clinic was understaffed, so she developed a community “whereby everything, chores and privileges, was distributed and shared under God’s watchful eye. I was God.”

A theology course called her to Britain in 1954. That year, a Royal Commission was appointed to study the provision of mental health care. It reported, three years later, that patients should be cared for in community settings – not just hospitals. It would be another two years until the Commission’s recommendations passed into law during a House of Lords debate – and Jansen would be there, watching from the Strangers’ Gallery. 

After leaving the Lords that day in 1959, she abandoned her plans to do missionary work in Sudan. After all, she “always took to the psychotic,” feeling “there was a very narrow line between sanity and insanity,” and with the legal change she could bring her interest and purpose together. 

Jansen worked to rent a large derelict house at 21 Lancaster Park in Richmond, South-West London: Lancaster Lodge. She called two psychiatric hospitals, persuading their staff to send discharged patients to her. “[T]he need was so enormous,” Jansen recalled, “I shouldn’t have been surprised at the huge response.”

Elly Jansen OBE, pictured in 1981

The Richmond Fellowship, Jansen’s first charity, was in business. By the 1980s, she had a web of interwoven charities, notably the Fellowship Charitable Foundation. She ran around 45 residences in Britain, and the Richmond Fellowship brand was on some 24 residences in Australia and 16 in the US. There were residences in New Zealand, Austria, Hong Kong, and India. There would soon be plans for Zimbabwe and many other developing countries. It was one of the biggest mental health charities in the world.

But, by the 1980s, serious problems were evident. She had married George Whitehouse – and they set up a trust for their benefit in 1974, the “Whitehouse Settlement”. But it was hard to work out where the Richmond Fellowship charities ended and the family’s finances began.

For example, the trust and Jansen owned a number of the Richmond residences, including Lancaster Lodge. They “leased” them to one charity who, in turn, allowed the Richmond Fellowship to use them. By 1988, the charity was making annual rental payments of £65,700 (£216,000 today) to the family – in addition to Jansen’s salary as director of the Richmond Fellowship, which went from £20,000 (£66,000) in 1982 to £48,500 (£106,500) in 1991.

The rental arrangement was informal, to say the least: minutes confirm that there were no “formal leases in existence [with] the Whitehouse Settlement”. It would later emerge that Jansen had, for example, billed a variety of expenses to the charity, including groceries, travel, and a high-end kitchen for one of the houses that didn’t suit the residents’ needs.

Jansen, though, was at the height of her power and influence. Her patrons were influential: Princess Alexandra; the archbishops of Canterbury and Westminter; the Chief Rabbi; Lord Goodman, a lawyer who chaired the 1970s Committee of Inquiry into Charity Law; and David Astor, editor of The Observer. Goodman and Astor would say “[h]er fame is international”.

During this period, though, the Charity Commission received numerous allegations of mismanagement at the Richmond Fellowship, the Fellowship Charitable Foundation, and the Richmond Fellowship International. After an initial inquiry, the Charity Commission established a formal inquiry in 1989. 

The summary of their investigation is damning, despite its soft language. 

“Confusion”, the commissioners said, was “generated by the use of one charity’s accounts for the purposes of another charity, or the Whitehouse Settlement, or for Miss Jansen’s and Mr Whitehouse’s personal affairs.” It increased the “[s]cope for error or misapplication of funds”.

There was “maladministration”. Jansen and her fellow trustees “failed to appreciate the danger to the charities of the confusion”. The use of a local authority grant to extend a property owned by Jansen on adjoining land owned by the Richmond Fellowship was an “unsatisfactory legal situation”.

“Large premiums” were paid to Jansen as director of the Richmond Fellowship, but they were to ensure she received a fair pension. The Fellowship Charitable Foundation’s account was controlled by Jansen and she didn’t always explain transfers or record them. This was described as “a weakness in financial controls”.

For all the attempts at understanding, the commissioners’ inquiry did force Jansen out of the Richmond Fellowship. (Since 1991, the Richmond Fellowship has operated independently of Jansen, her family and influence.) But they did not bar her directly. 

And since there was no formal ban, Jansen could remain a trustee of the Fellowship Charitable Foundation and she still controlled the Richmond Fellowship International. The commissioners “invite[d]” her to resign her official trusteeship and distance herself from the second charity. She declined.

A war of attrition developed between the Jansen-Whitehouse family on one side, and some of the staff and trustees at the charities on the other. Jansen cleared out Clyde House, a building renovated by the FCF, and moved herself and her family in. (It has remained her residence.) The move angered the Fellowship Charitable Foundation’s managers. Some went to the press.

In 1992, the Guardian’s social affairs correspondent David Brindle reported that Jansen’s affairs were “confused” with her charity’s. Lord Goodman, now her lawyer, and David Astor wrote a letter to the editor in her defence: “The demolition attempt of her petty ill-wishers will not affect her high place in the annals of mental health care in our time.”

But Brindle continued: he 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. 

At last, Jansen was publicly pressured into resigning her trusteeship of the Fellowship Charitable Foundation, too. But she remained active in the other charities. She continued using a company bank card and calling herself the president of Richmond Fellowship International – and flying around the world on their behalf – until the trustees acted there, too.

The founder of the Richmond Fellowship, Elly Jansen OBE, ended her career in her mid-60s, deposed from her charities by the sector regulator, trustees and staff. 

This spectacular fall from grace, though, would be almost without trace. 

First, Jansen sued The Guardian and Brindle for libel over the insinuation that she had stolen from the charity. Jansen’s argument was that the charity owed her money, so her drawing cash out of it was legitimate. The Guardian’s position internally was that they believed they were right on the facts, but it might be hard to persuade a jury. 

George Carman QC, the leading libel barrister of the time, advised Brindle and the newspaper that, when it came to Jansen’s obfuscated bookkeeping, “a jury would not want to, or be able to, get on top of this sort of detail”. Given her infirmity, Carman advised his clients that he’d have to cross-examine Jansen with his “kid gloves on”.

So the newspaper settled. On 22 March 1995, the Guardian printed an apology: she had not stolen charity funds; the charities were actually indebted to her. The newspaper paid her damages and legal costs – and made a donation to charity. The reporting stopped. There were few traces of her spectacular demise.

For over a decade, there was no public trace of Jansen, once a leading light of mental health care. She escaped without being directly banned from taking a position of responsibility in charities, and the Guardian’s reporting was inaccessible to anyone without time to look them up in an archive. There was no way of knowing what had come before.

In 2006, a new charity emerged with a familiar name: Richmond Fellowship Foundation International. 

In its very first annual accounts, Jansen was listed as the chief executive. Its stated aim was to promote better mental health care around the world. It celebrates Jansen’s “legacy of invaluable experience”. Three years after its founding, the charity’s name was changed to Richmond Psychosocial Foundation International and Jansen had retreated. By this point, she was a mere “consultant to the board”. But the charity changed its objectives; it now listed running care homes as a core activity.

Not only was Jansen’s charity back running homes, she was running the same homes in the same buildings – which, after all, belonged to the family. “Lancaster Lodge was the jewel in the crown,” Lyn Dade told Tortoise. “Lancaster Lodge was Elly’s first house… So it occupied a very particular place in her heart.”

Lancaster Lodge

Dade volunteered at RPFI in 2014. It was there that she first met Jansen. Jansen kept telling Dade that she wanted to retire, but that she couldn’t find anybody she could trust to replace her. She invited Dade to a board meeting: it was held at Jansen’s flat. There was wine; there were nibbles. Most board members were men who acted in deference to Jansen.

They were looking for a new chair of the board, but there were no takers. Dade volunteered, saying that she would act as an interim chair until they found someone else – and the first thing Dade set out to do was tour RPFI’s four residences. 

Dade says Jansen was curious as to why she would want to. “I’m chair of the board,” Dade replied. “I need to understand, I need to meet these people. They need to meet me.”

Dade realised that Jansen wanted her to be a stooge, and Jansen quickly realised Dade was more self-possessed than she had believed. “Elly didn’t actually want me to do anything but endorse her decisions,” Dade said. “That was my job.”

After her tour, Dade realised RPFI did well in some houses and badly in others. But there was one bright spot. Lancaster Lodge, under Hill, “was just so impressive as a therapeutic community. It’s incredible… what he, he was able to offer mainly troubled young people, you know, like lovely Sophie… And he had a great team around him… It was deeply impressive.” 

Dade was forming her own views about the charity’s best future – something that Jansen would not want to hear. And, around this time, she met a former volunteer at Richmond Fellowship who had known Jansen. The person showed Dade “The Guardian file” – a selection of Brindle’s reporting on Jansen. When she read it she thought, “My God, what have I got myself into?”

With the support of some of her board members, Dade began asking more pointed questions about RPFI’s governance. She felt increasingly worried about the influence of Jansen, a “consultant” who was not a staff or board member. As she dug deeper into the charity, she discovered an organisation in terrible shape.

It relied on grants and loans from the Whitehouse-Jansen family to keep going. The charity had few real assets. Some of the properties it did own had restrictive covenants attached to them, which would mean the charity would need to negotiate with Jansen in order to sell them – and the charity could not borrow against them. 

Whitehouse-Jansen family members owned the other houses, giving them on short-term leases to RPFI, which provided no security of tenure. Rents payable to the Whitehouse-Jansens amounted to £250,000 a year of RPFI’s just over £1 million annual turnover – and there was no reliable “paper trail” of the Whitehouse-Jansens’ loans and donations to the charity. 

The discovery that shocked Dade most of all was in a management agreement for Lexham House, one of the residences. Dade found that it had been altered between its adoption by the board in September 2013 and its signing in November 2013 to allow a payment to Jansen of £100,000.

The money was due from the sale of a US property that Jansen owned. When asked about this, Jansen told Dade and her board that the money had been transferred into the RPFI account in error, and so was sent to her own personal account. This method of addressing the problem was decided by the then chair and Jansen between board meetings and no discussions were minuted.

The old problems identified by the Charity Commission in the 1990s were in evidence once again: a founder whose personal finances mingled with the charity’s. Dade approached the Charity Commission for advice, but she was “brushed off as if this was something that didn’t really matter”. 

Dade said: “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?” The trustees sought advice from solicitors and confronted Jansen, hoping she would see how bad things were and “take the opportunity to retire, as she had so often said she wished to”. 

She didn’t. It became clear to Dade and her colleagues that, because RPFI’s finances are so closely bound up with Jansen’s, “she holds – and has always held – the key to its future no matter what the board might try to do”. Dade was astounded to see that Jansen was prepared for the organisation to go into liquidation rather than “lose” to the board.

Dade’s board managed to get RPFI on an even financial footing, mainly by closing two houses and making staff redundancies. Things remained difficult. Jansen and her daughter Natasha “still insisted on their rent for the other two houses. And Elly also wanted repaying for historical loans to the charity.” 

Once the reforms were completed, Dade and her supporters on the board promised they’d resign. And so they did. Dade resigned on 5 July 2015. The reforms, Dade said, “were about preserving Lancaster Lodge and the wonderful work that was going on there. Which makes it even more ironic that, you know, Vincent [Hill] was marched out the building and the whole thing resulted in the, the suicide of a beautiful, but very vulnerable young woman who frankly deserved so much better.”

Without trustees to intervene, Jansen was given free rein. Within months, Jhugroo and Lawrence were hired – and the “jewel” at Lancaster Lodge that the trustees had resigned to protect was in peril. Within a year, Sophie Bennett was dead.

This disaster had many parents. The courts have made their views plain. The CQC brought two prosecutions. Jhugroo, who has changed her name to Marilene Peggy Moylan, was fined £3,000 for her part in the mismanagement of Lancaster Lodge. RPFI was fined £40,000. Both were required to pay legal costs in addition. Lawrence, who had tried using an impersonator to stand in for him during one of the inquest hearings into Sophie’s death, was sentenced to four months in prison for refusing to cooperate with the coroner – though he has no conviction in relation to his professional conduct.

Jansen, RPFI and Jhugroo declined to reply to our requests for comment. 

Lawrence sent us a “wish list” for answering our questions – which included our publishing the first volume of his (as-yet unpublished) memoirs online – and that we should “alert all of the major/minor UK news agencies (including online and weekend versions) that they too can access my Volume 1:draft memoirs for free from your website from day one.”. He told us that this would explain that he was, in fact, a whistleblower. We declined this offer.

There are serious questions for the state. 

The CQC saw – and sees – the scale of the problem at Lancaster Lodge. They brought the prosecutions against Jhugroo and RPFI, for example – and (unsuccessfully) sought to force the closure of the service.

Rob Assall, a senior inspector at CQC, said: “We had no choice but to prosecute. I hope this case will serve to remind other providers to ensure they are taking all necessary steps to ensure that the care they provide is person-centred and appropriate for people’s needs, whatever these needs are.” 

They were also aware of the extent of the problems in March 2016, almost two months before Sophie’s death. Assall said that they “took urgent action [to] vary conditions in order to restrict admissions and issued two warning notices” prior to Sophie’s death – measures to force a response from the home’s management. They also raised concerns with the local authority and demanded ongoing information.

The legislation that established their powers, however, did not give them an easily deployed right to shut the home. When they sought to do so after she died, they lost in court. This meant that Sophie remained in the care of the charity – one which the care safety regulator believed was a danger to her – until she died. 

The Charity Commission, however, has the hardest questions to answer. The decision not to formally bar Jansen from leading a charity in the 1990s meant that there was no public warning to trustees or donors about the concerns surrounding her. And by keeping her name off the formal paperwork, she kept off the radar of anyone who knew what had happened in the 1980s. 

The Commission made a second series of errors in 2015. It is one thing for them not to have noticed Jansen’s return, but they were alerted by Dade, the chair of the trustees, that Jansen was secretly running the charity. And nothing happened.

This is alarming. Lancaster Lodge needed to be run sustainably, so it could maintain the environment that its residents needed. It needed to be kept stable. The Commission’s own guidance advises that, the more important a charity is to its users, the more carefully and conservatively it needs to be run. 

Given that, the fact that a charity was secretly being run by what Dade called a “shadow director” ought to have been a concern to them. The fact of Jansen’s involvement should have been a second red flag – but the Charity Commission did not know who Jansen was. In fact, they had lost all their records of their investigation into her. 

The Commission is currently looking into RPFI, but what records they have of the original investigations came from Brindle, who had retained a copy from his original reporting. 

They told Tortoise: “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 and we will publish a report later this year, detailing our conclusions and the action we have taken.”

In their statement, they also said: “All charities that care directly for vulnerable people need to put their safety and wellbeing above all else… 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.” 

Sophie Bennett was failed, above all, by the charity to whose care she was entrusted: Lancaster Lodge’s change in strategy is the background to her death. But she was also failed by the state. The system designed to make sure charities are well led failed entirely. The process intended to keep care facilities safe was too weak and too slow. 

Britain entrusts many of its most vulnerable citizens to the care of the charitable sector. But, as Sophie Bennett’s death shows, the processes that it has in place to keep them secure cannot be relied upon.

Photographs by Getty Images, PA Images and courtesy of Ben Bennett

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