“All of this was being fed back to staff in charge, but it wasn’t really being acknowledged,” he says.
The trust operated a traffic light system on patient files to indicate their level of need and the risk they posed to themselves or others. Mr New says these files were often not filled out accurately or updated properly, including risk assessments.
Mr New remembers one client who was flagged green or low risk. He later discovered they had recently been picked up by police following allegations of “assault and hostage-taking with a bladed weapon”.
The trust says it is sorry if any staff member felt unsupported or unsafe, and acknowledges that “workforce pressures have historically impacted the quality of care across the NHS.” It says it has made substantial investment in recruiting and retaining staff.
“We need a health system that prevents people ending up in crisis,” says Brian Dow from Rethink. “Too often we hear stories of people escalating unnecessarily.”
Alice Figueiredo’s mother, Jane, and stepfather, Max, have spent the last decade seeking justice and transparency over what happened to her.
“We should be able to expect safe, compassionate and diligent care for some of the most vulnerable people in society,” says Jane. “Urgent action is needed, not just at NELFT, but in all mental health hospitals, wards and services around the country.”
NELFT says it is sorry for Alice’s death and it remains “dedicated to ensuring that Alice’s memory continues to inspire positive change” and will “continue to work tirelessly to deliver safer, more compassionate care for the communities we serve”.
The BBC understands that Benjamin Aninakwa, who still works at NELFT, is appealing against his conviction for failure to take reasonable care for the health and safety of others affected by acts or omissions at work. He was acquitted of gross negligence manslaughter.