A hospital trust and an employee have been convicted of health and safety violations linked to the death of a young woman in a mental health facility.

Alice Figueiredo, aged 22, was receiving treatment at Goodmayes Hospital in east London when she took her own life in July 2015, following a history of prior attempts.

After a lengthy seven-month trial at the Old Bailey, a jury determined that the North East London Foundation NHS Trust (NELFT) and ward manager Benjamin Aninakwa did not do enough to prevent Alice from ending her life.

While the trust was acquitted of the more serious corporate manslaughter charge, Aninakwa, 53, from Grays in Essex, was also exonerated of gross negligence manslaughter.

The jury spent 24 days deliberating before reaching their verdicts, setting a joint record in British judicial history, as noted by the Crown Prosecution Service. Both the trust and Aninakwa were found guilty under the Health and Safety at Work Act.

This case marked only the second instance where an NHS trust faced a corporate manslaughter accusation.

Addressing Alice’s mother and stepfather following the verdict, Judge Richard Marks KC expressed that the evidence revealed she was an extraordinarily special young woman and highlighted their evident love for her. He expressed hope that the outcome of the case would bring them some measure of solace.

This article may include content that some readers might find upsetting.

If you are affected by any issues discussed in this story, support and advice can be accessed through the BBC Action Line.

Alice entered a mental health unit at Goodmayes Hospital in Ilford in February 2015 and was under close observation on the Hepworth Ward, managed by Aninakwa.

In the five months prior to her death, she attempted suicide 18 times, often using plastic or bin bags obtained from a shared toilet, as revealed in court.

The hospital had previously acknowledged the danger posed by keeping bin bags in the ward and had removed them from patient rooms. However, despite alerts from Alice’s family, these bags remained accessible in the communal toilet, which was left unlocked.

On July 7, 2015, during her 19th attempt, she took her life using a bag from that toilet.

During the trial, the prosecution argued that Alice was able to harm herself repeatedly while hospitalized and that these incidents were inadequately recorded or addressed.

Concerns were also raised in court regarding Aninakwa’s communication, clinical skills, and leadership abilities. He had been placed on a performance improvement plan for three years, which concluded in December 2014. Furthermore, the court noted a high turnover rate of agency staff on the ward.

Jane Figueiredo, Alice’s mother, recounted the “intense pain” of learning about her daughter’s death, describing it as a moment that changed their lives forever.

Instead of focusing on tragedy, her family prefers to remember Alice as an intelligent, creative, and lively young woman with a sharp sense of humor. “She could make me laugh like nobody else,” Mrs. Figueiredo said, adding, “I miss that greatly.”

Alice had battled severe depression since her teenage years and developed an eating disorder, leading to multiple hospital admissions. Her family noted that she generally improved with treatment.

Her stepfather, Max Figueiredo, emphasized the necessity of effectively managing her illness and having faith in the medical establishment to make prudent decisions.

Mrs. Figueiredo stated that she had voiced her concerns about her daughter’s care both verbally and in writing to the hospital and to Mr. Aninakwa on several occasions.

After Alice’s passing, the family found it challenging to obtain information regarding the circumstances surrounding her death.

For nearly ten years, they collected evidence and urged both the police and the Crown Prosecution Service (CPS) to take action.

NELFT is only the second NHS trust in England to face charges of corporate manslaughter, with the previous prosecution collapsing after two weeks.

According to Dr. Victoria Roper, an associate professor at Northumbria University specializing in corporate law, it is particularly challenging to pursue corporate manslaughter charges against complex organizations due to their intricate structures.

These charges are “reserved for the most egregious management failures resulting in death,” she explained. The larger the organization, the more difficult it is to demonstrate that senior management had any direct involvement in the incidents.

However, Dr. Roper indicated that public institutions, the police, and the CPS would closely monitor this case to extract lessons from it.

Mental health advocates believe Alice’s situation underscores the inadequate care provided to numerous mental health patients.

Lucy Schonegevel, director of policy and practice at the mental health charity Rethink, remarked that it serves as a heartbreaking reminder of the shortcomings in the current mental health system and that patients expect to be cared for and kept safe in inpatient settings.

However, she acknowledged that many patients experience failures in care.

Alice’s family maintains that any shortcomings in cases like hers must be transparent to encourage improvements in mental health services, and they have committed to continuing their advocacy.

“This has never been about revenge,” Mr. Figueiredo said. “Our focus has always been on justice, truth, and accountability. That’s what drives us.”

The trust was found guilty of failing to ensure that individuals not in its employment, namely the patients, were not exposed to health or safety risks related to the use of bin liners or similar plastic bags for self-harm in an acute psychiatric ward.

Aninakwa was convicted for his failure to take reasonable care for the health and safety of affected individuals by not adequately removing accessible bin bags from the ward that could be utilized in self-harming actions and for not ensuring incidents of self-harm were recorded, evaluated, and addressed.