The mysterious death of a psychiatric patient sparked an investigation into east London’s mental health services.
Throughout 2022, our Investigations Unit reported on a series of failures by NHS trusts.
They were often revealed in court hearings over patients’ deaths, covered by no other journalists.
The Unit, whose job is to investigate complex stories and hold public bodies to account, began by probing the unexplained death of a young patient – Sophia Yuferev.
Sophia, 37, was found decomposing in her Hornchurch flat in November 2021.
A coroner declined to hold an inquest, because a pathologist said she had died from diabetes or alcohol abuse.
But Sophia was a teetotaller and did not have diabetes.
After we reported this anomaly, the coroner ordered an inquest after all, where staff from the North East London NHS Foundation Trust (NELFT) were called to testify.
Sophia, a schizophrenia patient who needed regular anti-psychotic injections, was meant to be monitored by a care co-ordinator.
But, testified NELFT assistant director Irvine Muronzi, she had no co-ordinator for months because the trust was so under-staffed that it was flagged as a “risk”.
During this time, Sophia was mistakenly left off the register for her injection – so nobody noticed when she missed it.
By the time NELFT realised and looked for her, she had already died.
She died from high levels of acid in her blood, which can be caused by a period of starvation.
Sophia had told her mum that she was surviving on one sandwich a day after her benefits were wrongly axed.
None of this would have been heard in court without our initial reporting,
NELFT said it was “implementing learning” as a result of Sophia’s death.
Louise Allen and Robert Burills
Sophia’s case made us look more closely at NELFT.
An inquest into the death of Louise Allen, from Hawker Place, Walthamstow, heard evidence that NELFT had been under-staffed for years.
Assistant director Robin Sookhan said it already employed more people than its budget allowed, but even that was not enough.
“There is a shortage of social workers, occupational therapists, even doctors,” he said.
Two co-ordinators gave up Louise’s case, unable to cope with their caseloads.
Persistent signs that she might take her own life were missed. She died in June 2021.
Robert Burills, of Petersfield Avenue, Harold Hill, took his life in January 2022.
He was meant to be “closely monitored”. But nobody at NELFT contacted him for nine weeks.
Coroner Nadia Persaud raised formal concerns.
NELFT said it would “reflect on the coroner’s findings… to ensure that the quality of care at the trust continues to improve”.
Rosslyn Wolff, 74, died in a house fire in Myrtle Road, Romford, in January.
Relatives had raised concerns about her mental capacity. Her home was filled with rubbish and animal faeces.
NELFT repeatedly asserted that Mrs Wolff had sufficient mental capacity to refuse its help.
But in a report after she died, it admitted she may not have done.
NELFT’s lawyer accepted “a number of shortcomings in care”, including a failure to carry out a capacity test.
That inquest is pending.
Despite concerns raised in these hearings, the Care Quality Commission upgraded NELFT in autumn to a “good” rating.
“There was recognition that there was still much more to do but the progress was evident,” inspectors wrote.
A Newham case exposed failures by another mental health trust.
Ex-nurse Lillian John-Baptiste is believed to have died in late 2019, aged 73 – but her date of death is unknown. She was mummified by the time she was found in February 2022.
She lay dead for more than a year at her flat in Rymill Street, Canning Town.
Mrs John-Baptiste had schizoaffective disorder and was known not to properly care for herself or comply with treatment during relapses.
But when she did not answer phone calls from the East London NHS Foundation Trust (ELFT) in late 2019 and early 2020, it simply struck her off instead of investigating.
Evidence suggested she may have still been alive when those calls began, but was likely dead by the time she was struck off.
Coroner Graeme Irvine called the case “scandalous” and “shocking”.
ELFT expressed “sincere condolences” and said it was “thoroughly reviewing” the case.