The Charity Commission has strongly criticised the former trustees of a mental health charity in whose care a young woman tragically took her own life in 2016.

In an official inquiry report published today, the regulator makes findings of misconduct and mismanagement against three of RPFI’s former trustees, concluding that they exposed residents to significant avoidable harm. Two of the former trustees have now undertaken not to act as charity trustees or senior managers; the third died in 2019.

RPFI ran Lancaster Lodge, a residential home in Richmond, South London, that provided care for adults recovering from mental health issues and adolescents with complex emotional needs. In May 2016, a resident of the home, Sophie Bennett, took her own life.

A coroner’s report, published in February 2019, found that the then trustees oversaw abrupt changes at Lancaster Lodge during 2016, which included replacing experienced, qualified staff with unqualified staff, and removing residents’ access to external therapies. These changes were chaotic and resulted in a deterioration in care for residents.

In March 2021, the charity and Lancaster Lodge’s former registered manager were ordered to pay substantial fines and costs, having pleaded guilty to two separate charges under the Health and Social Care Act, following a prosecution brought by the Care Quality Commission.

The Commission’s own inquiry was opened in April 2019, following the coroner’s inquest, specifically to examine the role of the charity’s former trustees. Its investigation set out to determine whether the former trustees had complied with their governance duties and responsibilities under charity law, and to examine the trustees’ response to the coroner’s findings and what steps they were taking to address the serious failings identified in his report.

The investigation also considered the role of the charity’s founder, who acted as consultant to the board, and whether she was a de-facto trustee.

Today’s report finds that the former trustees were responsible for misconduct and mismanagement, and that they:

• failed in their duty to provide leadership and oversight of the charity
• failed to comply with the law such that the charity’s beneficiaries were exposed to “significant avoidable harm”, contributing to Sophie’s death
• were over-reliant on the former Chair (since deceased) who acted in breach of good governance requirements.
• took advice from the charity’s founder which was, according to the Coroner, “followed by RPFI staff without [the founder – Charity Commission clarification] ever meeting or having knowledge of the residents”.

The report also finds that the former trustees failed to properly manage the charity’s resources, including by failing to file annual accounts on time, and concerns about the management of the charity’s banking services, which potentially placed the charity’s funds at undue risk.

Two of the former trustees have signed undertakings to not act as charity trustees, or to be involved in any charity’s senior management.

A new board of trustees is in place at the charity. The new trustees have demonstrated to the Commission that they have carried out actions to significantly strengthen governance processes at the charity to ensure safeguarding policies and processes are followed and its beneficiaries are protected. Lancaster Lodge closed in 2017, but RPFI continues to run another home.

Helen Stephenson, chief executive of the Charity Commission, said:

Sophie Bennett’s death is a tragedy and the circumstances surrounding it remain deeply distressing.

Our findings are serious, and sobering: the former trustees of RPFI presided over decisions that, in a matter of months, turned a home rated ‘good’ by CQC into one in which residents were unsafe.

No official inquiry can turn back the clock and change what happened in 2016. But we can and must ensure lessons are learnt from this case. We urge trustees of charities that care for vulnerable people, like Sophie, to consider the findings of this inquiry, and to examine their own systems, structures, and indeed the expertise and competence of their board collectively to ensure they meet their legal duties.

Read the full report of the inquiry into Richmond Psychosocial Foundation International.

Notes to Editors:

1. The Charity Commission is the independent, non-ministerial government department that registers and regulates charities in England and Wales. Its purpose is to ensure charity can thrive and inspire trust so that people can improve lives and strengthen society.
2. The Commission has an important, but specific and limited role with regards to safeguarding. Its focus is on the conduct of trustees and the steps they take to protect beneficiaries, employees, volunteers and others who come into contact with the charity through its work. It is not responsible for dealing with incidents of actual abuse and does not administer safeguarding legislation and cannot prosecute or bring criminal proceedings. Some charities are regulated by other bodies in parallel with the Commission. In the case of RPFI, the CQC’s remit included registering and inspecting the care facility, to ensure the care provided by the charity met statutory requirements.
3. The inquest into Sophie Bennett’s death concluded in February 2019. The Commission opened a statutory inquiry into the charity on 5 March 2019. The former trustees are named in the inquiry report, along with details of the undertakings they have made.
4. The current trustees are listed on the register of charities.

Today Prime Minister Boris Johnson will convene the Biopharmaceutical CEO Roundtable of global industry leaders – including AstraZeneca, GSK and Pfizer – to accelerate discussions on pandemic preparedness, as world-leading scientists work at pace to better understand the Omicron variant.

With the new variant adding a sense of urgency to the talks, there will be a renewed focus on the significance of the domestic and international vaccine effort, including boosters.

Applying the lessons learned from the remarkable response to Covid-19, such as the vaccines taskforce and discovery of dexamethasone, the Prime Minister will outline ambitions for a dynamic partnership with industry that, together with the NHS and academia, can develop life-changing innovations and solve the most pressing health challenges of today including dementia, cancer, mental health and obesity.

The Prime Minister also welcomes nearly £500m of new investment from the sector today, which will create at least 420 high-skilled jobs and drive economic prosperity across the UK.

Prime Minister Boris Johnson said:

With scientists around the world working tirelessly to learn more about the Omicron variant, we have never been more indebted to the extraordinary power of Life Sciences.

Today I am bringing global industry leaders together to discuss our renewed efforts against Covid-19, while ensuring we are better equipped to tackle future healthcare challenges.

As we press ahead with our goal to become a science superpower, the new investments made today will help us forge life-changing breakthroughs against other diseases, such as cancer and dementia, while creating hundreds of high-skilled jobs across the country.

Today’s roundtable follows the Prime Minister’s commission to the G7 in February 2021, which launched the ambitious 100 Days Mission to accelerate the development of safe and effective diagnostics, therapeutics and vaccines [DTVs] in response to a new pandemic threat. G7 Chief Scientific Advisers have [today] published the first implementation report [link] for G7 Leaders, emphasising the need to harness rapid advances in science and technology and strong public-private collaboration to fill the gaps in our current arsenal of DTVs.

Sir Patrick Vallance, Government Chief Scientific Adviser, said:

Scientific innovation and public-private collaboration are essential to help us prepare for future pandemics.

The 100 Days Mission is ambitious, but also achievable and essential to ensure we have safe and effective diagnostics, therapeutics and vaccines within 100 days of a future pandemic threat being identified.

Today’s discussions will also cover the role of the NHS as a powerful driver of innovation in new treatments and technologies, alongside four critical Healthcare Missions – which build on the Life Sciences Vision published earlier this year. Government has already ringfenced £95m of funding for these areas, and it will continue to invest heavily into research on the greatest causes of death and diseases in the UK. The four Missions outlined below will help create an outstanding business and healthcare environment to generate further innovation and investment:

• Novel treatments for dementia, making the UK a leading place in the world to develop the first new treatments for dementia in a generation
• Treatment and prevention of obesity, using the most interesting new technologies to help people reach and maintain a healthy weight
• Increase the understanding of mental health conditions, developing the right tools to deliver game-changing outcomes for patients
• Diagnose cancer with increased specificity, making the UK the best place in the world to develop and use targeted diagnostics and treatments

Business Secretary Kwasi Kwarteng said:

The UK’s life sciences sector has been a shining light in our response to COVID-19 and the pandemic has taught us that scientific and technological innovation within a competitive, free market economy leads to the creation of effective medicines, vaccines and treatments.

That’s why we want to build a pro-enterprise environment that incentivises our most innovative life sciences firms to flourish, create jobs, commercialise and manufacture more life-saving products right here in the UK.

Today’s investment by Britain’s life sciences industry – at nearly half a billion pounds – is evidence that our 10 year Life Sciences Vision is working as we look to cement the UK’s status as global science superpower.

Helping to cement the UK as a Life Sciences superpower and build back better from Covid-19, the individual investments secured today include: £400m from Fujifilm Diosynth Biotechnologies to create the largest biopharmaceutical manufacturing site in the UK; £30m from GSK to deepen understanding of diseases such as Alzheimer’s, and improve the success and speed of R&D of new medicines using advanced technologies; £17m from Bristol Myers Squibb to expand their headquarters to accommodate global drug development in data science and biometrics; £11.7m from J&J for a new digital surgery ecosystem in Leeds; and £1.5 million from Roche for a blood test evaluation programme that will genomically profile lung cancer.

Underlining the confidence that BCR companies have in UK science, today’s new investments bring the total investment figure by these companies to over £9.5bn in the last two years. This year, UK Life Sciences companies raised a record breaking total of £6.6bn in the first 10 full months of 2021, a tenfold increase on the amount raised in 2012 (OLS analysis of S&P Capital IQ data).

This comes as the Department for International Trade adds a healthcare and life sciences landing page in the Investment Atlas, previously launched at the Global Investment Summit. This will highlight the UK’s strength in biopharmaceuticals and its offer to potential inward investors, as well as the extensive Government support available to potential inward investors.

Director-General, Mr Chairman, Distinguished Delegates, as the Conference of the States Parties convenes again in the shadow of the Covid-19 pandemic, I pay tribute to the Director-General and the staff of the Technical Secretariat for all their work to ensure the Conference can go ahead. And let me also congratulate Ambassador Svendsen on his appointment as Chair of the Conference.

Mr Chairman, the Chemical Weapons Convention is one of the most successful disarmament treaties in history. Within a couple of years, we will be able to acknowledge the end of declared stockpile destruction, a significant milestone. But just as this success is undeniable, so are the challenges that remain.

In recent years, we have seen chemical weapons used in Syria, Iraq, Malaysia, the UK and Russia. We must be clear about the scale of the problem; in the last decade, chemical weapons have killed and seriously injured thousands of people. This Conference must not ignore the threat. We must challenge the use of chemical weapons wherever it occurs, and whoever is responsible.

And all of this means that the Convention, and the Organisation, is approaching a crossroads. We must move in the right direction if we are to strengthen the Convention for the next generation.

Mr Chairman, Syria’s chemical weapons programme remains a grave concern. The stark fact is that the Asad regime has killed hundreds of its own people with chemical weapons. The United Kingdom continues to support the vital work of the OPCW’s Investigation and Identification Team, the IIT, to identify the perpetrators of the use of chemical weapons in Syria. And we welcome the publication of the IIT’s second report in April 2021. The report found regime forces had dropped chlorine on Saraqib in February 2018. And this represents the eighth authoritative finding of chemical weapons use by United Nations and OPCW independent investigations, an appalling further instance of chemical weapons use by the Asad regime.

In this context, it was right that the 25th Conference of States Parties suspended some of Syria’s OPCW rights and privileges until they demonstrate compliance with the Convention. Syria must cooperate fully with the Organisation and comply with United Nations Security Council Resolution 2118, including issuing visas to all OPCW staff that request them. Any retained chemical weapons that have not been destroyed pose a serious threat to international peace and security, and must be declared to the OPCW immediately. Syria, like every other State Party, must exclude completely the possibility of using chemical weapons in any circumstances. Syria must, above all, account for its deadly chemical attacks, declare every aspect of its chemical weapons programme, and resolve all outstanding issues in its original declaration.

Conference, it is high time that Syria does what is necessary to come into compliance with the Convention.

Mr Chairman, the Russian government must also account for its use of chemical weapons, both in the United Kingdom in 2018 and on its own territory in August 2020, against Mr Navalny. There is no plausible explanation for these poisonings other than Russian involvement and responsibility. The United Kingdom calls on Russia to declare Novichok and any other declarable chemical weapon production or programmes to the OPCW. Russia must explain to the Conference how a Novichok nerve agent, a weapon known to have been developed in the Soviet Union and Russia, came to be used last year against a Russian opposition politician on Russian territory.

In early October, the United Kingdom and 44 other states posed serious questions to Russia, using Article 9 of the Chemical Weapons Convention. The Russian authorities have made no attempt to account for the poisoning of Mr Navalny. Instead, we have heard ludicrous conspiracy theories and witnessed entirely unwarranted attacks on the integrity of others. Sadly, this mirrors Russia’s response to the Salisbury attack and serves to underscore that Russia is once again ignoring its obligations under the Chemical Weapons Convention.

Mr Chairman, the construction of the new Centre for Chemistry and Technology and the approaching end of declared stockpile destruction are an opportunity to ensure that the OPCW is fit for the next 25 years. We have an opportunity to ensure the Organisation is prepared for new threats and new demands. An opportunity to ensure the Organisation is using the most modern technology in vital areas like verification and inspections. And an opportunity to ensure the Organisation focuses its capacity-building offer squarely on the needs of the participating States in line with the Convention.

Mr Chairman, the Organisation is well placed to take advantage of these opportunities under the leadership of Director-General Arias. He has led the OPCW with distinction over his first term of office and the United Kingdom was pleased to join the other members of the Executive Council in recommending his re-appointment. On behalf of the United Kingdom, I offer our full support to Director-General Arias and look forward to the Conference confirming his second term.

The OPCW must have the resources needed to fulfil its mandate. We underline the need for all states to pay their assessed contributions in full and on time. The United Kingdom will be supporting the Director-General’s proposed programme and budget for 2022 and 2023, as recommended by the Executive Council. We encourage all states to join consensus on adopting the budget proposals.

The United Kingdom was delighted to sign agreements recently to provide further voluntary contributions to the OPCW, totalling £750,000. The funding will support further cyber security upgrades and contribute to the work of the Investigation and Identification Team. It will continue a project to support laboratories in Africa and Latin America to achieve OPCW designated status, following the success of a laboratory in Brazil in 2021. We are also continuing our contribution to the Africa Programme, where we want to focus more on tackling emerging threats, such as non-state actor use.

Mr Chairman, Non-Governmental Organisations play a key role in supporting the global fight against the use of chemical weapons. The United Kingdom is concerned that a handful of States Parties have blocked the accreditation of some NGOs. It is crucial that the CSP remains able to engage with a wide range of voices from civil society.

Mr Chairman, the OPCW, with a renewed budget and reappointed Director-General, will be well equipped to navigate the best route into the future. But as we walk this road together, it is vital that all States Parties fulfil their obligations under the Convention. And it is crucial that all States Parties hold to account those who do not. And it is more important than ever for all States Parties to support the work of the independent, impartial and dedicated Technical Secretariat.

We are all focussed on the common goal of a world without chemical weapons. This is only possible with an unwavering commitment from all of us to uphold the Chemical Weapons Convention in full.

The United Kingdom will continue to do all those things and remain a steadfast supporter of the OPCW and the Chemical Weapons Convention.

Mr Chairman, thank you very much indeed.

OPCW: UK Statement to to the 26th Conference of States Parties, delivered by Baroness Goldie DL