Inquests are always very sad affairs, and when the court is considering a suicide, it is particularly difficult for the loved ones of the person who has died.

Recently the media reported on the Inquest into the death of 19 year old Sophie Bennett, who killed herself at Lancaster Lodge Clinic in 2016.

Sophie suffered from some complex psychiatric problems. She was admitted to Lancaster Lodge in 2015, and at the time it appeared to be a well-run and safe environment for a teenage girl.

In 2016 there was a change in the senior management at the home, and a consultant, Duncan Lawrence implemented a new regime which Sophie described to her parents as being like a “boot camp”. All external therapies were cancelled, and residents were encouraged to get up early and do lots of exercise. When the Care Quality Commission assessed the clinic in March 2016 it was described as “inadequate” and in evidence at the Inquest a former staff member described it as “falling apart” and a “shambles”.

At the Inquest it also emerged that Mr Lawrence was not in fact medically qualified. He claimed to have a doctorate in management and administration from a Danish university, but the clinic was not able to produce any documentation to confirm this.

In April 2016 Sophie self-harmed, and told staff that she was having strong suicidal impulses. Evidently the lack of senior supervision was such that the staff had to phone Crisis Line for advice, and they were told that Sophie should be taken directly to hospital. This did not happen, and the Inquest heard that the decision not to take Sophie to hospital was made by “management”.

Sophie was supposed to have been observed at all times. She was also meant to be provided with a safe environment, in which there would be no means of self-harm. Despite this, she was somehow allowed to have a skipping rope, which she took into her bathroom, and used to hang herself.

Not surprisingly Mr Lawrence was summoned to give oral evidence at the Inquest. Clearly he had a responsibility to help the Coroner, and to explain to the family and indeed the public exactly what happened. However, as has been widely reported, not only did Mr Lawrence fail to turn up at the Inquest – he also used an impersonator to speak to the Coroner’s Office.

Subsequently – and quite rightly, he faced criminal charges of withholding evidence and documentation likely to be of assistance to the Coroner. He was fined £650 for failing to attend the Inquest, and he may now face a prison term.

We often represent families at Inquests, and this includes suicide cases. Whilst I have never come across a “boot camp” regime for mentally ill patients, I am sorry to say that elements of this story – junior or part qualified staff, not enough senior staff, and poor administration – are depressingly familiar.

As to the non-attendance from Mr Lawrence, I have had cases where witnesses have tried to avoid giving evidence, but a determined Coroner will usually make it clear that eventually the witness will have to turn up, and that excuses will not be accepted.