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Trustees in the frame over death at charity-run home - what can other charities learn?

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By Corinne Slingo, Alistair Robertson, Tracey Longfield and Anne-Marie Gregory


Published 16 December 2021


The Charity Commission has recently published its findings regarding a charity which provides care for adults recovering from mental health issues and adolescents with complex emotional needs. The charity is registered with the CQC and now only operates one residential home. In 2016, a 19 year old resident took her own life at a residential home operated by the charity. The Commission’s findings are a stark reminder of the duties on charity trustees to ensure that people who come into contact with their charity are protected from harm.

This case is also a striking example of how a serious incident occurring at a charity-run provision can mean the charity and its trustees facing potentially years of investigation and regulatory action on multiple fronts, including from the Coroner, the CQC and the Charity Commission.

In this briefing, we look at the case in more detail and what other charities can usefully learn from it.

What was the case about?

In 2016, a 19 year old took her own life at one of the charity’s residential homes.

Following the death, the Charity Commission opened an operational case to look at safeguarding matters. That case was subsequently closed to allow relevant statutory and regulatory agencies - including in this case the Coroner and the CQC - to carry out their own investigations.

The inquest into the death took place in February 2019, with the Coroner sitting with a jury. In their narrative conclusion, the jury made (multiple) very critical findings about matters they found to have contributed to the death. They found that changes introduced at the home in the months leading up to the death including:

  • withdrawal of external therapies;
  • departures of critical staff including registered manager, clinical leads and key workers (who were replaced by inadequately trained, inexperienced staff); and
  • certain staff not holding required qualifications for the roles they were carrying out

had led to a deterioration in the care provided by the charity, leaving residents feeling anxious and unsafe.

The jury’s findings also highlighted problems with the management of risk by the charity, including ‘grossly inadequate’ observation plans and steps to minimise access to ligature items. On the basis of all this, the jury concluded that the death had been contributed to by neglect.

The Coroner then issued the charity with a ‘Prevention of Future Deaths Report’ (PFD) setting out a long list of matters of concern, in respect of which the Coroner wanted action to be taken. These included the leadership and oversight by the charity’s board having been ‘grossly inadequate’ in numerous respects, including the lack of supervision and control in relation to the changes that had taken place at the home and potential conflicts of interest. The Coroner also raised a concern about the charity’s investigation following the death, describing this as ‘inadequate, verging on self-serving and not objective’.

Following the inquest, the CQC took the baton and, in May 2019, announced that it would be bringing a criminal prosecution against the charity and its registered manager for breach of the requirement to provide service users with safe care and treatment, resulting in them being exposed to a significant risk of avoidable harm (under Regulations 12 and 22 of the Health and Social Care Act (Regulated Activities) Regulations 2014 and section 91 of the Health and Social Care Act 2008 in respect of its registered manager). The charity and its former registered manager subsequently entered guilty pleas, and were sentenced in March 2021 to fines of £40,000 and £3,000 respectively, plus substantial costs.

That was not the end of the story however, because the Charity Commission has just published its own report into this matter, having opened a statutory inquiry in March 2019 (under s.46 Charities Act 2011) to examine the failings that had been highlighted by the inquest. 

What did the Charity Commission decide?

The Commission’s inquiry focused on the whether the charities’ trustees had complied with their duties and responsibilities under charity law, including whether they had sufficient oversight of arrangements for keeping the people being cared for in its residential home safe.

Given that the CQC prosecution was running in parallel with the Commission inquiry, the charity did not feel it could fully discuss with the Commission what had happened. Therefore, the Commission’s inquiry ended up relying heavily on the inquest conclusion and list of concerns in the Coroner’s PFD report, as outlined above.

The Commission’s inquiry concluded that the charity’s former trustees were responsible for misconduct and mismanagement in numerous respects, including failing in their duty to provide leadership and oversight of the charity, failing to act in the best interests of the charity and failing to exercise reasonable care and skill in the execution of their roles. Added to this was that fact that these failings had in turn exposed the charity to criminal prosecution by the CQC, resulting in significant financial loss and adversely affecting public trust and confidence in the charity. The former trustees had “failed to manage their resources responsibly, thereby exposing its beneficiaries and reputation to avoidable risk.”

In terms of the current state of play, the Commission’s report confirms that a new board of trustees is now in place at the charity. It is understood that they have been able to demonstrate that they have carried out actions to significantly strengthen governance processes at the charity to ensure that its beneficiaries are protected, including by addressing the misconduct and/or mismanagement issues.

How we can help

At the heart of any effective charity that can withstand the unrelenting pressures of risk, regulatory compliance and reputational damage, lies a well-planned, robust and sustainable governance structure. Trustees and senior managers are reminded that the definition of “misconduct and/or mismanagement” is broad and therefore they must have in place appropriate safeguards to safeguard both the charity and its beneficiaries.

We help charities:

  • Unleash potential - we have a good understanding of what good governance and regulatory compliance can achieve, helping charities learn from incidents and issues that arise
  • Risk management and board assurance - we can help charities who face dual regulation design their risk and assurance frameworks, including linking into delegations and conflict management
  • Full service - we work for many small and large charities and not-for-profits and can advise on structure and incorporation through to day-to-day management of disputes and enquiries
  • Training - we offer flexible and bespoke training on a range of governance, charity law and regulatory matters