Former champion swimmer Sophie Bennett knew something was wrong.
The 19-year-old had warned staff at Lancaster Lodge, a care facility in Richmond, that she had self-harmed and was struggling with suicidal thoughts, with a strong impulse to act on them.
Just four days later, on May 2, 2016, inside a locked bathroom she should never have been in, she hung herself.
Sophie's parents are now demanding a criminal inquiry after an inquest found the teenager's death was contributed to by neglect at the care facility.
What was going on at Lancaster Lodge before Sophie died?
Sophie was in the centre being treated for a complex combination of bipolar affective disorder, social anxiety disorder, and atypical autism, and had been since April 2015.
On Thursday (February 7), a coroner ruled her death had been "due to neglect" at the centre.
During the three-week jury inquest, it emerged that the man hired as consultant and clinical lead at Lancaster Lodge by the Richmond Psychosocial Foundation International (RPFI) had in fact obtained an unaccredited PhD from "Knightsbridge University in Denmark", in public management and administration.
The family's counsel said inadequate checks were carried out by the foundation, who were probably under the impression he was a medical doctor.
Dr Duncan Lawrence did not attend the inquest, despite being given a summons to appear for oral evidence.
He was also missing on the second day of a CQC inspection just before Sophie's death.
His LinkedIn lists his location as Bromley.
Despite being employed as clinical lead in January that year, by March he was still unable to tell CQC inspectors where patient care plans were kept.
That may have been because Dr Lawrence planned to end all psychotherapy at the centre and replace it with yoga sessions, a decision which forced then manager Vincent Hill to resign and may have started a chain of events that contributed to the neglect Sophie experienced.
Peggy Jughroo was appointed as new manager at Lancaster Lodge and also worked at Wandsworth Council.
While giving evidence to the inquest, she stated she had neither the qualifications or experience for the job.
She had been directly trained by the founder of the community, Elly Jansen OBE, who established the Richmond Fellowship in 1959 but was investigated by the charity commission in 1988 for financial conflicts of interests concerning her.
Jansen officially severed ties with Richmond Fellowship, the initial charity, but the RPFI was then established, with Jansen acting as a "consultant to the board".
She was described as a "sleeping director" of the charity by Lynn Dade, a former RPFI trustee who resigned in July 2015 following " grave concerns regarding the governance and financial affairs".
West London Coroner's Court heard that she was in fact operating "as a floating executive of the board" and had continued to exert financial influence on the way the centre was run.
The same was discovered for several new support workers hired by the foundation.
In a September 2015 CQC inspection, the centre was rated "good", but just months after Dr Lawrence took over, it was found to be "inadequate" and "chaotic".
Sophie told her parents Ben and Nicki that the changes had turned the centre into "a bootcamp".
Following the inadequate inspection result, the decision was made by Wandsworth Council to move Sophie elsewhere.
However, she would die at the centre before this could happen.
When Sophie had first warned staff about her suicidal intentions, the crisis line was called and staff were told to take Sophie to hospital immediately.
Days after her death, Sophie's care-coordinator was told that this was a decision taken by "management".
Instead, the centre put Sophie on "close observations", keeping her door open at all times and her room should have been regularly checked for anything she could harm herself with.
But days later she was allowed to lock the bathroom door and kill herself using an item which care workers had no record of her having.
What about after Sophie died?
After her death, the situation at the Lodge broke down further, with the leadership allegedly sending emails to "shift the blame to [South West London and St George's Mental Health NHS Trust]".
One of the witnesses in the case, support worker Faiza Adnan even told the court that a statement attributed to her was fake and that her name had not even been spelt correctly in the alleged forgery.
There was also an alleged email in which Dr Lawrence admitted his lack of credentials for that role, which was not found to be shown to the court, with lawyers for the foundation claiming their servers did not go back that far.
At the end of Thursday's hearing, coroner John Taylor ruled Sophie's death was contributed to by neglect on the part of RPFI.
The jury said that changes made at the centre, inadequate staff and leadership contributed to her death, as well as the actual plan she was placed on and her monitoring.
Replacement staff across all levels were not adequately trained, skilled, educated or experienced.
Leadership and oversight of the RPFI board was grossly inadequate.
A grossly inadequate observation plan of Sophie was put in place and not understood or followed.
There were grossly inadequate steps at minimising access to ligature items.
Changes were based on a one day audit, grossly inadequate.
Advice was provided by the founder and followed by RPFI staff without ever meeting or any knowledge of residents.
On Friday (February 8), Sophie's parents submitted requests for Prevention of Future Death (PFD) reports, with so many questions still left to be answered.
"It has been a complex inquest, concerning multiple agencies, but it has also has some exceptional features, including a key witness failing to answer a summons and attend to give evidence (Dr Duncan Lawrence)," the submission read.
What will be done to prevent another such tragedy?
The coroner agreed to write two PFD reports, one into governance at the RPFI and another into her post-death investigation.
A separate Letter of Concern was also agreed to with regards to Dr Lawrence.
The Bennett family's barrister, Caoilfhionn Gallagher QC, pointed out on Friday that Dr Lawrence's LinkedIn indicates he was interim manager at Slough Children's Services Trust for a number of months in 2018 and voiced concerns over his failure to attend.
A letter was also sent to the British Association for Counselling and Psychotherapy, where Dr Lawrence is registered.
In a statement released after the inquest, Ben and Nicki Bennett said: "We've waited nearly three years to find the truth about what happened to our beautiful daughter who, despite her many problems, had a fulfilling life ahead of her.
"We thank the jury for listening to the at times difficult evidence and their clear conclusions which vindicate our concerns.
"We await eagerly to see whether the CQC is to pursue a criminal prosecution, which we believe it should.
"We also want to see action by the Charity Commission.
"The Charity Commission has been conspicuous by its absence from this inquest despite our urging it to attend and hear the evidence.
"It has known about the issues surrounding the governance of RPFI since well before Sophie's death.
"I hope that it will now apply the full force of its powers to take action against those trustees who have clearly been negligent in their responsibilities."