The families of three teenage girls who killed themselves while in the care of the NHS are calling for a public inquiry into a mental health trust, calling it “a danger to the public”.
Christie Harnett, 17, Nadia Sharif, 17, and Emily Moore, 18, had been friends and spent time together in the secure mental health unit for children at West Lane Hospital in Middlesbrough, run by Tees, Esk and Wear Valleys NHS Trust (TEWV). They had all been diagnosed with complex mental health needs before taking their own lives between June 2019 and February 2020.
Three damning reports published today uncovered “systemic” failings at the trust, revealing a total of 119 “care and service” delivery problems in respect of the service provided to the three girls.
In January 2019, 36 members of staff at West Lane Hospital, including nurses and healthcare assistants, were suspended for the use of non-approved restraint techniques. The failure to consider the impact of this mass staff suspension was listed as one of the service delivery problems in Christie Harnett’s care. Among the 49 failings in Ms Harnett’s care was the fact that young people in the facility were exposed to inappropriate social media content.
In June 2022, the Care Quality Commission (CQC) announced that it was prosecuting TEWV for Ms Harnett’s death, stating that the trust “failed to provide safe care and treatment” which exposed her to “significant risk of avoidable harm”.
Ms Sharif had been diagnosed with autism and was treated at the Westwood Centre, part of West Lane Hospital. However, staff had a lack of knowledge about the condition, the report on Ms Sharif’s death, which uncovered 46 problems, found. A community services team offered to train staff in autism awareness but this offer was refused.
The report concluded that organisational failure to mitigate the risks over how Ms Sharif took her own life and “unstable and over-stretched” services at West Lane Hospital contributed to her death.
The report into Ms Moore’s death listed 24 care and service delivery problems in her care under TEWV. Despite her vulnerability, the report called her care plans whilst under the supervision of the trust “fragmented, incomplete and inconsistent”, with no effective risk management plan in place.
During a spell at a different hospital, Ms Moore also made allegations that she had been shouted at and sworn at by staff during her time at West Lane Hospital. The report noted that at 18, Ms Moore was automatically transferred to adult services. It said that there was a system expectation that she had to leave Child and Adolescent Mental Health Services at 18 based entirely on age without considering her clinical needs.
Following the deaths, West Lane Hospital was closed in 2019, but reopened as Acklam Road Hospital in May 2021, under the Cumbria Northumberland and Tyne and Wear NHS Trust.
The families of the three girls have launched a campaign, Rebuild Trust, to reduce the number of deaths and serious patient safety incidents throughout the NHS trust.
In a joint statement, they said: “Our beautiful girls should not have been failed in this way, and we need the answers to many more questions. Not just for us but for the many other families who we know have suffered the pain of losing a loved one who should not have died but should have been cared for properly.
“We call on the Government to start a public inquiry that looks at this trust and the services provided across the country for young people in crisis. For Christie, Nadia and Emily.”
Between April 2017 and March 2020, TEWV recorded 357 deaths. The trust received an overall requires improvement rating in its latest CQC inspection report. Wards for people with a learning disability or autism were rated inadequate.
The trust apologised unreservedly for the “unacceptable failings” in the care of the three teenagers. TEWV, chief executive, Brent Kilmurray said: “The girls and their families deserved better while under our care. I know everyone at the trust offers their heartfelt sympathies and condolences to the girls’ family and friends for their tragic loss. We must do everything in our power to ensure these failings can never be repeated. It is clear from the reports that no single individual or group of individuals were solely to blame – it was a failure of our systems with tragic consequences.”
Mr Kilmurray said the trust had since undergone a “thorough change” and changed the way it treats patients. “However, the transformation needed is not complete,” he said.
There is an ongoing inquiry into the deaths of mental health inpatients in Essex, following a series of contentious deaths. However, the inquiry does not have statutory powers so is being boycotted by many families affected, who continue to campaign for deeper scrutiny. The charity, Inquest, is calling for a statutory public inquiry into deaths and serious incidents in mental healthcare nationally.
Alistair Smith, from law firm Watson Woodhouse representing the Tees families, said: “The problems identified by this report put the whole provision of mental health services for the young across the UK under an intense spotlight.”
Maria Caulfield, minister for mental health and patient safety, said: “Every death in a mental health facility is a tragedy and my sympathies are with the families and loved ones of Christie Harnett, Nadia Sharif and Emily Moore.
“I am committed to working with NHS England and CQC to ensure inpatient mental health services are as safe as possible, and that where failures have happened it is vitally important we learn from them in order to benefit care across the NHS and protect patients in the future.”
In the UK and Ireland, Samaritans can be contacted on freephone 116 123, or email jo@samaritans.org or jo@samaritans.ie. In the US, the National Suicide Prevention Lifeline is at 800-273-8255 or chat for support. You can also text HOME to 741741 to connect with a crisis text line counsellor. In Australia, the crisis support service Lifeline is 13 11 14. Other international helplines can be found at befrienders.org
