Three teenage girls died after “multifaceted and systemic” failures in NHS mental health care, an independent investigation has found.
Christie Harnett, 17, Nadia Sharif, 17 and Emily Moore, 18, had all been diagnosed with complex mental health needs and had been patients at West Lane Hospital in Middlesbrough.
The hospital, run by Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV), is where Christie and Nadia died.
Emily died in Lanchester Road Hospital, Durham, in an an adult ward where she was moved to from West Lane Hospital just 11 days before.
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— The families of the three girls
The three girls took their own lives between June 2019 and February 2020.
Christie, originally from Slough, had a complex mental health disorder.
The report into the care and treatment of Christie said it was “the organisational failure to mitigate the environmental risks of self-ligature, accompanied by Christie’s increasing risk and changed presentation because of the recent move to her own home not being fully recognised, and the unstable and overstretched services in West Lane Hospital that were the root causes of Christie’s death.”
It added: “Our observation is that the failings at West Lane Hospital were multifaceted and systemic, based upon a combination of factors, including reduced staffing, low morale, ineffective management of change, lack of leadership, aggressive handling of disciplinary problems, issues with succession andcrisis management, failures to respond to concerns from patients and staff alike, and increased patient acuity.”
Nadia, who grew up in Middlesbrough, was diagnosed with autism spectrum disorder.
The report into the care and treatment of Nadia also referenced the “unstable and overstretched services” in the hospital, and that the failings were “multifaceted and systemic”.
Emily, who was from County Durham, was an inpatient under the care of TEWV Adult Services (Tunstall Ward) when she took her own life.
The report said issues at West Lane cannot be seen to have been immediate contributory factors in her death.
We must do everything in our power to ensure these failings can never be repeated— Brent Kilmurray, chief executive of TEWV
It said the two systems issues that had a direct impact on Emily’s death were the transition from CAMHS (Children and Adolescent Mental Health Services) to Adult Services which was based entirely on age and did not take Emily’s clinical needs into consideration, and the failure to address the low-level ligature risks identified in en-suite bathrooms on Tunstall Ward in 2019.
The report said Emily’s care plans in Newberry Ward in West Lane were “fragmented, incomplete and inconsistent”.
The families of the three girls are collectively calling for a public inquiry into the Trust, and after the publication of the reports 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.”
The lawyer for the three families, Alistair Smith, from the law firm Watson Woodhouse, said: “These reports are damning.
“The Government must determine how such failings could have been allowed within these facilities and whether we have the complete picture of the issues at this Trust.”
He said that while these reports detail the failings in caring for the three young women, he believes the problems “persist to this very day and are far more widespread” affecting many more families in the North East.
“The problems identified by this report also put the whole provision of mental health services for the young across the UK under an intense spotlight,” he said.
Brent Kilmurray, chief executive of Tees, Esk and Wear Valleys NHS Foundation Trust, said: “On behalf of the trust, I would like to apologise unreservedly for the unacceptable failings in the care of Christie, Nadia and Emily which these reports have clearly identified.
“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.
“However, we know that our actions must match our words. We accept in full the recommendations made in the reports – in fact the overwhelming majority of them have already been addressed by us where applicable to our services.”
The investigation was commissioned by NHS England and carried out by Niche Health and Social Care Consulting.
