Three girls died after major failings at ‘unstable’ hospital

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Three teenage girls died after major failings at an “unstable and overstretched” mental health hospital, an inquiry has found. Christie Harnett and Nadia Sharif, both 17, and Emily Moore, 18, took their own lives within eight months of each other while under the care of Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV). 

All three had been patients at West Lane Hospital, which was shut down after the deaths of Christie and Nadia. 

Emily died at Lanchester Road Hospital but had previously been treated at West Lane in 2018 and 2019.

The investigations, commissioned by NHS England, identified 120 failures in “care and service delivery” across a number of agencies involved in their treatment. 

The damning reports said the failings at West Lane Hospital were “multifaceted and systemic”, spanning reduced staffing, lack of leadership, failure to respond to staff and patient concerns and “aggressive handling of disciplinary problems”.

It said: “This was all set within weak internal and external systems of safeguarding governance.”

A lack of places for young people needing mental health treatment also played a part. 

Nadia’s family described her as an “extrovert” who was “bubbly with her friends and sociable until she went into hospital”. 

More than 100 episodes of self-harm were recorded in the month before she took her own life but an increase in risk was not recognised, the investigation found. 

It also found she was inappropriately restrained twice, on one occasion being “dragged” down a corridor backwards. 

The 17-year-old died in August 2019. A failure to address hanging risks and a failure to recognise her changing behaviour were listed among the “root causes” of her death in the report. 

Christie took her own life in June 2019 after spending 603 nights out of 752 in hospital between May 2017 and her death. She struggled with mental health issues including an eating disorder. 

Christie’s stepfather Michael Harnett told the BBC patients had to “clean the blood up off their own walls from headbanging”.

He said: “Part of their policy was that the kids had to clean it up because they needed to learn to manage their illness”.

Along with other parents of the girls, he is calling for an independent inquiry to follow the reports. He said: “We want everybody to see the truth.” 

Emily’s family said she was “let down” by the health trust in the lead-up to her death in February 2020. The report said her care plans whilst under the supervision of the Trust were “fragmented, incomplete and inconsistent”.

The report highlighted a lack of action in response to family concerns. It said: “From April to July 2019, Emily’s father raised concerns regarding the multiple self-harm incidents despite Emily being on increased observations. However, there is little evidence of these concerns being considered in accordance with multi-agency procedures.”

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It found there were “two systems issues” that had “a direct impact” on her death; not taking her clinical needs into consideration when she moved to adult services, and a failure to address hanging risks.

Responding to the reports’ findings, 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’ families 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.”

Mr Kilmurray, who became chief executive at the Trust the year after the girls’ deaths in 2019 and 2020, added: “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.

“We have since undergone a thorough change in our senior leadership team and our structure and, as importantly, changed the way we care and treat our patients. However, the transformation needed is not complete. We need to get better and ensure that respect, compassion and responsibility is at the centre of everything we do.”

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