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Damning probes into suicides of three teenage girls in the same NHS mental health trust uncover 120 failures
2 November 2022, 13:46 | Updated: 2 November 2022, 14:36
*WARNING: distressing content* An independent investigation has found failings by an NHS trust contributed to the deaths of three teenagers.
17-year-olds Christie Harnett and Nadia Sharif and 18-year-old Emily Moore died within eight months of each other at West Lane Hospital in Middlesborough.
They had all been diagnosed with complex mental health needs and took their own lives between June 2019 and February 2020 whilst under the care of North-East NHS Trust.
The three reports, released today on November 2, listed 119 care and service delivery failings in the care of the young women by Tees, Esk and Wear Valleys NHS Trust (TEWV), which covers the north-east constituency of Prime Minister Rishi Sunak.
Now the lawyer for the three families, Alistair Smith, from the lawfirm Watson Woodhouse, has called on the government to launch a public inquiry into failings at the Trust.
Mr Smith 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. It is clear from the very latest CQC reports that these problems persist, and lessons are not being learned.
“Whilst these reports detail the many failings in caring for these three women, we believe the problems are not in the past, that they persist to this very day and are far more widespread, affecting many more families in the Northeast.
“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.”
The hospital closed in October 2019 but reopened as the Acklam Road Hospital under the Cumbria Northumberland and Tyne and Wear NHS trust.
In January 2019, 36 members of staff at West Lane Hospital, including nurses and health care assistants, were suspended for the use of non-approved restraint techniques. The failure to consider the impact of mass staff suspension was listed as one of the service delivery problems in Christie Hartnett’s care.
Christie, originally from Slough, tried to take her own life in March 2019 under the supervision of TEWV. During the initial attempt, the report found no evidence that bathroom fixtures had been investigated.
According to the report, an ‘organisational failure’ which, alongside a lack of efficient treatment, therapy, and problems in her care planning, contributed to her death. Nadia Sharif from Middlesborough died in August 2019. She had been diagnosed with Autism and was treated at the Westwood Centre, part of West Lane Hospital.
The report on Nadia’s death listed 46 care and service delivery problems, including a lack of knowledge by staff about Autism which affected communications with Nadia. According to the report, a community services team offered to train staff in autism awareness. However, this offer was refused.
The report concluded that organisational failure to mitigate the risks over how she took her own life and ‘unstable and over-stretched’ services at West Lane Hospital contributed to her death.
Emily Moore from County Durham died in February 2020. Due to her complex mental health needs, she had been a patient on the Newberry Ward at West Lane Hospital.
The report into her death listed 24 care and service delivery problems in her care under TEWV.
During a spell at a different hospital, she 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, Emily was automatically transferred to adult services. It said that there was a system expectation that Emily had to leave Child and Adolescent Mental Health Services (CAMHS) at 18 based entirely on age without considering her clinical needs.
The families of the three girls have launched a campaign, Rebuild Trust.
They are collectively calling for a public inquiry into the Trust and released this statement after the publication of the reports: “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.”
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