The government have apologised after an independent inquiry found that three teenage girls died following major failings in NHS mental health services. The girls, who all had complex mental health issues, were all treated at the now-closed West Lane Hospital which falls under the Tees, Esk and Wear Valleys (TEWV) NHS trust.
Christie Harnett, 17, Nadia Sharif, 17, and Emily Moore, 18, all took their own lives within eight months of each other from June 2019 to February 2020. The inquiry into their care found 120 failures in ‘care and service delivery’ across several agencies. Two of the teens were in-patients at West Lane Hospital when they took their own lives, while Emily Moore ended her life seven months after leaving the facility.
In 2019, prior to West Lane Hospital being closed because of the deaths, Christie’s stepfather Michael Harnett alleged that Christie had been restrained without warning, illegally strip-searched and male staff members had been present while she was naked. She had attempted to take her own life just three months prior to her death. The report into her death found 49 failings in care, including no plans to manage her risk of self-harm or investigate the previous suicide attempt.
‘Something needs to be done before anything happens to the other children,’ he told BBC. ‘We had a child in the place that was meant to help keep her safe, and she managed to kill herself. Our daughter went in there and got a lot worse. It doesn't seem anyone's getting better or getting help.’
After making his above allegations in 2019, Tees, Esk and Wear Valleys NHS Trust said it would be 'inappropriate' to comment on Ms Harnett's care but confirmed an investigation will be conducted. It added it was taking 'immediate and urgent actions' to address concerns raised by the Care Quality Commission (CQC).
Our daughter went in there and got a lot worse.
In June this year, the Care Quality Commission (CQC) announced TEWV would be prosecuted over Christie's death as it had 'failed to provide safe care and treatment' exposing her to 'significant risk of avoidable harm'.
TEWV said: 'Our hearts go out to the family and friends of Kristie, Emily and Nadia for the loss they have suffered and we are deeply sorry. Significant changes have been made since 2019 in staffing and the way we treat those in care, and we are working hard to deliver the changes the families have every right to expect.'
The report into Nadia’s care found 46 separate failings, including that staff were not properly trained to deal with her autism and the facility did not have translation services to ensure her family were fully informed and involved in her care.
Parents Hakeel and Arshad Sharif told ITV ‘We remember Nadia all the time. We cry a lot when we remember her. We look at her picture every single day. We let go of Nadia and went along with the decision that she is going to be living separately under the promise that they will take care of Nadia but they did actually not take care of her.’
Emily died one week after her 18th birthday, in a bathroom on an adult ward of the Lanchester Road Hospital in Durham, having previously been treated at West Lane. She had initially been moved to a children’s mental health hospital run by the neighbouring Cumbria, Northumberland, Tyne, and Wear Trust but sent to Lanchester for adult care. The report has thus criticised the transfer of care being based on age, as opposed to clinical needs. Her case found 24 failings.
‘These reports are damning,’ said Alistair Smith, of the solicitors Watson Woodhouse, who are representing the three families. ‘The care was just not bad it was just awful. The combination of all three of these reports shows a trust in a shambles. Three lives are lost because of it. Three lives should still be here. I mean what does it take? How many times do they need to be told about these things before they take action? Everybody thinks somebody in hospital is safe but they weren’t and they should have been.’
Smith pointed to recent inspection reports by the Care Quality Commission (CQC), the NHS care watchdog, which showed that TEWV was still giving poor care. In a report into care for adults with a learning disability or autism, the regulator has rated the service as inadequate. ‘Lessons are not being learned,’ Smith said.
In response to the Care Quality Commission’s inspection report, Jennifer Illingworth, care group director for children and young people and learning disabilities at the Trust, said: 'Given the previous good ratings for this service, this is clearly disappointing. We are committed to improving the experience for patients in our care and we are delivering an urgent action plan that is already showing we are making improvements.
'We immediately commissioned an independent peer review into the service after the inspection in May and acted swiftly on its recommendations,' she continued. 'Going forward, we will continue to work with our partners on the future provision of learning disability and autism services to ensure that together we offer the right packages of care that meets the needs of patients and their families.'
Lessons are not being learned.
The families are suing the trust for breach of civil rights and negligence. West Lane Hospital was closed in 2019, last year the building re-opened under a new name, Acklam Road hospital, and is being run by a different mental health trust.
‘On behalf of the trust, I would like to apologise unreservedly for the unacceptable failings in the care of Christie, Nadia and Emily,’ said Brent Kilmurray, TEWV’s chief executive. ‘The girls and their families deserved better while under our care.’
‘These reports make for difficult reading and our thoughts are with the families of these three young people,’ Margaret Kitching, NHS England’s chief nurse for the north-east and Yorkshire, said .’We have put measures in place to protect patients while we support the trust in making the comprehensive programme of improvements at every level from its wards to its boardroom.’
The families have not accepted apologies made by Kilmurray, dismissing letters they received from him as ‘nothing more than an 11th-hour PR exercise.’
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