Damning reports lay bare the shocking treatment of three teenage girls who went on to take their own lives.
Nadia Sharif, Emily Moore and Christie Harnett were inpatients under the care of Tees, Esk and Wear Valley’s NHS Foundation Trust after long mental health battles.
All three teenagers – who died within an eight month period – suffered a catalogue of heartbreaking failures at the hands of the trust, new reports have found.
Their deaths prompted a public outcry of anger and led to the closure of West Lane Hospital in Middleborough.
The family are now calling for answers as to how the failings were allowed to happen.
Christie and Nadia were both just 17 when they took their own lives at the hospital in June and August 2019 respectively.
Emily 18, died in February 2020 after being found unresponsive at Lanchester Road Hospital, in Durham. She had previously been a patient at West Lane – where her dad, David, had protested outside the hospital with a banner at the level of care she was receiving.
The tragedies prompted three independent investigations looking into their care and treatment and the damning NHS reports were released on Wednesday highlighting shocking failures, reports Teeside Live.
The three reports reveal heartbreaking failures in care. In one incident, Nadia was dragged down a corridor backwards with staff holding her under her arms.
In another, Emily reported being sworn and shouted at by healthcare staff. Christie was restrained, her outfit cut from her, and she was placed in strong clothing.
A total of 119 “care and service delivery” failures across a number of agencies were found over the treatment.
The reports for Christie and Nadia found an “organisational failure” to reduce the risk of hanging, with 96 identified around their care which were combined “as contributory factors” before the suicides.
Unstable and overstretched services were root causes of their deaths, it added while the three reports highlighted poor management, staffing issues and failures in responding to concerns from patients and staff.
Margret Kitching, the chief nurse for NHS England, North East and Yorkshire, said measures are now in place after their deaths.
“These reports make for very difficult reading and our thoughts are with the families of these three young people,” she said.
“We have put measures in place to protect patients while we support the trust in making the comprehensive programme of improvements needed at every level from its wards to its board room.
“Governance arrangements have been identified as a particular area of weakness and a further independent report has been commissioned to address this.
“There have been significant changes in the trust’s leadership since these events took place.”
Dozens of recommendations have been made to the organisations involved to stop further deaths.
TEWV must ensure that trauma-informed therapy is a routine aspect of a young person’s care provision where there are any considerations of previous trauma, not just diagnosed post-traumatic stress disorder (PTSD), and that there are sufficient staff with the requisite skills to provide this.
Local authorities and health providers must ensure that there is clarity about the roles and responsibilities of each agency in the planning and delivery of care to young people in Tier 4 CAMHS provision where they are in the care of the Local Authority to ensure that support is holistic and meets the educational; social; physical health and emotional needs of children and young people as well as their mental health needs.
TEWV and Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust (CNTW) must ensure that any young person with a recent history of self-ligature has a written care plan that identifies how staff (or families in the case of a community setting) are to care for the young person, and mitigate the risks of fatal self-Tees, Esk and Wear Valley’s NHS Foundation Trust has ‘apologised unreservedly’ for the ‘unacceptable failings’ and accepts the recommendations.
Brent Kilmurray, chief executive officer at Tees, Esk and Wear Valleys NHS Foundation Trust, said: “Firstly let me say how incredibly sorry I am to the family and friends of Christie, Emily and Nadia.
“The reports have been incredibly thorough and we fully accept all the recommendations. We’re really clear that improvements need to be demonstrated – we’ve already made a significant start.”
Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust said it is also committing to improving care and will reflect on the recommendations.
James Duncan, chief executive at Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust said: “Our thoughts are very much with the families of Christie, Emily and Nadia at this incredibly difficult time.
“With the addition of Lotus Ward in Middlesbrough to our services, CNTW is now the sole provider of specialist inpatient services for children and young people across the North East and North Cumbria. We are committed to improving the care, treatment and wellbeing of children and young people in our services.
“We will reflect on all the recommendations in the report, to ensure that we are providing the best care possible to the young people we support and their families.”
The families of the teenagers have spoken out following the reports.
Emily’s father David believes his daughter was let down.
He said: “At West Lane we’d argue every week with them about things that weren’t being done and things that were being done wrong – Emily was let down.
“When she needed help the help wasn’t there. They trust say there’s been significant changes since 2019 but Emily died in 2020, so how can that be?
“There’s been recommendations and reports before but they are continually given bad ratings. It’s not good enough and as a family we won’t stop until we get answers.”
The reports follows years of controversy over the Tees, Esk and Wear Valley’s NHS Foundation Trust’s mental health services, with Stockton councillors calling for a public inquiry after sub-par verdicts from the CQC.
The grieving families have also called for the trust to face public hearings and intervention. Just last month, Christie’s father Michael cycled more than 280 miles from his home in Newton Aycliffe to Downing Street to deliver letters on behalf of his and other families sharing their stories and asking for a public enquiry into the trust.
In response to the report, he said: “We were shocked at how bad it was, there was lots in the report that we weren’t aware of. From what we’ve been through it wasn’t a surprise.
“We knew just how bad it was anyway – seeing it all on paper was really quite hard. In the report it spoke about things that weren’t documented, that was one of the main failings in it – that they weren’t documenting it.
“There were many a time when we went to see her that she’d have a new cut or a new graze or mark around her neck or lump on her head. Near enough every time there was something different and a lot of the time towards the end it was Christie herself who was actually telling us about the incidents. She knew the hospital wouldn’t.
“It must have been horrible for her doing that and feeling that she had to then explain to us what had happened.”
“Hopefully we will get that public inquiry once these reports are out and we’re waiting on the force report coming out as well. Hopefully when that one comes out it will get people looking and seeing that something needs to be done.”