Investigation finds Tees, Esk & Wear Valleys NHS trust failings contributed to teen deaths

A health trust has apologised "unreservedly" over the care of three teenage girls who died within eight months in Middlesbrough.

Three independent investigations found failings contributed to the deaths of 17-year-old's Christie Harnett and Nadia Sharif and 18-year old Emily Moore between June 2019 and February 2020.

The three reports released today (2 November 2022) list 119 care and service delivery failings in the care of the three young women by Tees, Esk and Wear Valleys NHS Trust (TEWV).

Christie, Nadia and Emily had all been diagnosed with complex mental health needs and had all been patients at West Lane Hospital, run by TEWV, before taking their own lives.

Now the lawyer for the three families, Alistair Smith, from the law firm 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.”

NHS England and NHS Improvement commissioned the reports conducted by Niche Health and Social Care Consulting. West Lane Hospital was a mental health facility in Middlesbrough, approximately 20 miles from the constituency office of the new Prime Minister.

The hospital closed in October 2019 but reopened as the Acklam Road Hospital under the Cumbria Northumberland and Tyne and Wear NHS Trust.

'Organisational failure'

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 this mass staff suspension was listed as one of the service delivery problems in Christie Harnett’s care.

Christie, who was originally from Slough, died in June 2019. She is described in the report as having a complex mental health disorder and had tried to take her own life in March 2019 whilst under the supervision of TEWV.

Despite this initial attempt, the report found no evidence that the circumstances around this incident involving bathroom fixtures had been adequately investigated.

There was also no consideration by the hospital of the risks posed by bathroom fixtures in the centre and Christie’s access to them. 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.

Amongst the 49 care and service delivery failings in Christie’s care, which the report called ‘multi-faceted and systemic’, was the fact that young people in the facility were exposed to inappropriate social media content.

In June 2022 the CQC announced that it was prosecuting TEWV for Christie’s death, stating that the Trust "failed to provide safe care and treatment" which exposed Christie to "significant risk of avoidable harm".

'Unstable and over-stretched'

Nadia Sharif from Middlesbrough 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.

On 5 October 2022, the Care Quality Commission released an update on TEWV concerning ‘Wards for people with a learning disability or autism’ and found that the Trust was still rated as inadequate.

The CQC found:

“Staff were using high levels of restrictive practice including seclusion, restraint and rapid tranquillisation for some people. Restrictive practice was not always recorded, and staff did not learn from those incidents to reduce the levels or restrictions in place for some people.”

'Fragmented, incomplete and inconsistent'

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.

Despite her vulnerability, the report called her care plans whilst under the supervision of the Trust ‘fragmented, incomplete and inconsistent’, with no effective risk management plan in place.

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.”

On 28 October 2022, the CQC updated their report on TEWV about Forensic or Secure Wards, finding that the services ‘ require improvement’.

The CQC report noted:

“The service did not always provide safe care. The wards did not have enough nurses to carry out all clinical duties to meet the needs of the patients. The service did not always have enough staff to provide a timely response to patient safety incidents. There was not always enough staff who knew patients well to keep patients safe."

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