Girl who took her own life was 'failed by place supposed to keep her safe'

A teenage girl who took her own life at a mental health facility was "failed by the place that was supposed to keep her safe", her family have said.

Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV) has been fined £200,000 for offences relating to the care of two patients who died as a result of self-inflicted incidents at its hospitals.

Christie Harnett, 17, died after being found unconscious in a bathroom at the Newberry Centre at West Lane Hospital, Middlesbrough, in June 2019.

A mother-of-four, referred to as Service User X after a judge ruled her name could not be reported, died in November 2020 - three days after being found unconscious in the bathroom of her room at Roseberry Park Hospital, also in Middlesbrough.

On Friday, the mental health trust responsible for the women's care was fined at Teesside Magistrates' Court after pleading guilty to two offences of failing to provide safe care and treatment to people who were exposed to a significant risk of avoidable harm.

The Care Quality Commission, which brought the prosecution, said the trust failed to mitigate the known risks the women were exposed to following previous self-harm incidents.

The court heard Christie had "experienced significant past trauma in childhood" and had been diagnosed with a "complex and emerging mental health disorder" leading to her spending 603 out of 672 nights in hospital before her death.

Prosecutor Jason Pitter KC said she had been detained under the Mental Health Act on 11 occasions from the age of 15, and that there were "numerous self-harm incidents in that time".

She fatally harmed herself in a communal bathroom on the ward on June 23 2019, and was found by a healthcare assistant after a service user saw water running under the bathroom door.

An investigation revealed a number of failings in her care, including a failure to adequately identify the high risk of self harm and set out appropriate ways this was to be managed by staff, Mr Pitter said.

The trust failed to respond to previous ligature incidents involving Christie in March and May, and put in place appropriate measures, it was said.

Risk assessments and care plans failed to prevent Christie using the bathrooms without any additional risk control, such as removal of items she could use to attempt to tie a ligature, Mr Pitter said.

In its response under caution, the trust accepted that "in relation to the use of the ward bathroom the risk of self harm had been underappreciated by staff and risks were not mitigated as fully as they could have been".

"inadequate approach to carrying out observations"

The court heard Service User X had a history of depression and anxiety and was admitted to hospital following an overdose in 2020.

On the day of her death, a staff member doing a care observation round looked round her bedroom door, but did not go into the bathroom and wrongly reported there was no-one in the room before completing her round.

The staff member then tried to find out where Service User X was, and returned to the room with another employee. This time they entered the bathroom and found Service User X unconscious, the court heard.

After her death, the CQC found TEWV had an "inadequate approach to carrying out observations" and a "failure to embed its observation and engagement procedure amongst its staff and population".

In a statement read in court, Christie's stepfather Michael Harnett said he had met her at the age of five after starting a relationship with her mother Charlotte, and that "she considered me to be her dad", which he said was a massive honour.

He said Christie was "such a happy child" who dreamed of becoming a singer.

"The day Christie went into hospital was the start of the worst period of our lives," Mr Harnett said.

"Sometimes we would travel for an hour to see her only to be turned away because Christie had misbehaved."

He described watching his daughter "climb over a fence to try to see you" on those occasions, and told how seeing her "covered in scratches, cuts and bruises" during visits was "traumatising" for Christie's family.

Mr Harnett said he would never see Christie turn 18, or 21, or "become a mother which she was looking forward to so much".

"These things people take for granted but not for us. We have had them stolen from us because the place that was supposed to keep her safe, in my opinion, totally failed her," he added.

Christie's sister, Ellis Brayley, said her mental health "declined rapidly" after she was admitted to hospital, adding: "I can't even bring myself to say the name of the place because it fills me with so much anger."

The mother of Service User X said in a statement that her children "will never be able to live their lives normally" after her death.

"My daughter is dead and it's like she is a number on a piece of paper rather than a young lady with amazing potential," she said.

"My daughter deserved better, she deserved to be cared for. The trust, in my opinion, should have done better."

Paul Greaney KC, mitigating, said the trust wished to apologise to the families of Christie and Service User X, and read a statement from its chief nurse - Beverley Murphy - saying how sorry it was for the incidents and that the care on these occasions "had fallen short of that which we would expect".

Mr Greaney said TEWV was not being sentenced on the basis that it caused the women's deaths, and that it did have systems designed to ensure care and treatment were provided in a safe way.

"This is not a case where nothing was done. There were systems and these systems failed," Mr Greaney said.

"Staff on those wards did care for Christie and Service User X."

He told the court the leadership of the trust "has changed beyond all recognition" since the time of the offending and it was "determined to learn the lessons arising out of Christie and Service User X".

Mr Greaney said the money to pay the fine would have to be diverted from funds "that would otherwise be used to support patient care".

Middlesbrough MP Andy McDonald described the financial penalty against the TEWV as "ludicrous" and said it would not "help them in any way improve on the delivery of services".

He added: "There must be a better way than this to admonish a Trust who have failed in their care of patients.

"And let us not forget that whilst there were clear systemic failures, no individual or individuals have been held personally accountable for their particular errors and failures that were part of the events that led to these avoidable deaths.

"NHS England commissioned independent reports into these deaths and were utterly scathing in their conclusions and their recommendations are far reaching.

"But the anxiety now is that we are not going to get progress with the broader issues that these tragic cases lay bare.

"I have repeatedly called for a public inquiry, not just into these deaths but into the broader provision of mental health for children and young people.

"A financial penalty against TEWV is not the answer here."

For mental health support, contact the Samaritans on 116 123, email them at jo@samaritans.org or visit samaritans.org to find your nearest branch.

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