The families of three teenage girls who took their own lives in hospitals run by a North East mental health trust have called for its boss to resign following damning reports into their deaths.
NHS England commissioned an independent investigation into the deaths of 17-year-olds Christie Harnett and Nadia Sharif, and Emily Moore, who was 18, following their deaths while under the care of the Tees, Esk and Wear Valleys NHS Trust (TEWV).
Christie and Nadia died within weeks of each other at West Lane Hospital in Middlesbrough in 2019.
Eight months later Emily, who had previously been a patient at West Lane, took her own life at the trust's Lanchester Road Hospital in Durham.
In total, the three reports carried out by independent consultants NICHE identified 120 failings.
It said the failings at West Lane Hospital were multi-faceted and systemic and were based on factors including reduced staffing, low morale, a lack of leadership and a failure to respond to concerns from patients and staff.
Christie, from Newton Aycliffe, died on 27 June 2019.
Her family described her as a beautiful, courageous, caring, independent young woman with a fiery temper and spirit.
Her step-father Michael said: "She was amazing, she really was. When you came into the room she was smiling even in the hospital. Every time we went to see her she always had a very infectious smile and always singing, everyday as much as she could.“
Christie took her own life in a bathroom at West Lane Hospital in Middlesbrough. She had made a similar attempt three months earlier and was put on life support.
This was despite a warning by the NHS of a potential hazard in the bathrooms. However, recommended changes were not made.
Christie’s grandmother Casey Tremain said if those changes had been made, Christie may still have been alive.
She said: "The place that should have been keeping her safe was killing her. She died because they failed her.“
The report into Christie’s death identified 49 failings in care, including no plans to manage her risk of self-harm or investigate a previous suicide attempt.
It found there was a failure to respond to concerns raised by Christie, her family and staff and there had been an absence of sufficiently skilled staff or training to manage her risk.
Mr Harnett said he was shocked by how many failings there were.
He said: “It was horrible. We weren't expecting that many. Seeing them there in black and white - it was horrible to see what she had to go through."
Ms Tremain has called on the trust’s chief executive Brent Kilmurray to resign from his role.
She said: “I would tell him to resign, to leave. Do the right thing by us. Do the right thing by the families."
Nadia Sharif, from Middlesbrough, died on 9 August 2019, six weeks after Christie.
She also took her own life at West Lane Hospital.
The 17-year-old from Middlesbrough has been described by her family as caring, very bright, always smiling and funny to be around. They say she was a dancer, a gymnast and was sociable and bubbly with friends until she went into hospital.
Speaking to ITV Tyne Tees through a translator her mother Arshad Sharif said: "We remember Nadia all the time. We cry a lot when we remember her. Her sister has got pictures of Nadia in the room upstairs. 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."
Nadia had autism and the report identified that staff were not properly trained to deal with this and there was no autism pathway at West Lane.
Her father Hakil Sharif said they let her down.
He said: "Every time she would go somewhere they would tell her she is in the wrong place. She liked the quiet and it was too noisy there. The care wasn’t there for her, the right care.
"She’s always in my heart, I still think about her everyday. I miss the phone calls I used to have a phone call everyday. I don’t get it anymore. It is just sad."
The report into Nadia’s care also found there were no translation services available for her mother and her family were not fully involved in her care.
A seclusion room where she was placed had observation blind spots and there were opportunities for self harm.
It also found Nadia’s increasing risks, individual needs and changed presentation was not being recognised.
Mr Sharif said it was not easy to send Nadia to hospital. He added: "Sometimes you don’t have a choice to send them. It was not a better place for her."
Emily Moore’s family said the report into her death shows repeated failures.
Emily, from Shildon in County Durham, was her parents David and Susan's only daughter and said they miss ‘Our Emily’ every single day.
She loved shopping, was an animal lover and died on the same day as Caroline Flack, who she loved watching on Love Island, one of her favourite programmes.
They said she had her whole life ahead of her but she was taken by mental health issues and a lack of proper professional care.
Emily died in a bathroom on an adult ward of the trust's Lanchester Road Hospital in Durham, a week after her 18th birthday.
She had previously been a patient at West Lane and her parents asked for her death to be part of this investigation.
She had moved to Lanchester Road from a children's mental health hospital run by the neighbouring Cumbria, Northumberland, Tyne and Wear Trust.
The report criticised the transfer of care being based on age and not clinical needs.
It found when she has been at Lanchester Road there was a failure to address risks in her accommodation.
There had also been a complete breakdown between the Tees, Esk and Wear Valleys NHS Trust and Emily’s family.
Mr Moore said: "I didn’t see Emily that much at Lanchester Road because she was only in for seven days but West Lane - hell hole.
"It was just a youth club where people were dressed in dressing gowns all day long, watching TV.
"Nothing happened. In my world, that is not caring and it is certainly not a hospital.
"The thought of Emily just lying there dying is hard to comprehend. It is just hard. Hard as a dad, hard as a mam.
"These are the things we are going to miss. No grandchildren, getting married andjust seeing her smile as she comes through the door. It has all gone, taken away.”
Alistair Smith, a solicitor for Watson Woodhouse, is representing the families of Christie, Nadia and Emily.
Mr Smith said: "I have found it really quite awful. I mean there are some things in there that no family should ever read about what's happened to their child.
"It would grieve me as a parent, it must be awful for them and 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 havebeen."
The families of the three girls have called for a public inquiry into the Tees, Esk and Wear Valley trust.
In October, Mr Harnett cycled to Downing Street to hand a petition and letters from other families who have lost loved ones under the trust's care.
Mr Harnett said: "We are three small families from the North East and we are trying as hard as we can to be the voice of girls more than anything.
"They have been failed now and we need to make sure no one else gets failed by the trust.”
Hours before the reports were published Emily Moore's father protested outside the trust's headquarters in Darlington calling for a public inquiry.
He was invited into the hospital by the trust's chief executive where they held a meeting.
In response to the findings of the reports, Brent Kilmurray, chief executive of Tees, Esk andWear Valleys NHS Foundation Trust, said: “On behalf of the trust, I would like to apologise unreservedly for the unacceptable failings in the care of Christie, Nadia and Emily which these reports have clearly identified.
“The girls and their families deserved better while under our care. I know everyone at the trust offers their heartfelt sympathies and condolences to the girls’ family and friends for their tragic loss.
“We must do everything in our power to ensure these failings can never be repeated.
“However, we know that our actions must match our words. We accept in full the recommendations made in the reports – in fact the overwhelming majority of them have already been addressed by us where applicable to our services.” Mr Kilmurray, who became chief executive at the trust the year after the girls’ deaths in 2019 and 2020, added: “It is clear from the reports that no single individual or group of individuals were solely to blame – it was a failure of our systems with tragic consequences.
“We have since undergone a thorough change in our senior leadership team and our structure and, as importantly, changed the way we care and treat our patients. However, the transformation needed is not complete.
"We need to get better and ensure that respect, compassion and responsibility is at the centre of everything we do.”
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