An independent investigation has identified 120 failings in the care of three teenage girls who died within months of each other at mental health hospitals in the North East.
The inquiry into the Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV) was commissioned by NHS England following the deaths of Christie Harnett, 17, Nadia Sharif, 17, and 18-year-old Emily Moore.
The teenage girls had been treated by TEWV for several years prior to their deaths in 2019 and 2020.
They had all been patients at West Lane Hospital in Middlesbrough which was later shut down.
Three separate reports have been released into their care and treatment.
Christie Harnett, 17
Christie Harnett, from Newton Aycliffe, County Durham, first came into contact with TEWV at the age of 10 in October 2012.
She took her own life at West Lane Hospital in June 2019 after making a similar attempt three months earlier.
The investigation into her death uncovered 49 failings by the trust, including no plans to manage her risk of self harm or investigate her previous suicide attempt in March 2019.
The report also revealed a failure to respond to concerns raised by Christie, her family and staff, as well as an absence of skilled staff or training to manage her risk.
It was also found rapid changes to staffing, including a mass suspension in November 2018, impacted Christie's care.
Nadia Sharif, 17
Nadia Sharif grew up in Middlesbrough and had been under the care of TEWV since 2012 when she began receiving treatment for her mental health.
She was an in-patient at West Lane Hospital when she took her life, six weeks after Christie Harnett.
The report into her death found 47 failings in her care, including a lack of staff training to deal with autism, which Nadia was diagnosed with in April 2016.
There were also no translation services, either in writing or through interpreters, available for Nadia's mother and her family were not fully involved in her care.
It was also revealed her care plan included seclusion, as well being expected to "earn" access to her own clothes.
The seclusion room where she was placed had observation blind spots and ligature suspension points.
Emily Moore, 18
Emily Moore, from Shildon, County Durham, died in another of the trust's hospitals a week after her 18th birthday.
However, because of the time she spent at West Lane, her death is included in the report with Christie and Nadia.
She took her life in a bathroom on an adult ward at the Lanchester Road Hospital, seven days after she moved from a children's mental health hospital run by the neighbouring Cumbria, Northumberland, Tyne and Wear trust.
The report into her death uncovered 24 failings and criticised Emily's transfer from child to adult services being based on age and not clinical needs.
It found when she had been at Lanchester Road, there had been a failure to address ligature risks in Emily's accommodation.
There had also been a complete breakdown of trust between TEWV trust and Emily's family, with her parent's concerns not investigated.
Timeline of events:
January 2019 - 20 staff suspended
20-24 June - Inspectors rule services inadequate
29 June - Christie Harnett takes her own life. New admissions suspended
9 August - Nadia Sharif takes her life
23 August - West Lane Hospital is closed
15 February 2020 - Emily Moore dies at Lanchester Road Hospital
In response to the findings of the reports, Brent Kilmurray, chief executive of Tees, Esk and Wear 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.”
Margret Kitching, the Chief Nurse for NHS England, North East and Yorkshire, said: “These reports make for very difficult reading and our thoughts are with the families of these three young people.
“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.”
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