What happened at West Lane Hospital and why was Tees, Esk and Wear Valleys NHS Trust investigated?
A report has described how there was a "deteriorating spiral" of poor care at a mental health hospital in the months before it closed following the death of two teenage girls.
An independent investigation was carried out into concerns and issues raised in relation to the safety and quality of mental health services for young people provided by Tees Esk and Wear Valleys (TEWV) NHS Foundation Trust at West Lane Hospital, in Middlesbrough.
The hospital closed in August 2019, shortly after the deaths of 17-year-olds Christie Harnett and Nadia Sharif.
A review, which also considered the death of 18-year-old Emily Moore, who was treated at West Lane and died at Lanchester Road Hospital, in March 2020, was carried out by Niche Health and Social Care Consulting (Niche) and looked at the governance at West Lane from 2017 up until the hospital closure in 2019.
A series of 12 recommendations have now been made.
It follows an independent investigation in November that found there were 120 failings in the care of three teenage girls who took their own lives at mental health hospitals in our region.
All three girls had been patients at West Lane in Middlesbrough, which was shut down in 2019. Reports into their deaths found failings were multifaceted and systemic. It said services were overstretched and unstable and there was a lack of leadership.
Brent Kilmurray, chief executive of the Tees, Esk and Wear Valleys NHS Trust, who took over in 2020, says it has undergone a thorough change in leadership and structure and has changed the way it cares for patients.
This is the timeline of events that led to the independent investigation which found there were 120 failings in the care of the three teenagers.
20 staff are suspended from West Lane Hospital which is run by the Tees, Esk and Wear Valleys (TEWV) NHS Foundation Trust.
The Care Quality Commission (CQC) releases a damning report which found that patients were at risk of "avoidable harm", ruling its services inadequate.
Christie Harnett, 17, ends her life while a patient at West Lane Hospital.
New admissions are suspended.
Nadia Sharif, 17, ends her life while a patient at West Lane Hospital.
Inspectors close down West Lane Hospital, with responsibility transferred to Cumbria, Northumberland, Tyne & Wear NHS Trust (CNTW).
NHS England orders an independent investigation into the trust, which is tasked with looking into the deaths of both girls.
This is later extended to include a third death - that of 18-year-old Emily Moore in February 2020.
Emily Moore ends her life after a week under the care of Lanchester Road Hospital, which is also run by the Tees, Esk and Wear Valleys NHS Trust.
She had previously been cared for at West Lane Hospital.
Brent Kilmurray, described as an experienced senior leader, returns to the trust and takes up the role of chief executive at the Tees, Esk and Wear Valleys NHS Trust.
He had previously been chief operating officer at Tees, Esk and Wear Valleys NHS Trust until June 2018.
The CQC inspect following the death of a patient. Acute wards for adults of working age and psychiatric intensive care units are rated as "inadequate". A warning notice is issued.
The Tees, Esk and Wear Valley NHS Trust responds by saying it's spending £3.6 million on recruiting 80 more care staff.
This service rating was raised to "requires improvement" in a follow-up inspection in May 2021.
West Lane Hospital reopens under a new name Acklam Road Hospital.
It is being run by the neighbouring Cumbria, Northumberland and Tyne and Wear NHS Foundation Trust.
A CQC report finds improvements have been made within the trust, and its rating is lifted from "inadequate" to "requires improvement". This is a follow-up inspection from January 2021 for psychiatric services.
Another inspection report by the CQC is released and enforcement action is taken against the trust for the second time in a year.
Forensic inpatient services were downgraded from "good" to "inadequate".
The CQC said it carried out an unannounced inspection of forensic inpatient wards due to concerns around unsafe staffing numbers and poor culture within the service.
The CQC announce the trust is to be prosecuted over the death of Christie Harnett. The charges brought claim the trust failed to provide safe care and treatment, exposing the 17-year-old to a significant risk of avoidable harm.
The Care Quality Commission (CQC) tells the Tees, Esk and Wear Valleys NHS Trust to make improvements following an inspection of inpatient wards for people with autism and/or learning disabilities and for a "significant deterioration in standards of care".
A re-inspection of forensic inpatient or secure wards sees the service upgraded from "inadequate" to "requires improvement".
NHS England's independent investigation into the deaths of Christie Harnett, Nadia Sharif and Emily Moore is released.
It identified 120 failings in their care.
An independent investigation into concerns and issues raised in relation to the safety and quality of mental health services for young people provided by Tees Esk and Wear Valleys (TEWV) NHS Foundation Trust at West Lane Hospital, in Middlesbrough is released.
The report frequently described the environment as "chaos" along with a failure to put patients' needs first, where those in their care did not feel safe, and somewhere that facilitated self-harm.
A series of 12 recommendations were made.
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