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 has been 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 series of 12 recommendations has now been made following the investigation by Niche Health and Social Care Consulting (Niche) looked at the governance at West Lane from 2017 up until the hospital closure in 2019.
The review, published on Tuesday 21 March, also looked at the treatment of Emily Moore, from County Durham, who had been a patient at West Lane and died at Lanchester Road Hospital, also run by TEWV, in March 2020.
As part of the report, 100 staff members were interviewed, along with 16 former patients or their parents.
'Deteriorating spiral of poor care'
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.
On how staff interacted with patients, it said the way they were observed was intrusive and often degrading and that the use of restraints were excessive, inappropriate and damaging to both patients and staff.
Some of those who worked at the trust were seen as being uncaring and judgemental, with some parents and carers even saying they felt bullied.
It criticised the trust's board for being unaware of the scale of the problems, sometimes ignoring complaints made by staff, or red flags in regards to safety, and quality of care.
It summarised that there was a deteriorating spiral of poor care, an absence of effective leadership, and repeated missed opportunities to make improvements.
Young people interviewed said they had been treated in an "uncaring" way and that verbal interactions were "judgemental" - and at times "felt abusive".
One young person told the interviewers they were called “a maniac” and a “stupid little girl” while a parent interviewed for the review described the hospital as like “the Lord of the Flies”.
One patient reported being restrained while completely naked, while another said: “They made me feel like I’m just a waste of a bed”.
Another young person told the interviewer: “They let me do a degree of harm to myself which I know now should not have been possible”.
The report adds that every parent spoken to during the review was unhappy about how their children had been treated at West Lane.
Tees, Esk and Wear Valleys NHS Foundation Trust said it would be taking part in any interviews due to ongoing legal proceedings.
'Shortfalls in both care and leadership'
In a statement responding to the report, trust chair David Jennings, said: "We would like to reiterate how deeply sorry we are for the events that contributed to the deaths of Christie, Nadia and Emily.
“Brent Kilmurray, our chief executive, and I have met each of the young women’s families to apologise to them in person. I thank them for allowing us to do that. I cannot begin to imagine how painful it has been for them.
“This report covers a period of time where it was abundantly clear there were shortfalls in both care and leadership. Over the last three years, how we care for people, how we involve patients, families and carers, and our leadership and governance structure have changed significantly.
“We will continue to work hard to make sure we deliver safe and kind care to the people we support, as they have every right to expect."
Margaret Kitching, the Chief Nurse for NHS England, North East and Yorkshire, said: “This report raises extremely significant concerns and our thoughts are with the patients and families of all those patients who haven’t received the care they deserve.
"Whilst we recognise improvements have been made, the trust has a duty to ensure all the actions required of it are applied consistently across the organisation. We continue to closely monitor the trust’s progress to ensure all of the recommendations are fully addressed."
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