A health trust has apologized “unreservedly” for the care of three teenagers who died within eight months in hospitals under its control.
It comes after three separate independent investigations found that failures of the Tees, Esk and Wear Valleys NHS Foundation Trust contributed to the deaths of Christie Harnett, 17, Nadia Sharif, also 17, and Emily Moore, 18, who had all been diagnosed with complex mental health needs and took their own lives between June 2019 and February 2020.
Their families said the reports had found “multifaceted and systemic” failures in the care of the adolescents, calling for a public inquiry after investigators listed a total of 120 failures in care and service delivery and made 47 recommendations.
Inquiries looked at the care and treatment of the three girls at West Lane Hospital in Middlesbrough and, additionally, for Emily, at Lanchester Road Hospital in Durham, as well as the actions of partner organisations.
Christie, originally from Slough and described by her family as a talented artist who loved to sing and dance, died in June 2019.
The report says he had a complex mental health disorder and had attempted suicide in March 2019, after which there was “a failure to recognize and act on the heightened risk of serious harm or death.”
Nadia, a talented mathematician from Middlesborough, had been diagnosed with autism and died in August 2019.
“We believe it was the organization’s failure to mitigate the risks of self-ligation, coupled with Nadia’s increased risks, individual needs and changing presentation that went unrecognized, and the unstable and overburdened services at West Lane Hospital that underlying causes of Nadia’s death,” the investigators said in their report.
Animal lover Emily, from County Durham, died in February 2020.
The report says that his care plans while under the supervision of the Trust were “fragmented, incomplete and inconsistent”.
Responding to the reporting findings, Brent Kilmurray, chief executive of the Tees, Esk and Wear Valleys NHS Foundation Trust, said: “On behalf of the trust, I would like to apologize unreservedly for the unacceptable failures in the care of Christie, Nadia and Emily that these reports have clearly identified.
“The girls and their families deserved better while in our care. I know that everyone at the trust offers their sincerest condolences to the families and friends of the girls for their tragic loss.
“We must do everything in our power to ensure that these failures are never repeated.
“However, we know that our actions must match our words. We fully accept the recommendations made in the reports; in fact, the vast majority of them we have already addressed where applicable to our services.”
Kilmurray, who became chief executive of the Trust a year after the girls’ deaths in 2019 and 2020, added: “It is clear from the reports that no individual or group of individuals was solely to blame – it was a failure of our systems with tragic consequences.
“Since then, we have undergone a complete change in our senior leadership team and our structure and, more importantly, we have changed the way we care for and treat our patients. However, the necessary transformation is not complete. We need enhancing and ensuring that respect, compassion and responsibility are at the core of everything we do.”
The girls’ families said in a statement: “Our beautiful girls should not have been let down in this way, and we need answers to many more questions. Not just for us but for many other families we know have suffered through the pain.” of losing a loved one who should not have died but should have been properly cared for.
“We are calling on the government to launch a public inquiry looking into this trust and the services provided across the country for youth in crisis. For Christie, Nadia and Emily.”
