Three adolescents died after major failures in the care they received from National Health Service mental health services in the northeast of England, independent research has found.
The “multifaceted and systemic” failures of the Tees, Esk and Wear Valleys (TEWV) NHS trust contributed to the self-inflicted deaths of the young women within eight months of each other, it concluded.
Christie Harnett died aged 17 on June 27, 2019 at the Trust’s West Lane Hospital in Middlesbrough. Nadia Sharif, also 17, died there six weeks later, on August 5. Emily Moore, who had been treated there, died on February 15, 2020 at another hospital in Durham. All three had complex mental health problems and had been receiving NHS care for a number of years.
The inquiry into their deaths, commissioned by the NHS, found that there had been 119 “care and service delivery issues” by NHS services, especially TEWV.
Charlotte and Michael Harnett, Christie’s parents, said their daughter had “lost her life while in a hospital run by the TEWV Trust where there was little or no care or compassion”. Emily’s parents, David and Susan Moore, said she received “horrible care” while she was at West Lane. Services at the hospital were understaffed, “unstable and overburdened,” the final report of the investigation found.
Both families, and also Nadia’s parents, Hakeel and Arshad Sharif, said the dangerous inadequacy of care provided by TEWV, and the likelihood that other mentally fragile patients have died as a result, show that ministers should order an investigation. full public. “This mental health trust is a danger to the public,” the Moores said.
The report says that TEWV failed to adequately monitor the girls, given their known risk of self-harm; take seriously the concerns about their care and the risk of suicide raised by their families; and remove all possible tie points.
The investigation, carried out by specialist health and care consultancy Niche, found that “it was organizational failure to mitigate the environmental risks of self-ligation, accompanied by Christie’s increased risk and presentation change due to its recent move to his own home, not being fully recognized, and the unstable and overburdened services at West Lane Hospital, were the root causes of Christie’s death.” It involved 49 separate failures.
The report, released Wednesday, found that very similar failures were “the root causes” of Nadia’s death, though in her case they included “Nadia’s increasing risks, individual needs, and changing presentation that go unrecognized.” Her death involved 46 separate failures.
The failures at West Lane were “multifaceted and systemic” in both cases, Niche found.
The inquest found that in Emily’s death, “the problems at West Lane cannot be considered to have been immediate contributing factors in her death” as she had left the facility seven months before she died. However, the 24 “care and service delivery issues” from various NHS agencies in her case included West Lane staff failing to respond adequately to concerns raised by her father.
“These reports are damning,” said Alistair Smith of Watson Woodhouse attorneys, who represent the three families. He described the care of the girls as “appalling and chaotic”. Recent inspection reports from the Care Quality Commission (CQC), the NHS care watchdog, showed that TEWV continued to provide poor care, he added. “The lessons are not being learned.” The CQC is prosecuting the trust for allegedly exposing Christie to a “significant risk of avoidable harm”.
Investigations into the deaths have been opened and stopped pending the publication of the report. The families are also suing the trust for breach of civil rights and negligence.
West Lane was closed in 2019 after the deaths of Christie and Nadia. However, it reopened last year under the new name Acklam Road Hospital and is being run by a different mental health trust.
“On behalf of the trust, I would like to apologize unreservedly for the unacceptable failures in the care of Christie, Nadia and Emily,” said Brent Kilmurray, executive director of TEWV. “The girls and their families deserved better while in our care.”
However, the families dismissed the apology letters they recently received from Kilmurray as “nothing more than a last minute public relations exercise”, saying they did not accept his apology.
Margret Kitching, NHS England Chief Nurse for the North East and Yorkshire, said: “These reports are hard to read and our thoughts are with the families of these three young people. We have put in place measures to protect patients while supporting confidence in making the comprehensive program of improvements at every level, from your wards to your boardroom.”
