THE details of a final inspection which led to the closure of a crisis-hit mental health unit have been released by the health watchdog.

Both child and adolescent mental health service units (CAMHS) at West Lane Hospital in Middlesbrough, were closed by the Care Quality Commission following the death of two 17-year-olds, just weeks apart.

In June, Christie Brayley of Newton Aycliffe died days after being found unconscious in a coma at the site.

Weeks later, Nadia Sharif of Middlesbrough was discovered also unconscious and in a coma in August.

Both inpatients were taken to James Cook University Hospital in Middlesbrough, where they later died.

On August 23, the CQC closed the hospital’s Evergreen Centre and Westwood Centre after its final inspection, prompted by whistleblowers, revealed patients were at immediate risk, ‘little learning’ had taken place following reported incidents, and staff complained that the service was ‘traumatised’.

The final inspection found staff did not complete incident reports consistently to clearly identify that physical restraint was being used on patients, while it said a patient had presented items that risked their safety to the CQC’s inspection team, which had not been identified or managed by staff.

The final inspection, which took place on both August 20 and 21, followed on from an inspection on August 6 which led to the Tees, Esk and Wear Valleys NHS Foundation Trust’s CAMHS being deemed the worst possible rating, ‘inadequate’.

Last night, Jenny Wilkes, Head of Mental Health Inspection at the CQC, said: “Leading into these inspections we had deep concerns about the quality of the care being provided at West Lane Hospital – we had previously placed enforcement conditions on the service and were monitoring its performance very closely.

“Despite being repeatedly assured that improvements were being made to the service, we were alerted to further concerns and found the care had not improved.

“People were not safe or being provided with care in line with their needs.

“Observations were not being recorded well, staff training and knowledge of care for young people with complex needs was poor and incidents were not consistently reported or reviewed well.

“There was limited experienced managerial oversight of the wards and a culture existed that was not working to the benefit of the people there.”

CAMHS across the Tees, Esk and Wear Valleys NHS Foundation Trust had previously achieved a rating of Good during inspections in June 2018.

However, in the CQC’s four inspections, which took place between June and August, inspections consistently identified that there was a high risk of 'avoidable harm'.

Ms Wilkes said: “Ultimately, considering the inspections’ findings, we could not allow the service to continue and took urgent action to prevent further admissions being made to the service, which led to the closure of the hospital.

“We appreciate action of this nature can cause distress to the people using the service and their families, however our priority is always the safety of people that use services and we will use our enforcement powers to ensure this.”

Ms Wilkes said the CQC continued to work closely with the trust, NHS England and local commissioners to ensure affected patients received care.

A CQC spokesperson added: “CQC has taken urgent enforcement action at Tees, Esk and Wear Valleys NHS Foundation Trust which will lead to the closure of the Child and Adolescent Mental Health Service units at West Lane Hospital.

“The Holly unit at West Park Hospital and Baysdale Unit at Roseberry Park are unaffected. The action follows continued concerns identified at earlier inspections in June and August, and the recent inspection on 20 and 21 August 2019.

“Inspectors are currently working closely with the trust and NHS England who are arranging appropriate alternative care and support for the young people affected, in a safe and timely manner."

On Thursday, Middlesbrough MP Andy McDonald said: “I note that all the young people previously in West Lane have now moved out from the hospital and the wards are now closed.

"I also note the reference to the internal and external reviews and investigations. The key investigation and inquiry here is that of NHS England.

"I have already written to the Trust to make it clear that not only is it imperative that the appointment of the Chair of the NHS England Inquiry is totally independent.

“It is also imperative that the families of patients and staff are consulted as to the scope and the terms of reference of the inquiry.

"What is clear is that their voices were not heard prior to these tragic events and ultimate closure and if we are to truly learn the necessary lessons their voices need to be heard now.

“I have met with the families of the two young women who tragically died while in West Lane Hospital and I will continue to do all I can to support them.”

  • The spokesperson said the full report will be published by the CQC on its website in due course.