Heartbroken parents have warned an NHS mental care trust is a "danger to the public" after three girls took their own life following 'appalling' failings in NHS mental health care.

Damning new reports into the deaths of teenagers Christie Harnett, Nadia Sharif and Emily Moore identify a shocking 119 failings in health and social care which led to their deaths. 

The findings provide a damning assesment of the care given by the Tees, Esk & Wear Valleys NHS Foundation Trust (TEWV), while it also exposed “multifaceted and systemic” failings at West Lane Hospital in Middlesbrough where the three girls stayed.

Christie and Nadia, both 17, died at the Teesside facility in 2019, while Shildon teenager Emily died at Lanchester Road Hospital, Durham, in 2020.

Their deaths prompted a public outcry of anger and led to the closure West Lane Hospital. 

Brent Kilmurray, chief executive of Tees, Esk and Wear Valleys NHS Foundation Trust, apologised for the ‘unacceptable failings’, adding the families ‘deserved better’

Shocking details reveal how one girl was shouted and sworn at by staff when she self-harmed - a time when she needed support the most. Another ended up in intensive care after attempting to kill herself but the incident was never properly investigated.

Investigators also uncovered CCTV footage of Nadia being 'dragged' down a corridor backwards through access to a separate serious investigation report. 

The Northern Echo: Nadia and Christie pictured together Nadia and Christie pictured together (Image: The Northern Echo)

Now, the families of the three girls have launched a campaign, Rebuild Trust, and are collectively calling for a public inquiry into the trust.

The parents of Christie, Charlotte and Michael Harnett, from Newton Aycliffe, said: “Our beautiful Christie, just 17 years old, lost her life whilst in a hospital run by TEWV Trust. Where there was little to no care or compassion. Three years on the trust are still being rated inadequate and are rolling out the same 'copy and paste' platitudes and apologies. A public inquiry is the only way to stop the failings continuing.”

The parents of Nadia Sharif, Hakeel and Arshad Sharif, of Middlesbrough, added: “This has been awful and goes on and on. We need a public inquiry to see what went wrong.”

The Northern Echo: Emily Moore, from Shildon, was 18 when she died at Lanchester Road HospitalEmily Moore, from Shildon, was 18 when she died at Lanchester Road Hospital (Image: The Northern Echo)

And issuing a united call for an inquiry into the deaths, the parents of Emily Moore, David and Susan Moore, said: “As a family who have seen with our own eyes and witnessed our daughter Emily’s horrific care amongst others, we believe a public inquiry is paramount to TEWV either moving forward or losing their licence to serve the publics mental health needs.

“Even nearly three years after Emily’s death the Trust is inadequate in many of its locations and this just does not get any better. This mental health trust is a danger to the public and cannot move on without the need for a public inquiry.”

The families have partnered with INQUEST lawyers group as they seek justice for the tragic deaths.

Read more: Investigation gets underway into mix-up that saw family visit wrong grave for 17 years

What the damning reports reveal


The investigation was commissioned by NHS England and carried out by Niche Health and Social Care Consulting.

Issues highlighted in the independent reports include ineffective management, reduced staffing, lack of leadership, aggressive handling of disciplinary problems, issues with succession of crisis management, failures to respond to concerns from patients and staff alike and more.

Between April 2017 and March 2020, the Trust recorded 357 deaths. The latest CQC inspection of secure wards at the trust found these services still require improvement.

In the case of Emily, the investigation found "fragmented, incomplete and inconsistent" care plans, "gaps in psychology provision" and a lack of "effective risk management plans in place". She also alleged that staff "would shout and swear at her when she harmed herself".

Investigators identified 47 care and service delivery problems which contributed to Nadia's death in August 2015. 

Christie was involved in a serious self-harm incident in March 2019 which left her needing treatment in intensive care, but investigators say they "have not seen any evidence that this was adequately investigated by TEWV".

Complaints from Christie's family went without response for months despite repeated complaints. Why it took the trust 18 months to formally respond to one complaint has not been explained and this response was seven months after Christie’s death.

West Lane Hospital closed in 2019 but reopened under the new name Acklam Road Hospital in May 2021. However, recent inspections by the Care Quality Commission (CQC) highlight dangerous cultures and practices remain. The CQC announced in June that it will be bringing criminal charges against TEWV. 

What the trust says


Brent Kilmurray, chief executive of Tees, Esk and Wear Valleys NHS Foundation Trust, said: “On behalf of the trust, I would like to apologise unreservedly for the unacceptable failings in the care of Christie, Nadia and Emily which these reports have clearly identified.

“The girls and their families deserved better while under our care. I know everyone at the trust offers their heartfelt sympathies and condolences to the girls’ family and friends for their tragic loss.

“We must do everything in our power to ensure these failings can never be repeated.

“However, we know that our actions must match our words. We accept in full the recommendations made in the reports – in fact the overwhelming majority of them have already been addressed by us where applicable to our services.”

Mr Kilmurray, who became chief executive at the trust the year after the girls’ deaths in 2019 and 2020, added: “It is clear from the reports that no single individual or group of individuals were solely to blame – it was a failure of our systems with tragic consequences.

“We have since undergone a thorough change in our senior leadership team and our structure and, as importantly, changed the way we care and treat our patients. However, the transformation needed is not complete. We need to get better and ensure that respect, compassion and responsibility is at the centre of everything we do.”

John Pearce, Durham County Council’s corporate director for children and young people’s services, said: “We note the contents of the reports and have already taken a number steps to address points raised within them.

"Since 2020, we have implemented a series of measures to ensure young people receive as much support as possible during and after discharge from inpatient mental health provision."

If you're in need of support, call the friendly team at Samaritans on 116 123

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