The treatment three girls received before they tragically took their own life has exposed shocking failures in NHS mental health services.

An investigation into the deaths of Christie Harnett, 17, Nadia Sharif, 17 and Emily Moore, 18, identifies 119 failings in health and social care which led to their deaths.

The three girls took their own lives between June 2019 and February 2020, had all been diagnosed with complex mental health needs and had been patients at West Lane Hospital in Middlesbrough.

The hospital, run by Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV), is where Christie and Nadia died. Emily died in Lanchester Road Hospital, Durham, in an adult ward where she was moved to from West Lane Hospital just 11 days before.

The findings provide a damning assesment of the care given by the Tees, Esk & Wear Valleys NHS Foundation Trust as the families of the girls criticised the lack of “care or compassion” and labelled it a “danger to the public”. 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.

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

Read more: Teenagers died after 'appalling' care at Durham and Middlesbrough hospitals 

Christie Harnett

The Northern Echo:

Christie, originally from Slough, had a complex mental health and eating disorder and had made several attempts to take her own life, the report said. She was a talented artist and loved to sing and dance.

The 17-year-old 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.

She was repeatedly rehomed by staff in line with her complex care needs but investigators say they could not find any plans to help Christie develop the life skills for living alone.

A total of 49 care and service delivery problems were identified as contributory factors which led up to her death.

The report into the care and treatment of Christie said it was “the organisational failure to mitigate the environmental risks of self-ligature, accompanied by Christie’s increasing risk and changed presentation because of the recent move to her own home not being fully recognised, and the unstable and overstretched services in West Lane Hospital that were the root causes of Christie’s death.”

It added: “Our observation is that the failings at West Lane Hospital were multifaceted and systemic, based upon a combination of factors, including reduced staffing, low morale, ineffective management of change, lack of leadership, aggressive handling of disciplinary problems, issues with succession and crisis management, failures to respond to concerns from patients and staff alike, and increased patient acuity.”

Read more: Government says sorry after three teens died at Durham and Middlesbrough hospital

Nadia Sharif

The Northern Echo:

Nadia, who grew up in Middlesbrough, was diagnosed with an autism spectrum disorder. She had a love for theme parks and was a technically gifted Mathematician.

The report into the care and treatment of Nadia referenced the “unstable and overstretched services” in the hospital, and that the failings were “multifaceted and systemic”.

It says the organisation failure to mitigate the risks of self-harm, accompanied by a lack of support for Nadia’s individual needs were the “root causes” for her death.

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

It identified 47 care and service delivery issues with her treatment.

Emily Moore

The Northern Echo:

Emily, from Shildon, was an inpatient under the care of TEWV Adult Services (Tunstall Ward) when she took her own life. She loved shopping and animals and took great care in looking after her pet guinea pigs.

The report said issues at West Lane cannot be seen to have been immediate contributory factors in her death, but added that Emily’s care plans in Newberry Ward in West Lane were “fragmented, incomplete and inconsistent”.

Emily alleged that staff "would shout and swear at her when she harmed herself" – a time when she needed support the most – while at the Ferndene facility.

It said the two systems issues that had a direct impact on Emily’s death were the transition from CAMHS (Children and Adolescent Mental Health Services) to Adult Services which was based entirely on age and did not take Emily’s clinical needs into consideration, and the failure to address the low-level ligature risks identified in en-suite bathrooms on Tunstall Ward in 2019.

A total of 24 care and service delivery problems were identified during Emily’s care before her death.

Health trust apologises

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

If you are in need of support you can contact Samaritans for free on 116 123


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