A report released today into the deaths of three girls made reference to details surrounding their treatment, published in a Care Quality Commission report published November and detailed below: 

An investigation into the deaths of Christie Harnett, 17, Nadia Sharif, 17 and Emily Moore, 18, identify 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.

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.

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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.”

The Northern Echo:

Health minister Maria Caulfield told MPs she will examine calls for a public inquiry amid concerns over inpatient mental health services.

Ministers will make a decision “in the coming days” on whether a full public inquiry or a “rapid review” should be carried out into the failings.

Responding to an urgent question, Ms Maria Caufield told MPs: “The findings from the investigation into the deaths make for painful reading and the death of any young person is a tragedy, and all the more so when that young person should have been receiving care and support.

“My thoughts and I’m sure the thoughts of this whole House are with their families and friends, and I want to apologise for the failings in the care that they received.”

Read more: 'Failures' exposed at West Lane Hospital before deaths of three girls

Read more: Andy McDonald MP's inquiry call into Tees, Esk and Wear Valley Trust

Read more: Shocking comments about patient treatment West Lane Hospital

“On the issue of a public inquiry, I am not necessarily saying there won’t be a public inquiry but it needs to be on a national basis and not just on an individual trust basis, because as we’ve seen in maternity very often when we repeat these inquiries they produce the same information and we need to learn systemically about how to reduce these failings.

“The issue I have with a public inquiry is they’re not timely, they can take many years, and we’ve clearly got some cases now which need some urgent review and some urgent action.

“So I will look at her request, but I am taking urgent advice – as is the Secretary of State – because we take this extremely seriously and one death from a failing of care is one death too many.”