By Charlotte Webster-
A Health trust has admitted failings over the care of three teenage girls who died within eight months at hospitals under its control and offered an unreserved apology for their deaths.
The apology follows three separate independent investigations which found that failings by Tees, Esk and Wear Valleys NHS Foundation Trust contributed to the deaths of 17-year-old Christie Harnett, Nadia Sharif, also 17, and 18-year-old Emily Moore who had all been diagnosed with complex mental health needs and took their own lives between June 2019 and February 2020.
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The three friends were treated at West Lane Hospital in Middlesbrough, where two of the girls took their own lives.
The trust admitted it had “unacceptable failings” and apologised unreservedly.
West Lane Hospital, which closed in 2019 following the deaths, provided specialist child and adolescent mental health services, including treatment for eating disorders.
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Their families said the reports had found “multi-faceted and systemic” failings in the care of the teenagers and called for a public inquiry after investigators listed a total of 120 care and service delivery failings and made 47 recommendations.
The investigations looked at the care and treatment of all three girls at West Lane Hospital in Middlesbrough, and in addition for Emily, at Lanchester Road Hospital in Durham, as well as the actions from partner organisations.
Christie, who was originally from Slough and was described by her family as a talented artist who loved to sing and dance, died in June 2019.
The report said she had a complex mental health disorder and had tried to take her own life in March 2019 – after which there had been “a failure to recognise and act upon the increased risk of serious harm or death”.
While many failures were the responsibility of TEWV to address, several belonged to other agencies involved in looking after them, the reports said.
The reports for both girls – who had complex mental health needs – said failings were “multifaceted and systemic”, based upon a combination of factors, including reduced staffing, low morale and lack of leadership, as well as failures to respond to concerns from patients and staff alike.
They also highlighted a shortage of skilled children and adolescent mental health services (CAMHS) staff.
Miss Moore, from Shildon in County Durham, took her own life in February 2020 after being moved to adult services at Lanchester Road Hospital, which was run by the same trust.
The report said her parents were particularly concerned about the quality of her care at West Lane Hospital and felt “very strongly” that it should be part of the review.
Miss Moore had claimed that staff there “would shout and swear at her” when she harmed herself.
Nadia, a gifted mathematician from Middlesbrough, had been diagnosed with autism and died in August 2019.
“We believe it was the organisational failure to mitigate the risks of self-ligature, accompanied by Nadia’s increasing risks, individual needs and changed presentation not being recognised, and the unstable and overstretched services in West Lane Hospital that were the root causes of Nadia’s death,” investigators said in their report.
Animal lover Emily, from County Durham, died in February 2020.
The report said her care plans whilst under the supervision of the Trust were “fragmented, incomplete and inconsistent”.
Responding to the reports’ findings, 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’ families 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.”
The families of the girls said in a statement: “Our beautiful girls should not have been failed in this way, and we need the answers to many more questions. Not just for us but for the many other families who we know have suffered the pain of losing a loved one who should not have died but should have been cared for properly.
“We call on the government to start a public inquiry that looks at this Trust and the services provided across the country for young people in crisis. For Christie, Nadia and Emily.”
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