It comes after three separate independent inquiries 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 needs mental health and committed suicide between June 2019 and February 2020. Their families said the reports had found “multifaceted and systemic” failings in the teenagers’ care and called for a public inquiry after investigators listed a total of 120 care and service failures and made 47 recommendations. The inquiries looked at the care and treatment of all three girls at West Lane Hospital in Middlesbrough, and additionally for Emily, at Lanchester Road Hospital in Durham, as well as actions by partner organisations. Christie, who was 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 attempted to take her own life in March 2019 – after which there was a “failure to recognize and deal with the increased risk of serious harm or death”. Nadia, a gifted mathematician from Middlesbrough, was diagnosed with autism and died in August 2019. “We believe that it was organizational failure to mitigate the risks of self-ligating, coupled with Nadia’s increasing risks, individual needs and changing presentation that went unrecognised, and the unstable and overstretched services at West Lane Hospital were the root causes of of Nadia’s death. ,” the researchers said in their report. Animal lover Emily, from County Durham, died in February 2020. The report said her care plans while under the Trust’s supervision 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 apologize unreservedly for the unacceptable failings in the care of Christie, Nadia and Emily that these references have clearly identified. “The girls and their families deserved better while in our care. I know everyone at the trust extends their sincere condolences and sympathies to the families and friends of the girls for their tragic loss. “We must do everything in our power to ensure that these failures can never happen again. “However, we know that our actions must match our words. We fully accept the recommendations made in the reports – in fact the vast majority of them have already been addressed by us where applicable to our services.” Mr Kilmurray, who became chief executive at the Trust in the year after the girls’ deaths in 2019 and 2020, added: “It is clear from the reports that no one person or group of people is solely to blame – it was a failure on our part. systems with tragic consequences. “We have since undergone a thorough change in our senior leadership team and structure and, just as importantly, changed the way we care for and treat our patients. However, the transformation required is not complete. Compassion and responsibility it’s at the heart of everything we do.” The girls’ families said in a statement: “Our beautiful girls should not have failed in this way and we need answers to many more questions. Not just for us but for many other families we know who have suffered the pain of losing a loved one who should not have died but should have been properly cared for. “We are calling on the Government to launch a public inquiry looking into this Trust and the services provided across the country for young people in crisis. For Christie, Nadia and Emily.”
