“Multi-faceted and systemic” failings by Tees, Esk and Wear Valleys (TEWV) NHS trust contributed to the young women’s self-inflicted deaths within eight months of each other, it found. Christy Harnett died aged 17 on 27 June 2019 at the trust’s West Lane Hospital in Middlesbrough. Nadia Sharif, also 17, died there six weeks later on August 5. Emily Moore, who was being treated there, died on February 15, 2020 at a different hospital in Durham. All three had complex mental health problems and had been in NHS care for several years. The inquest into their deaths, commissioned by the NHS, found that 119 “care and service delivery issues” had been raised by NHS services, especially TEWV. Charlotte and Michael Harnett, Christie’s parents, said their daughter “died while in a hospital run by the TEWV trust where there was little or no care or compassion”. Emily’s parents, David and Susan Moore, said she received “appalling care” while at West Lane. Services at the hospital were understaffed, “unstable and overstretched”, the inquiry’s final report found. Both families, as well as Nadia’s parents, Hakeel and Arshad Sharif, said the dangerous inadequacy of the care provided by TEWV and the possibility that other patients with fragile mental health had died as a result showed ministers should order a full public inquiry. “This mental health trust is a danger to the public,” the Moores said. The report said TEWV failed to monitor the girls properly given their known risk of self-harm. to take seriously the concerns about care and suicide risk raised by their families; and to remove all possible points of attachment. The investigation, carried out by specialist health and care consultancy Niche, found that ‘it was the organizational failure to mitigate the environmental risks of self-ligating, coupled with Christie’s increasing risk and the change in presentation due to its recent move to her house. The full recognition and erratic and excessive services at West Lane Hospital were the root causes of Christie’s death.” It involved 49 separate failures. The report, published on Wednesday, found that very similar failings were “the root causes” of Nadia’s death, although in her case they included “failure to recognize Nadia’s increasing risks, individual needs and changing presentation”. Her death involved 46 separate failures. The failures at West Lane were “multifaceted and systemic” in both cases, Niche found. The inquest found that in Emily’s death, “the issues at West Lane cannot be considered to have been direct contributing factors in her death”, as she had left the facility seven months before she died. However, the 24 “problems with care and service provision” from various NHS bodies in her case included staff at West Lane failing to respond properly to concerns raised by her father. “These reports are damning,” said Alistair Smith, of solicitors Watson Woodhouse, who are representing the three families. He described the girls’ care as “disgusting and chaotic”. Recent inspection reports from the Care Quality Commission (CQC), the NHS care watchdog, showed TEWV was still providing poor care, he added. “Lessons are not taken.” The CQC is prosecuting the trust for allegedly exposing Christie to a “significant avoidable risk of harm”. Archie Bland and Nimo Omer take you to the top stories and what they mean, free every weekday morning Privacy Notice: Newsletters may contain information about charities, online advertising and content sponsored by external parties. For more information, see our Privacy Policy. We use Google reCaptcha to protect our website and Google’s Privacy Policy and Terms of Service apply. Inquiries into the deaths have been opened and stopped pending the release of the report. The families are also suing the trust for civil rights violations and negligence. West Lane closed in 2019 following the deaths of Christie and Nadia. However, it reopened last year under the new name Acklam Road hospital and is run by a different mental health trust. “On behalf of the trust, I would like to apologize unreservedly for the unacceptable failings in the care of Christie, Nadia and Emily,” said Brent Kilmurray, chief executive of TEWV. “The girls and their families deserved better while in our care.” But the families dismissed recent apology letters they received from Kilmurray as “nothing more than an 11th hour PR exercise” and said they did not accept his apology. Margret Kitching, NHS England’s chief nurse for the North East and Yorkshire, said: “These reports make difficult reading and our thoughts are with the families of these three young people. We have taken measures to protect patients while supporting the trust in delivering its comprehensive program of improvements at every level, from the wards to its boardroom.”
