Three girls died after major lapses in NHS mental health care, inquest finds

Three teenage girls have died after major lapses in the care they received from NHS mental health services in the North East of England, an independent inquest has found.

The “multifaceted and systemic” failures of the Tees, Esk and Wear Valleys (TEWV) NHS trust contributed to self-inflicted deaths of young women within eight months of each other, it concluded.

Christie Harnett died aged 17 on June 27, 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 had been treated there, died on February 15, 2020 at another hospital in Durham. All three had complex mental health issues 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” by NHS services, in particular TEWV, had occurred.

Charlotte and Michael Harnett, Christie’s parents, said their daughter had “lost her life 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 “horrendous care” at West Lane. Hospital services were understaffed, “unstable and overwhelmed”, according to the final report of the inquest.

The two families, as well as Nadia’s parents, Hakeel and Arshad Sharif, said the dangerously inadequate care provided by TEWV, and the likelihood that other patients with fragile mental health 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 says TEWV failed to properly monitor the girls, given their known risk of self-harm; take seriously concerns about their care and the risk of suicide raised by their families; and remove all potential ligation points.

The investigation, conducted by specialist health and care consultancy Niche, found that “it was the organizational failure to mitigate the environmental risks of self-ligation, accompanied by the growing risk of Christie and d ‘an altered presentation due to his recent move to his own home not being fully recognised, and the unstable and overwhelmed wards at West Lane Hospital, which were the root causes of Christie’s death. 49 separate breaches.

The report, released on Wednesday, found very similar failures were the “root causes” of Nadia’s death, although in her case they included “Nadia’s increasing risks, individual needs and unrecognized change in presentation. “. His death involved 46 separate failures.

West Lane’s failings were “multifaceted and systemic” in both cases, Niche found.

The inquest found that when Emily died, “problems at West Lane cannot be considered immediate contributory factors to her death”, as she had left the establishment seven months before her death. However, the 24 ‘care and service delivery issues’ 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 attorneys Watson Woodhouse, who represent the three families. He described the girls’ care as “appalling and chaotic”. Recent inspection reports from the Care Quality Commission (CQC), the NHS care watchdog, showed the TEWV was still delivering poor care, he added. “Lessons are not learned.” The CQC is suing the trust for allegedly exposing Christie to “significant risk of avoidable harm”.

Inquests into the deaths have been opened and suspended pending the release of the report. The families are also suing the trust for violation of civil rights and negligence.

West Lane was closed in 2019 after Christie and Nadia died. However, it reopened last year as Acklam Road Hospital and is run by another mental health trust.

“On behalf of the trust, I would like to apologize unreservedly for the unacceptable lapses in the care of Christie, Nadia and Emily,” said Brent Kilmurray, chief executive of TEWV. “The girls and their families deserved better while they were in our care.”

However, the families dismissed the apology letters they recently received from Kilmurray as ‘nothing more than an 11-hour PR exercise’, and said they did not accept his apology.

Margaret Kitching, NHS England’s chief nurse for the North East and Yorkshire, said: “These reports are difficult to read and our hearts go out to the families of these three young people. We have measures in place to protect patients while supporting confidence in delivering the comprehensive program of improvements at every level, from its services to its boardroom.

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