West Lane: Teenagers died after failures at 'unstable' hospital

Three young women died after a catalogue of failures at an "unstable" and "overstretched" mental health hospital, an inquiry has found.

Christie Harnett and Nadia Sharif, both 17, and Emily Moore, 18, died under the care of Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV).

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.

Three independent reports were commissioned by NHS England into how each young woman was cared for - and the reports formed part of the inquiry.

A total of 120 failures in "care and service delivery" across a number of agencies were found over the treatment provided to them.

All three, who had been friends, died within eight months of each other.

Miss Harnett, from Newton Aycliffe, County Durham, took her own life at West Lane Hospital in June 2019 and Miss Sharif, from Middlesbrough, died there two months later.

Miss Moore took her own life in February 2020 at Lanchester Road Hospital. She had previously been treated at West Lane in 2018 and 2019.

The reports for Miss Harnett and Miss Sharif said there was an "organisational failure" to reduce the risk of hanging, accompanied with not recognising "increasing" risks and "changed presentation".

They found "unstable and overstretched" services were "the root causes" of their deaths.

The reports identified 96 problems around their care, with both saying they believed these combined "as contributory factors" which led up to their suicides.

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.

Because she was no longer an inpatient at West Lane when she died, the issues there "cannot be seen to have been immediate contributory factors in her death", the report said.

Part of the aim of the report was to "identify any actions that could have led to a different outcome for Emily".

It found that in its view, there were "two systems issues" that had "a direct impact" on her death; not taking her clinical needs into consideration when she moved to adult services, and a failure to address hanging risks.

The girls' families have called for a public inquiry.

TEWV faces a prosecution by watchdog the Care Quality Commission over its failure to protect Miss Harnett and a full inquest into her death is yet to take place.

Her stepfather Michael Harnett, from Newton Aycliffe, said patients had to "clean the blood up off their own walls from headbanging".

"Part of their policy was that the kids had to clean it up because they needed to learn to manage their illness," he said.

"We want everybody to see the truth. It's all well and good us telling everybody and coming on camera and saying this is how she was treated but, I think, until people see it in black and white from an independent [report] they're not going to really believe it."

Her grandmother, Casey Tremain, said she believed the conditions there were "more reminiscent of how the Victorian institutions used to be".

"I remember telling her, if you tell them everything that's going on in your head they'll help you. And you'll be able to live your life," she told the BBC.

West Lane reopened under the name Acklam Road Hospital in May 2021, and inpatient provision for children and adolescents is now provided by Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust.

Brent Kilmurray, who became chief executive of TEWV in 2021, said the young women and their families "deserved better" and the organisation must do "everything in our power" to ensure these failings were not repeated.

"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," he said.

"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."

Margret Kitching, chief nurse for NHS England, North East and Yorkshire, said the reports "make for very difficult reading".

"We have put measures in place to protect patients while we support the trust in making the comprehensive programme of improvements needed at every level from its wards to its board room," she said.

"Governance arrangements have been identified as a particular area of weakness and a further independent report has been commissioned to address this."

Middlesbrough Labour MP Andy McDonald said the reports were "littered with instances" of how all three young women were "so catastrophically failed".  

He added he was "immensely disappointed" about the further delay of another report which would "apparently deal with broader issues" but now "in all likelihood" would not be published until the new year.

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