An investigation concluded that three young women passed away as a result of a string of mistakes at a “unstable” and “overstretched” mental health centre.
Under the care of Tees, Esk and Wear Valleys NHS Foundation Trust, Christie Harnett, Nadia Sharif, both 17 years old, and Emily Moore, 18 years old, all passed away (TEWV).
Two of the three girls committed suicide while the other two were receiving medical care at Middlesbrough’s West Lane Hospital.
The trust freely apologised for its “unacceptable shortcomings” and acknowledged them.
West Lane Hospital, which closed in 2019 following the deaths, provided specialist child and adolescent mental health services, including treatment for eating disorders.
In order to better understand how each young woman was treated, NHS England commissioned three independent reports. These papers were used as part of the investigation.
Over the course of their care, 120 failures in “care and service delivery” were discovered by several agencies.
All three of them passed away eight months apart despite having been friends.
In June 2019, Miss Harnett of Newton Aycliffe, County Durham, committed suicide there, and Miss Sharif of Middlesbrough passed away there two months later.
At Lanchester Road Hospital in February 2020, Miss Moore committed suicide. In 2018 and 2019, she received treatment at West Lane.
According to the investigations for Miss Harnett and Miss Sharif, there was a “organisational failure” to limit the danger of hanging, as well as a “changing presentation” and a failure to recognise “growing” risks.
They discovered that the “fundamental causes” of their deaths were “unstable and overstretched” services.
The investigations listed 96 issues relating to their care, and both parties said that they considered these issues to be “contributory factors” in their suicides.
The investigations said that while many faults were TEWV’s obligation to resolve, a number belonged to other agencies involved in taking care of them.
The assessments for both girls—who had severe mental health needs—stated that failures were “multifaceted and systemic,” based on a number of issues, such as reduced staffing, low morale, a lack of leadership, as well as failures to address concerns from both patients and staff.
They also emphasised the need for qualified workers in the field of children and adolescent mental health services (CAMHS).
In February 2020, after being transferred to adult services at Lanchester Road Hospital, which was managed by the same trust, Miss Moore, a resident of Shildon in County Durham, committed suicide.
According to the report, her parents felt “extremely strongly” that the study should include information regarding how well she was treated at West Lane Hospital.
When Miss Moore hurt herself, staff members, according to Miss Moore, “would shout and swear at her.”
After being transferred to adult services at the same trust’s Lanchester Road Hospital, Miss Moore, a resident of Shildon in County Durham, committed suicide in February 2020.
Her parents’ “extremely strong” belief that the evaluation should include their daughter’s care at West Lane Hospital was stated in the report as a source of significant concern for her parents.
Staff there, according to Miss Moore, “would shout and swear at her” if she hurt herself.
