Damning reports uncover ‘systemic failings’ by NHS trust over deaths of three young women

Christie Harnett, Nadia Sharif and Emily Moore all died following failings by Tees, Esk and Wear Valleys NHS Foundation Trust

The parents of Nadia Sharif, who died in August 2019, have called for a public inquiry (Inquest)

‘Systemic’ and ‘multifaceted’ failings at a scandal-hit NHS trust prior to the deaths of three patients have been uncovered in a series of damning reports.

Three young women, Christie Harnett, Nadia Sharif and Emily Moore, all died following failings at West Lane Hospital, which is run by the Tees, Esk and Wear Valleys (TEWV) NHS Foundation Trust.

Reports on the circumstances surrounding their deaths found that “inappropriate restraint” had been used and there was an “absence of consideration” at the hospital.

There are now calls for a public inquiry into the deaths after the reports found “systemic failings” in the care of the patients, including low staffing and the failure of the trust to respond to concerns raised by patients and staff.

Reviewers from consultancy Niche said that the failures on the part of the trust had occurred within a context of wider “systemic pressures” on mental health beds and social housing for young people nationally.

This is the latest in a series of articles published in the past few weeks that highlight concerns about safety within mental health services across the UK. A report published recently by The Independent prompted calls for a public inquiry into mental health hospitals in the UK.

Labour has called on the government to carry out a “rapid review” of services in light of the series of scandals uncovered in recent weeks. However, the government is yet to commit to this or to an inquiry.

NHS England commissioned independent reports into the deaths of the three young women after the West Lane Hospital, at which they had been treated, was closed by the Care Quality Commission (CQC) in 2019.

The reports, published today, warned that the failings relating to their deaths “were multifaceted and systemic, based upon a combination of factors, including reduced staffing, low morale, ineffective management of change, lack of leadership, aggressive handling of disciplinary problems, issues with succession and crisis management, failures to respond to concerns from patients and staff alike, and increased patient acuity”.

Three years later the trust is still rated inadequate, and the CQC has said it is taking action against it.

Christie Harnett died in June 2019 (Inquest)

Christie Harnett, who died at just 17 years old, was a “vibrant, passionate, exuberant, beautiful young woman who was going to step into her future life”, her parents Charlotte and Michael Harnett said.

She died in June 2019 after attempting to self-ligature when she was an inpatient at West Lane Hospital.

Just one month prior to her death, Ms Harnett had a serious incident with a ligature that resulted in her being admitted to hospital. However, reviewers found that this incident had not been investigated and that the trust had not changed its approach to ligature risks.

The report also warned that there had been an “absence of consideration” by NHS England and the CQC of the total incidences of harm at West Lane Hospital when concerns were raised. It also referred to the absence of adequate care capacity across the region for young people needing mental health treatment.

Charlotte and Michael Harnett said: “Our beautiful Christie, just 17 years old, lost her life whilst in a hospital run by TEWV Trust, where there was little to no care or compassion.

“Three years on, the trust is still being rated inadequate and is rolling out the same ‘copy and paste’ platitudes and apologies. A public inquiry is the only way to stop the failings from continuing.”

Nadia Sharif died in August 2019. Her parents, Hakeel and Arshad Sharif, have called for a public inquiry to be held.

They described their daughter as “caring, very bright, always smiling and funny to be around”.

Reviewers identified at least 26 problems with her care, by the trust and other agencies, that contributed to her self-ligaturing.

The review into her death revealed that serious incident investigations had been carried out by the hospital into “inappropriate restraint” used by staff on Nadia and another patient.

Emily Moore was also an inpatient at West Lane Hospital (Inquest)

Emily Moore died after taking her own life at Lancaster Road Hospital, also run by TEWV, in February 2020. However, the review highlighted failings at West Lane Hospital where she had previously been an inpatient.

Prior to her death, Emily’s father had raised serious concerns about West Lane Hospital and the trust.

Her parents David and Susan Moore said: “As a family who have seen with our own eyes and witnessed our daughter Emily’s horrific care, amongst others, we believe a public inquiry is paramount to TEWV either moving forward or losing their licence to serve the public mental health needs.

“Even nearly three years after Emily’s death, the trust is inadequate in many of its locations, and this just does not get any better. This mental health trust is a danger to the public and cannot move on without the need for a public inquiry.”

Deborah Coles, the director of charity Inquest, said: “These damning reports uncover systemic failings and dangerous and coercive culture and practice within this trust.

“The reports also raise serious doubt about the effectiveness of regulators in informing and enforcing much-needed changes on the ground before preventable deaths take place.”

She said the incidents are not isolated nationally or locally, and that repeated calls have been made for the government to commission a statutory public inquiry into deaths and incidents in mental health services.

Brent Kilmurray, who became chief executive of the TEWV trust in 2019, said he apologised “unreservedly” for the “unacceptable failings” in care identified.

He said: “The girls and their families deserved better while under our care. I know everyone at the trust offers their heartfelt sympathies and condolences to the girls’ families and friends for their tragic loss.

“We must do everything in our power to ensure these failings can never be repeated. However, we know that our actions must match our words.”

Mr Kilmurray said that since the girls’ deaths the trust had undergone a change in its leadership team and structure, however he acknowledged that the transformation is not complete.