Inquiry concludes more than 120 failures in death of 3 teenagers

An independent NHS inquiry into a mental health hospital in Middlesbrough, described by family members of three teenage girls from the Teesside region as a “hell hole” where nobody cared about their daughters, has concluded that there were more than 120 different failures to care for the girls properly and adequately. 

The three girls, Christie, Nadia, and Emily were all known to Tees, Esk and Wear Valleys NHS Foundation Trust and had received treatment in various facilities, including West Lane Hospital, over several years.  All three took their own lives following significant failings by the Trust to deal with their complex mental health conditions.

All three of these cases are incredibly difficult to read about and our sympathies go out to the families and loved ones of Christie, Nadia, and Emily.  They had every right to believe that their daughters would be protected and cared for once they were admitted to the care of the NHS Trust and they were badly let down.  In all three cases, care was grossly lacking and negligent, staff were undertrained, unmotivated and inexperienced and changes could and should have been made so that all three girls would still be alive today. 

Christie Harnett was 17 when she took her own life at West Lane Hospital following years of inadequate care.  She was moved into her own flat without any proper risk assessment or any support to enable her to live independently at such a young age.  She had spent most of her teenage years as an inpatient and the arrangement was allowed to continue even when Christie herself expressed that she was in crisis and needed help.  Failings in Christie’s care included inadequate staffing, policies that were vague and difficult to follow or implement and failing to listen to concerns raised by patients or their families.  Christie’s mum and grandmother raised a complaint with the Trust about treatment Christie had received long before she died and the Trust completely failed to deal with the complaint, which could have had an impact on Christie’s treatment, until after she had died. 

Nadia’s parents were not given any help with translation and did not understand what she was going through as they could not communicate with staff, who were not helpful.  Shortly before her death, the increase in self-harm events for Nadia was dramatic and this was not picked up by staff at the Trust.  As with Christie, the inquiry found that the Trust’s policies were vaguely worded and were not being implemented properly due to the inexperience of staff.  Ultimately the inquiry found that there was a lack of focus on Nadia’s autism diagnosis in her care plan and that the whole care plan in place for Nadia’s care was inappropriate and unlikely to have benefited her. 

Emily Moore was 18 when she took her own life at the Trust’s Lanchester Road hospital, following treatment at West Lane.  She also died in a bathroom on an adult ward, having been moved from a children’s ward run by Cumbria, Northumberland, Tyne & Wear Trust where she was said to have been making progress.  The inquiry found that the transfer to an adult ward was based solely on age and not what Emily needed for her care.  Again, as with Nadia and Christie, the inquiry found that care plans were inadequate, incomplete, and inconsistent and there was a lack of consistent psychological help for Emily, which meant that she could not effectively engage with her own care.  She was assessed as being a risk for self-harm and her family raised concerns about the number of self-harm incidents, which were ignored, leading to a complete breakdown in trust between the Trust and the family. 

Emily had access to items that she could use to self-harm, despite this being a significant risk for her and she and her family were additionally failed by social services, who did not contact them for an unacceptable period.  Ultimately, there were no adequate plans in place for what would happen to Emily when she turned 18 and she was left with very few suitable options.  In addition, as with Christie’s case, the Trust had carried out a risk assessment of ligature risks in 2019.  It was noted that the en suite bathrooms held a low-level ligature risk, but nothing was done to change the design of the bathrooms, so the risk remained. 

At TBI we have heard of patients being ignored by ward staff when they expressed that they were having a mental health crisis, family members of new mothers being ignored when they expressed that their loved one was ‘not right’ after giving birth, and people not being assessed in a timely manner when they have expressed thoughts of self-harm or ending their lives.  In many cases, policies in place for mental health provision and assessment are inadequate or confusing and there is a significant lack of suitably qualified and experienced mental health practitioners across the NHS generally. 

For all the focus on mental health issues and ‘self-care’ in the media and online, the situation on the ground is unfortunately far from ideal.  So what can we do about it?  At TBI we have specialist clinical negligence solicitors who can investigate the care that you or your loved one received and consider whether it met the threshold for appropriate care or whether there was any negligence.  We also work with specialist medical experts and barristers who have experience of considering the complex issues that present themselves in cases of mental health care.  Cases that we can deal with range from short-lived mental health problems like anxiety or adjustment disorders following road traffic accidents right up to PTSD and complex trauma or suicide.  We are happy to consider your case if you have sustained a physical injury that has left you with depression or agoraphobia, for example, or if you have not been physically injured but something that happened to you left you with a significant mental health condition that was not properly dealt with by the NHS or other agencies.  We can also consider cases where you or a loved one have attempted suicide or where your loved one has taken their own life.