Three Girls Died After Major Failings In NHS Mental Health Care, Inquiry Finds
An independent investigation has found that three teenagers died in the north-east of England who were severely deprived of NHS mental health services.
"Multi-faceted and systemic" failure at NHS Tees, Esk and Wear Valleys (TEWV) Trust led to the suicides of young women over an eight-month period.
Christy Harnett died on 27 June 2019 at West Lane Hospital, Middlesbrough, aged 17. Six weeks later, on August 5, 17-year-old Nadia Sharif died there. Emily Moore, who was treated there, died on February 15, 2020, at another Durham hospital. All three have complex mental health problems and have been treated by the NHS for several years.
An NHS-commissioned inquiry into her death found 119 "problems with care and service provision" by NHS services, particularly TEWV.
Christie's parents Charlotte and Michael Harnett said their daughter "died in a hospital run by the TEWV Trust with little or no care or affection". Emily's parents, David and Susan Moore, said she was "treated appallingly" at West Lane. The inquiry concluded that hospital services were understaffed, "inconsistent and overburdened".
The two families, as well as Nadia's parents Haqeel and Arshad Sharif, say the care provided by TEWV was so grossly inadequate that another patient with poor mental health died as a result, prompting ministers to order a public inquiry. "These beliefs about mental health are dangerous to society," Mures said.
The report alleges that TEWV did not adequately supervise the girls given the risk of self-harm; to take care of them and take their family's risk of suicide seriously; and remove all possible connection points.
Research by specialist health and care consultants Niche found that "the organisation's failure to mitigate environmental risk combined with Christie's increased risk and rebranding due to internal action". “It is fully acknowledged that the service at West Lane Hospital was inconsistent and excessive, which was the main cause of Christie's death. This includes 49 separate failures.
The report released on Wednesday said many similar errors were the "main cause" of Nadia's death, although her condition included "unrecognized variations in Nadia's increased risk, individual needs and presentation". His demise included 46 separate errors.
Either way, the failure at West Lane was "multifaceted and systemic," Nish said.
The inquest found that in Emily's death, "the disturbance at West Lane cannot be considered a direct factor in her death", as she had left the institution seven months before her death. However, 24 "care and service delivery issues" were raised in his case by various NHS bodies, including West Lane staff failing to respond adequately to concerns raised by his father.
"This report is damning," said lawyer Alistair Smith of Watson Woodhouse, who is representing the three families. He called the attitude of the girls "terrible and confusing". A recent inspection report by NHS care regulator the Care Quality Commission (CQC) found that TEWV was still providing poor care. "The lessons have not been taken." The CQC sued the trust, alleging it exposed Christie to a "significant risk of preventable harm".
An investigation into the deaths has been launched and the report is expected to be released. The family also sued the trust for civil rights violations and negligence.
West Lane closed in 2019 following the deaths of Christy and Nadia. However, it reopened last year under a new name, Acklam Road Hospital, and is run by a different mental health trust.
TEWV chief executive Brent Kilmurray said: "On behalf of Test, I apologize unreservedly for the unacceptable failure of Christy, Nadia and Emily." "The girls and their families deserve better while in our care."
However, the family dismissed a recent letter of apology from Kilmurray as "no more than 11 hours of homework" and said they did not accept his apology.
Margaret Kitching, chief nurse for NHS, North East and Yorkshire England, said: "These reports are difficult to read and our thoughts are with the families of these three young people. We have taken steps to protect patients by supporting the trust to build a comprehensive recovery program at all levels, from the courtroom to the boardroom. .
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