Three teenage girls tragically took their own lives in a mental health unit that has been slammed as “chaotic and unsafe”, according to a damning new report.
An independent inquiry into Middlesbrough’s West Lane Hospital made a number of shocking revelations.
It shows “excessive and inappropriate” restraint was used on a number of occasions, including when patients were dragged along the floor.
The unit, supposed to be providing child and adolescent mental health services, became an environment that “facilitated self-harm” according to patients.
One patient was told "if you really wanted to kill yourself, you would be dead by now” and staff said they were even told not to intervene on self-harm incidents unless they were likely to be fatal.
The 121-page report came after the deaths of three teenage girls, Christie Harnett, 17, Nadia Sharif, 17, and Emily Moore, 18 and highlighted "red flags" that had been missed by health chiefs.
They all took their own lives during an eight-month period up to February 2020 whilst under the trust’s care.
Tees, Esk and Wear Valley NHS Foundation Trust (TEWV) said they were “deeply sorry” for the events that “contributed” to the deaths of the three girls.
Following the deaths, West Lane was closed, and today’s report, commissioned by NHS England and undertaken by Niche Health and Social Care Consulting, is the fourth and final investigation into the problem-ridden unit.
The report spoke to former patients, their parents, members of staff, and the families of the three teens who died.
It highlighted a swathe of failings including one incident in November 2018, that saw 33 members of staff removed from duty after a review of CCTV footage of restraints found a shocking number of incidents of “inappropriate restraint”.
This included three patients being dragged along the floor.
The handling of this issue by the unit’s board and TEWV created an environment described as “chaos”.
There was then nine months that were called a “deteriorating spiral of poor care” until the Care Quality Commission issued a closure notice in August 2019.
But this notice followed the deaths of Christie and Nadia, who died “as the result of the care and misapplied controls at West Lane Hospital”.
Christie had been a “looked-after” child, who suffered complex mental health needs as well as autism.
She did not receive “any targeted treatment” for her emotionally unstable personality disorder and PTSD diagnosis.
She died on 27 June, 2019, after taking her own life and had been in the Newberry Centre of West Lane Hospital.
Less than six weeks after that, Nadia, who had been an inpatient at the Westwood Centre, also died.
The report identified 26 care delivery problems, and 20 service delivery problems in her care across a number of agencies.
Emily had been an inpatient at the Newberry Centre until July 2019, when she was moved, ending up in an adult acute ward in February 2020 when she turned 18. She would take her own life one week later.
The report found a “consistent failure to put the young people at the heart of care” and one young person interviewed said the care environment “facilitated self-harm” and that they did not feel safe there.
The report said that an issue of powerlessness was identified from interviews with patients.
They spoke of being treated with a lack of dignity and one said staff made them feel like “I’m just a waste of a bed”.
Another was restrained by male staff "when I was completely naked" and at times, interactions were described as verbally abusive with some staff not just uncaring, but seen as “intentionally negative”.
One patient said: “I was called a maniac, a stupid little girl - lots of comments like that. I was told, if you really wanted to kill yourself, you would be dead by now.”
Thanks to the structure and management of the unit, young people couldn’t access therapy to help them recover, and every parent that the report spoke to was unhappy with the treatment their young person had received at West Lane.
Often they described an environment where they could not safely raise concerns and at times they felt actively “judged and undermined by staff”.
One described feeling "manipulated into not making more fuss about things".
The report made 12 recommendations which covered dealing with complaints, staff training, communication between care agencies and more.
In response to the report, David Jennings, chair of Tees, Esk and Wear Valleys NHS Foundation Trust, said: “We would like to reiterate how deeply sorry we are for the events that contributed to the deaths of Christie, Nadia and Emily.
“Brent Kilmurray, our chief executive, and I have met each of the young women’s families to apologise to them in person. I thank them for allowing us to do that. I cannot begin to imagine how painful it has been for them.
“This report covers a period of time where it was abundantly clear there were shortfalls in both care and leadership. Over the last three years, how we care for people, how we involve patients, families and carers, and our leadership and governance structure have changed significantly.
“We will continue to work hard to make sure we deliver safe and kind care to the people we support, as they have every right to expect.”
The Samaritans is available 24/7 if you need to talk. You can contact them for free by calling 116 123, email jo@samaritans.org or head to the website to find your nearest branch. You matter.
