The Government has apologised and is considering a public inquiry after three teenage girls died following “multifaceted and systemic” failures in NHS mental health care.
Health minister Maria Caulfield said the independent investigation into the deaths of Christie Harnett, 17, Nadia Sharif, 17 and Emily Moore, 18, made for “painful reading” and described the incidents as “completely unacceptable”.
She told MPs a decision will be taken in the coming days on the next steps, with a need to make sure the “same failings” are not happening in other parts of the country.
I am not satisfied that the failings we've heard about today are necessarily isolated incidents at a handful of trusts— Maria Caulfield, health minister
Christie, Nadia and Emily were diagnosed with complex mental health needs and had been patients at West Lane Hospital in Middlesbrough.
The hospital, run by Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV), is where Christie, originally from Slough, and Nadia, who grew up in Middlesbrough, died.
Emily, who was from County Durham, died in Lanchester Road Hospital, Durham, in an adult ward where she was moved to from West Lane Hospital just 11 days before.
The three girls took their own lives between June 2019 and February 2020.
Ms Caulfield, responding to an urgent question from Labour, told the House of Commons: “I want to apologise for the failings in the care that they received.”
Ms Caulfield said she, alongside Health Secretary Steve Barclay, are “working closely” with NHS England and the Care Quality Commission over the improvements being made by TEWV.
(Public inquiries) can take many years, and we've clearly got some cases now which need some urgent review and some urgent action.— Maria Caulfield, health minister
The minister said this included investing £5 million in reducing ligature risks across the estate, and how it develops and implements care plans.
Ms Caulfield highlighted “other recent scandals” in mental health care, adding: “I am not satisfied that the failings we’ve heard about today are necessarily isolated incidents at a handful of trusts.
“Myself and the Secretary of State are urgently meeting the national director of mental health to look at the system as a whole, to look at the role of the CQC inspections and the system for flagging concerns.
“I will also be meeting the new patient safety commissioner to seek her guidance too and, based on that, will make a decision on how we proceed in the coming days.”
Ms Caulfield said NHS England has commissioned a “system-wide investigation into the safety and quality of services across the board”, particularly in relation to child and adolescent mental health services (Camhs).
She added: “On the issue of a public inquiry, I am not necessarily saying there won’t be a public inquiry but it needs to be on a national basis and not just on an individual trust basis because, as we’ve seen in maternity, very often when we repeat these inquiries, they produce the same information and we need to learn systemically about how to reduce these failings.
“The issue I have with a public inquiry is they’re not timely, they can take many years, and we’ve clearly got some cases now which need some urgent review and some urgent action.
“So I will look at her request, but I am taking urgent advice – as is the Secretary of State – because we take this extremely seriously and one death from a failing of care is one death too many.”
Why do undercover reporters seem to have a better grip on the crisis than the Government?— Dr Rosena Allin-Khan, Labour
Conservative MP Paul Howell (Sedgefield) read out testimony from one the families, saying: “It is emotional this, but Christie’s family in their statement in the report, their description of Christie was that ‘family was everything to Christie and we all miss her so much, nothing will ever be the same again now that our sunshine has gone’.”
Mr Howell added: “It is imperative that we do all that we can to give the families of these young ladies what little satisfaction can be delivered by a proper and full inquiry into these atrocious failings.”
Ms Caulfield, in her reply, said: “My concern about a public inquiry is the time that these inquiries take and whether a rapid review would be more appropriate. I will make that decision in the coming days once advice has been taken.”
For Labour, shadow mental health minister Dr Rosena Allin-Khan earlier asked the Government to conduct a “rapid review” and warned: “In the last five weeks, there have been reports on the Huntercombe Group, Essex Partnership University Trust and the Edenfield Centre.
“Why do undercover reporters seem to have a better grip on the crisis than the Government?
“Patients are dying, being bullied, dehumanised, abused and their medical records are being falsified – a scandalous breach of patient safety. The Government has failed to learn from past failings.”
