The 'chaotic and unsafe' system inside a North East hospital where two teenagers tragically took their own lives has been unearthed in a damning report.
West Lane Hospital in Middlesbrough provided specialist child and adolescent mental health services, including treatment for eating disorders. It closed after two patients and one former patient took their own lives within a eight-month period.
An independent report has now revealed claims of abuse and bullying, inappropriate restraints, suspensions and inadequate staffing levels. It also identifies issues and "red flags" within the governance of the hospital, which were consistently missed by health chiefs.
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In the report, which was published on Tuesday, young patients described how the environment "facilitated self-harm" and staff were told not to intervene unless it was "life-threatening".
Teesside Live reports how it follows the tragic deaths of Christie Harnett, Nadia Sharif, both 17, and Emily Moore, 18, who all took their own lives within an eight-month period after long mental health battles.
Christie, from Newton Aycliffe, County Durham, and Nadia, from Middlesbrough, were patients at the hospital, which was operated by Tees Esk and Wear Valley NHS Foundation (TEWV), when they died less than two months apart in 2019.
Emily, from Shildon, County Durham, was a former patient at the hospital. At the time of her death, she was at Lancester Road Hospital, another hospital operated by the same trust.
TEWV apologised and said significant changes had been made
The tragedies prompted three independent investigations looking into their care and treatment, which were published in November, and revealed 119 failures.
- Read Emily's story and her failings in her care
- Read Nadia's story and the failings in her care
- Read Christie's story and the failings in her care
Now, a fourth and final report - which is an overarching system-wide independent investigation into concerns and issues raised relating to the safety and quality of the CAMHS provision at West Lane Hospital - has been described as the "most damning and shocking of them all".
Former patients, their parents and staff, as well as the families of the three teenagers who died, were all interviewed by the report's authors. It found a "consistent failure to put the young people at the heart of care".
On November 7, 2018, a young person complained of being inappropriately restrained in the Westwood Centre, one of three centre's which made up the crisis-hit trust's 42 child mental health beds. CCTV footage was reviewed, which supported the complaint, and it led to all CCTV footage of all restraints from the preceding four weeks to be reviewed.
In total, 18 incidents of inappropriate restraint, predominately involving three patients being dragged along the floor, were identified. This led to 33 members of staff being removed from duty and eight subsequently disciplined.
The restraint issues and how it was handled by the board and leadership of TEWV created an environment which is often described as "chaos". The report states: "A deteriorating spiral of poor care delivery ensued in the nine months between the suspensions and the receipt of the closure notice from the Care Quality Commission in August 2019."
'They made me feel that I'm just a waste of a bed'
Former hospital staff say they were told not to intervene in incidents of self-harm until the situation became life-threatening, the report states. This was part of the concept of ‘least restrictive practice', which was broadly misunderstood and inconsistently implemented at the hospital, according to the review.
The reality of it was that children and young people would be allowed to cause harm to themselves before staff stepped in. In fact, patients felt that they had to be alert to others self-harming as they didn't trust staff to keep them safe.
In one shocking testimony, a former patient said: "...at a mealtime when all the staff were down in the dining toom and I had to cut off another patient's ligature because there were no staff and they wouldn't come down. They said it's protected mealtimes, if you want to do those things to yourself that's not our problem."
Service-level risk registers did not capture known ligature risks, according to the report, and this fostered a tacit acceptance that these risks were "simply part of the West Lane Hospital environment".
Young people told reviewers that they were often treated in an uncaring way - describing verbal interactions as judgemental and at times felt abusive. A key theme of powerlessness was identified and some staff were perceived by patients to be intentionally negative - described by some interviewees as like a form of bullying.
One patient spoke of how they were able to do a "degree of harm" to themselves while another said that "men would restrain me when I was completely naked". Another spoke of having to wait for staff to be able to go to the toilet, but they never came, forcing them to use a towel and bucket.
"They made me feel that I'm just a waste of a bed," said a patient. While another told interviewers: "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'd be dead by now."
Many of the parents that the report's authors spoke to felt actively judged and undermined by staff, while others described feeling a fundamental lack of confidence that raising concerns would result in positive change.
Damaging restraints and staffing issues
The use of restraint at the hospital was "excessive, inappropriate and ultimately damaging to patients, as well as staff", the report states. In one incident, Middlesbrough-teen Nadia was dragged down a corridor backwards with staff holding her under her arms.
Emily reported being sworn and shouted at by healthcare staff. While Christie was restrained, her outfit cut from her, and she was placed in strong clothing in an incident which sparked a complaint to the CQC.
The Niche report states: "Staff had resigned themselves to the belief that this patient cohort would always need to be frequently restrained, to a degree that, in any other clinical setting, would prompt challenge and scrutiny."
Staff were struggling to cope with the complexity and demands of the patient cohort.
There was little collaboration between the three wards - Newberry, Westwood and Evergreen - as well as a lack of robust service-level leadership, which was repeatedly cited as one of the key contributory factors underpinning the "dysfunctional service-level culture".
Insufficient staffing meant there was not the capacity to undertake the recommended level of observations. Anti-tear clothing was used in lieu of observations, reviewers found, which was described by the authors as "unacceptable".
'Red flags' and missed opportunities
An absence of effective leadership was found within the hospital. Reviewers pinpointed "numerous missed opportunities for concerns about care and treatment at West Lane Hospital to receive the attention and response they required from those responsible for governance and oversight at the trust".
Red flags in relation to quality, safety and performance were present in reporting to Quality and Assurance Committee several years before the hospital was closed. As far back as 2016, committee meeting reports documented issues with escalating acuity, staffing shortages and recruitment, bed pressures, high levels of self-harm, high levels of restraint and problems with the Force Reduction Project.
The TEWV board’s scrutiny of West Lane Hospital after it was informed of the 2018 inappropriate restraint incidents was "significantly lacking". And the lack of attention given to the hospital by the board continued until the trust received the CQC enforcement notice in June 2019, states the report.
The board should have prioritised the issues following 33 staff being investigated and taken out of duty, "given that this was an almost existential risk to clinical care and matters of reputation". But concerningly, risks that were raised by staff did not seem to penetrate to the board’s attention.
An email sent by a staff nurse after the suspension states: "We are very rarely managing to have breaks which is leading to the staff getting burnt out. I have been nurse in charge today and I must say I have found it extremely difficult and stressful trying to manage the staff and ensure that the safety of everyone is maintained. I have also not been able to complete the daily nursing tasks and have had to do the bare minimum for the shift."
The report states that this extensive and at times pleading email was met with, in their view, a platitudinous response.
The Care Quality Commission had been aware of risks to the care and treatment of children and young people over 12 months prior to their issuing of the closure notice in August 2019. The authors found evidence that suggests that prior to November 2018, the CQC’s scrutiny of safety at WLH "lacked rigour".
'Deeply sorry'
A total of 12 recommendations have been made which included dealing with complaints, staff training, communication between various care agencies and liaising with families after the death of a patient.
It recommended NHS England reviewed progress within six months to a year.
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.”
Margaret Kitching, the Chief Nurse for NHS England, North East and Yorkshire, said: “This report raises extremely significant concerns and our thoughts are with the patients and families of all those patients who haven’t received the care they deserve.
"Whilst we recognise improvements have been made, the trust has a duty to ensure all the actions required of it are applied consistently across the organisation. We continue to closely monitor the trust’s progress to ensure all of the recommendations are fully addressed."
'Complete and utter system wide failure'
Andy McDonald, MP for Middlesbrough, has called for an independent judge led inquiry into the West Lane Hospital deaths and broader mental health provision.
He said: "It’s hard to imagine how it could be any worse. The conclusions are devastating in every particular from managing risk, the use of restraint, the lack of controls around self-harming websites, the closed culture, the lack of effective leadership, the failures in corporate governance by the then board, the failings in inter-agency working and regulatory oversight. It goes on and on.
"We owe it to Christie, Nadia and Emily to leave no stone unturned in making sure we understand the immediate and root causes of what went so badly wrong, that people are held to account and that future mental health care is fit for purpose. But the time for the system to mark its own homework is over.
"There are systemic issues that any inquiry would need to address over and above the immediate failings be they at West Lane Hospital, or the Trust or deep within the machinery of oversight, but none of that negates the need to pursue and secure justice for the deceased and their families and the essential changes that are so clearly necessary."
Christie took her own life at West Lane Hospital in June 2019. Her friend and fellow patient Nadia died there two months later. Emily ended her life in February 2020 at Lanchester Road Hospital. She had previously been treated at West Lane in 2018 and 2019.
A CQC spokesperson said: "We welcome the system wide independent investigation report commissioned by NHS England into concerns and issues relating to the safety and quality of children and young people’s mental health services (CAMHS) at West Lane Hospital, run by Tees, Esk and Wear Valleys NHS Foundation Trust.
"We will look closely at the recommendations and make any necessary improvements to our regulation that may help prevent tragic events reoccurring.
"Our main priority is always the safety of people using health and social care services, and if we have concerns we will not hesitate to take action in line with our regulatory powers.
"We would encourage anyone who has concerns about a health and social care service to let us know. This can be done by using the give feedback on care form on our website or via our customer service centre on 03000 616161."
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