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‘Our beautiful girls should not have been failed in this way’: Damning probes into suicides of THREE teenage girls while IN care of same scandal-hit NHS mental health trust uncovers 120 failures and ‘systemic’ problems

  • Christie Harnett, 17, Nadia Sharif, 17 and Emily Moore, 18, took their own lives
  • Reports into the deaths of the trio were commissioned by NHS England chiefs
  • ‘Systemic’ problems uncovered at Tees, Esk and Wear Valleys Foundation Trust
  • Heartbroken families of the three girls today jointly called for a public inquiry 

A trio of teenage girls who took their own lives were each failed by a troubled mental health trust, a damning series of reports has concluded.

Christie Harnett, 17, Nadia Sharif, red dots on vicodin pills 17 and Emily Moore, 18, took their own lives in hospital during an eight month period before the pandemic.

The reports, commissioned by NHS England and published together, identified a staggering 120 failings in their care and ‘systemic’ problems within the Tees, Esk and Wear Valleys Foundation NHS Trust (TEWV) that played a key role in the teenagers’ tragic deaths.

West Lane Hospital in Middlesbrough, where all three were treated for mental health problems, was found to have ‘unstable and overstretched services’ that were among the ‘root causes’ of Christie and Nadia’s deaths.

The families of the three girls today jointly called for a public inquiry.

Christie Harnett, 17, Nadia Sharif, 17 and Emily Moore, 18, took their own lives in hospital during an eight month period before the pandemic. Christie (pictured) was initially referred to the NHS trust’s eating disorder team two years earlier. She suffered weight loss for not eating properly and was later detained under the Mental Health Act after self-harming and aggressive behaviour. She was described by her family as academically bright with a talent for art and a love of musicals and shopping

Nadia (pictured) had been under the trust’s care for five years before she took her own life and was diagnosed with Asperger’s Syndrome. The teenager had ambitions to become an accountant and enjoyed keeping fit, her family said

Emily (pictured) was also treated at West Lane Hospital but was transferred on turning 18 to Lanchester Road Hospital in Durham where she died in February 2020. There were 200 self-harming incidents in her final 12 months and little consideration was given to her father’s concerns about them, the report found. There was a ‘complete breakdown of trust’ between her parents and the trust

They said: ‘Our beautiful girls should not have been failed in this way, and we need the answers to many more questions. 

‘Not just for us but for the many other families who we know have suffered the pain of losing a loved one who should not have died but should have been cared for properly.

‘We call on the government to start a public inquiry that looks at this Trust and the services provided across the country for young people in crisis.’

CHRISTIE HARNETT 

Christie was initially referred to the NHS trust’s eating disorder team two years earlier. 

She suffered weight loss for not eating properly and was later detained under the Mental Health Act after self-harming and aggressive behaviour.

Christie was described by her family as academically bright with a talent for art and a love of musicals and shopping.

The report by an independent Manchester-based consultancy found 29 ‘care delivery’ problems and 20 ‘service delivery’ problems that contributed to her taking her life in June 2019.

These included failures in risk assessment, record-keeping, care planning, community support, safeguarding failures in West Lane Hospital where she self-harmed and lack of staff with appropriate skills.

NADIA SHARIF

Nadia had been under the trust’s care for five years before she took her own life and was diagnosed with Asperger’s Syndrome. 

The teenager had ambitions to become an accountant and enjoyed keeping fit, her family said.

However, concerns increased at her ‘controlling behaviour’ at home, which included deciding who could be in each room and chasing other family members out. She would grab knives, forcing family to call the police.

A number of ‘serious incidents’ led to her being detained under the Mental Health Act.

Whilst at West Lane Hospital she was twice ‘restrained inappropriately’, her report found, with staff dragging her backwards down a corridor by holding her under her arms.

In her case, 47 care and service problems were identified by report’s authors. 

Her parents were not included in care planning, staff lacked autism knowledge and training and safeguarding procedures were not instigated to protect her.

EMILY MOORE

Emily was also treated at West Lane Hospital but was transferred on turning 18 to Lanchester Road Hospital in Durham where she died in February 2020.

There were 200 self-harming incidents in her final 12 months and little consideration was given to her father’s concerns about them, the report found.

There was a ‘complete breakdown of trust’ between her parents and the trust.

In total 24 care and service delivery problems were identified.

Failures at West Lane Hospital in her case were not contributory factors to her death.

Both Christie and Nadia died in the care of West Lane Hospital in 2019.

Christie was initially referred to the NHS trust’s eating disorder team two years earlier. She suffered weight loss from not eating properly and was later detained under the Mental Health Act after self-harming and aggressive behaviour.

She was described by her family as academically bright with a talent for art and a love of musicals and shopping.

‘Christie was a beautiful, courageous, caring, independent young woman, with a fiery temper and spirit,’ said her family. ‘There was never a dull moment with her around especially with her cracking sense of humour.’

But she developed a complex mental health disorder and spent 603 out of 752 nights in hospital before her death. She was detained under the Mental Health Act 11 times and 170 incidents of self-harm were recorded.

The report by an independent Manchester-based consultancy found 29 ‘care delivery’ problems and 20 ‘service delivery’ problems that contributed to her taking her life in June 2019.

These included failures in risk assessment, record-keeping, care planning, community support, safeguarding failures in West Lane Hospital where she self-harmed and lack of staff with appropriate skills.

Christie’s stepfather Michael Hartnett said: ‘Everybody failed her from the top to the bottom. The fact she could self-harm so often, it was near enough every day she was doing it.’

In June the Care Quality Commission (CQC) announced it was prosecuting the TEWV for breaches of the 2008 Heath and Social Care Act in connection with Christie’s care.

Nadia had been under the trust’s care for five years before she took her own life and was diagnosed with Asperger’s Syndrome. The teenager had ambitions to become an accountant and enjoyed keeping fit, her family said.

However, concerns increased at her ‘controlling behaviour’ at home, which included deciding who could be in each room and chasing other family members out. She would grab knives, forcing family to call the police.

A number of ‘serious incidents’ led to her being detained under the Mental Health Act.

Whilst at West Lane Hospital she was twice ‘restrained inappropriately’, her report found, with staff dragging her backwards down a corridor by holding her under her arms.

In her case, 47 care and service problems were identified by report’s authors. Her parents were not included in care planning, staff lacked autism knowledge and training and safeguarding procedures were not instigated to protect her.

Emily was also treated at West Lane Hospital but was transferred on turning 18 to Lanchester Road Hospital in Durham where she died in February 2020.

There were 200 self-harming incidents in her final 12 months and little consideration was given to her father’s concerns about them, the report found.

There was a ‘complete breakdown of trust’ between her parents and the trust.

In total 24 care and service delivery problems were identified.

Failures at West Lane Hospital in her case were not contributory factors to her death.

However the report found the transition to adult care and failure to address ligature risks on her ward at Lanchester Road Hospital had a ‘direct impact’ on her death.

Yesterday Brent Kilmurray, TEWV chief executive, said he ‘apologised unreservedly for the unacceptable failings’ in the care of the three teenagers.

West Lane Hospital in Middlesbrough, where all three were treated for mental health problems, was found to have ‘unstable and overstretched services’ that were among the ‘root causes’ of Christie and Nadia’s deaths. Failures at West Lane Hospital in Emily’s case were not contributory factors to her death

‘The girls and their families deserved better while under our care.’ Adding: ‘We must do everything in our power to ensure these failings can never be repeated.’

Margaret Kitching, the Chief Nurse for NHS England, North East and Yorkshire, said: ‘These reports make for very difficult reading and our thoughts are with the families of these three young people.

‘We have put measures in place to protect patients while we support the trust in making the comprehensive programme of improvements needed at every level from its wards to its board room.’

Last month the CQC found wards caring for adults with autism and learning difficulties at Lanchester Road Hospital and Bankfields Court in Middlesbrough run by TEWV were inadequate.

West Lane Hospital has reopened as Acklam Road Hospital and is being run by another NHS trust.

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