West Lane: Teenagers died after failures at 'unstable' hospital

Three young women died aft a catalogue of failures astatine an "unstable" and "overstretched" intelligence wellness hospital, an enquiry has found.

Christie Harnett and Nadia Sharif, some 17, and Emily Moore, 18, died nether the attraction of Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV).

All 3 were treated astatine West Lane Hospital successful Middlesbrough, wherever 2 of the girls took their ain lives.

The spot admitted it had "unacceptable failings" and apologised unreservedly.

West Lane Hospital, which closed successful 2019 pursuing the deaths, provided specializer kid and teen intelligence wellness services, including attraction for eating disorders.

Three autarkic reports were commissioned by NHS England into however each young pistillate was cared for.

A full of 119 "care and work delivery" failures crossed a fig of agencies were recovered implicit the attraction provided to them.

All three, who had been friends, died wrong 8 months of each other.

Miss Harnett, from County Durham, took her ain beingness astatine West Lane Hospital successful June 2019 and Miss Sharif, from Middlesbrough, died determination 2 months later.

Miss Moore took her ain beingness successful February 2020 astatine Lanchester Road Hospital. She had antecedently been treated astatine West Lane successful 2018 and 2019.

The reports for Miss Harnett and Miss Sharif said determination was an "organisational failure" to trim the hazard of hanging, accompanied with not recognising "increasing" risks and "changed presentation".

They recovered "unstable and overstretched" services were "the basal causes" of their deaths.

The reports identified 96 problems astir their care, with some saying they believed these combined "as contributory factors" which led up to their suicides.

While galore failures were the work of TEWV to address, respective belonged to different agencies progressive successful looking aft them, the reports said.

The reports for some girls - who had analyzable intelligence wellness needs - said failings were "multifaceted and systemic", based upon a operation of factors, including reduced staffing, debased morale and deficiency of leadership, arsenic good arsenic failures to respond to concerns from patients and unit alike.

They besides highlighted a shortage of skilled children and teen intelligence wellness services (CAMHS) staff.

Miss Moore, from Shildon successful County Durham, took her ain beingness successful February 2020 aft being moved to big services astatine Lanchester Road Hospital, which was tally by the aforesaid trust.

The study said her parents were peculiarly acrophobic astir the prime of her attraction astatine West Lane Hospital and felt "very strongly" that it should beryllium portion of the review.

Miss Moore had claimed that unit determination "would outcry and curse astatine her" erstwhile she harmed herself.

Because she was nary longer an inpatient astatine West Lane erstwhile she died, the issues determination "cannot beryllium seen to person been contiguous contributory factors successful her death", the study said.

Part of the purpose of the study was to "identify immoderate actions that could person led to a antithetic result for Emily".

It recovered that successful its view, determination were "two systems issues" that had "a nonstop impact" connected her death; not taking her objective needs into information erstwhile she moved to big services, and a nonaccomplishment to code hanging risks.

Her stepfather Michael Harnett, from Newton Aycliffe, said patients had to "clean the humor up disconnected their ain walls from headbanging".

"Part of their argumentation was that the kids had to cleanable it up due to the fact that they needed to larn to negociate their illness," helium said.

"We privation everybody to spot the truth. It's each good and bully america telling everybody and coming connected camera and saying this is however she was treated but, I think, until radical spot it successful achromatic and achromatic from an autarkic [report] they're not going to truly judge it."

Her grandmother, Casey Tremain, said she believed the conditions determination were "more reminiscent of however the Victorian institutions utilized to be".

"I retrieve telling her, if you archer them everything that's going connected successful your caput they'll assistance you. And you'll beryllium capable to unrecorded your life," she told the BBC.

West Lane reopened nether the sanction Acklam Road Hospital successful May 2021, and inpatient proviso for children and adolescents is present provided astatine Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust.

Brent Kilmurray, who became main enforcement of TEWV successful 2021, said the young women and their families "deserved better" and the organisation indispensable bash "everything successful our power" to guarantee these failings were not repeated.

"We judge successful afloat the recommendations made successful the reports - successful information the overwhelming bulk of them person already been addressed by america wherever applicable to our services," helium said.

"It is wide from the reports that nary azygous idiosyncratic oregon radical of individuals were solely to blasted - it was a nonaccomplishment of our systems with tragic consequences.

"We person since undergone a thorough alteration successful our elder enactment squad and our operation and, arsenic importantly, changed the mode we attraction and dainty our patients."

Margret Kitching, main caregiver for NHS England, North East and Yorkshire, said the reports "make for precise hard reading".

"We person enactment measures successful spot to support patients portion we enactment the spot successful making the broad programme of improvements needed astatine each level from its wards to its committee room," she said.

"Governance arrangements person been identified arsenic a peculiar country of weakness and a further autarkic study has been commissioned to code this."