Christie Harnett, Nadia Sharif and Emily Moore died within months of each other under the care of the trust
A mental health unit criticised over the deaths of three teenagers was “chaotic and unsafe”, a report found.
An independent inquiry found “excessive and inappropriate” restraint was used at Middlesbrough’s West Lane Hospital.
The environment “facilitated self-harm”, said patients, and staff were told not to intervene unless it was likely to be fatal.
Tees, Esk and Wear Valley NHS Foundation Trust (TEWV) apologised and said significant changes had been made.
The report followed the deaths of Christie Harnett, Nadia Sharif, both 17, and Emily Moore, 18, who took their own lives in an eight-month period up to February 2020 under the trust’s care.
West Lane, which closed following the deaths, provided specialist child and adolescent mental health services, including treatment for eating disorders.
Tuesday’s report was commissioned by NHS England and undertaken by Niche Health and Social Care Consulting. It found “clear synergies” between care failings delivered to all three.
It is the latest in a series of reports which identified failings.
Image source, Google
The hospital has been renamed and is now run by a different health trust
The report’s authors spoke to former patients, their parents and staff as well as the families of the three teenagers who died.
It found a “consistent failure to put the young people at the heart of care”.
Young people interviewed said the care environment “facilitated self-harm” and they did not feel confident that they were safe.
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‘Called a maniac’
A key theme of powerlessness was identified from patient interviews, the report said.
Patients spoke of being treated with a lack of dignity, with one saying staff made them feel “that I’m just a waste of a bed”.
Another spoke of being restrained by male staff “when I was completely naked”.
Some verbal interactions were described as judgemental, and at times abusive.
“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”, said one former patient.
Every parent spoken to as part of the investigation was unhappy with the care of their young person.
Many felt “undermined” with reports of failures to inform them of incidents involving their children and one described feeling “manipulated into not making more fuss about things”.
‘Deeply sorry’
The use of restraint at the hospital was excessive, inappropriate, and ultimately damaging to patients, as well as staff.
Staff were struggling to cope with the complexity and demands of the patient cohort, the report found, and little support was given to staff to assist in de-escalating situations, which is likely to have contributed to an over-reliance on restraint.
West Lane was frequently described as a”closed culture” and in terms of corporate governance there was insufficient curiosity regarding the culture there, the report said.
And there was no evidence that there was a collaborative effort by the trust or its partners to ensure that there was a robust safeguarding framework in place to protect children and young people.
Image source, Google
The hospital was run by the Tees, Esk and Wear Valley NHS Foundation Trust
The report made 12 recommendations 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.
TEWV chairman David Jennings said it was “deeply sorry” and they had met the families of the three young women and apologised.
“This report covers a period of time where it was abundantly clear there were shortfalls in both care and leadership,” he said.
“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: “We continue to closely monitor the trust’s progress to ensure all of the recommendations are fully addressed.”
Miss Harnett, from Newton Aycliffe, County Durham, took her own life at West Lane Hospital in June 2019 and Miss Sharif, from Middlesbrough, died there two months later.
Miss Moore, also from County Durham, took her own life in February 2020 at Lanchester Road Hospital. She had previously been treated at West Lane in 2018 and 2019.
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