Independent investigation reports into the care and treatment of Christie, Nadia and Emily at Tees, Esk and Wear Valley NHS Foundation Trust (November 2022)

Summary

These reports outline the findings of separate investigations into the deaths of three teenage girls who were detained mental health patients in the care of Tees, Esk & Wear Valleys NHS Foundation Trust (TEWV). The reports uncover many systemic failings at West Lane Hospital in Middlesbrough, the secure mental health unit for children where Christie Harnett and Nadia Sharif, both 17 years old, died and where Emily Moore, 18, was placed prior to her death in Lanchester Road Hospital, Durham. The girls had been friends and spent time together at West Lane, and all three deaths were self-inflicted.

The reports highlight a total of 119 care and service delivery problems at West Lane including ineffective management, reduced staffing, lack of leadership, aggressive handling of disciplinary problems, issues with succession of crisis management and failures to respond to concerns from patients and staff.

Although West Lane was closed in 2019, it was reopened in May 2021 under the new name of Acklam Road Hospital. Subsequent Care Quality Commission (CQC) inspections and further deaths demonstrate that dangerous cultures and practices are still operating in the Trust's inpatient mental health units. In June, the Care Quality Commission (CQC) announced that they will be bringing criminal charges against TEWV in relation to Christie’s death.

This document contains three separate investigation reports relating to Christie Harnett, Nadia Sharif and Emily Moore's individual cases.