Staff allowed young patients at a failing mental hospital to self-harm and access suicide websites amid ‘chaotic’ ward conditions, a damning independent investigation has found.
The report was ordered after three teenagers Christie Harnett, 17, Nadia Sharif, 17, and Emily Moore, 18, took their own lives during an eight-month period before the Covid pandemic following treatment at West Lane Hospital in Middlesbrough.
Understaffed and inadequately trained, as well as a lack of leadership, often made child and adolescent psychiatric units appear “chaotic and unsafe” to staff and patients.
A policy of ‘least restrictive practices’ meant that young patients with complex problems were largely left to fend for themselves, skipping education classes to hang around and surf malicious websites on the Internet.
The report revealed that the young patients “were allowed to decide whether to attend classes and were not always restrained from bringing inappropriate high-risk and potentially deadly items to the wards.”
Nadia Sharif, 17 (pictured) had been under the trust’s care for five years before committing suicide and being diagnosed with Asperger’s syndrome. The teen had ambitions to become an accountant and liked to keep fit, her family said
Emily Moore, 18 (pictured) was also treated at West Lane Hospital but was transferred to Lanchester Road Hospital in Durham when she was 18, where she died in February 2020. There were 200 self-harm incidents in her last 12 months and little attention was paid to her father’s concerns about them, the report found. There was a “complete breach of trust” between her parents and the trust
Christie Harnett, 17 (pictured) was first referred to the NHS Trust’s eating disorders team two years earlier. She suffered weight loss due to not eating properly and was later detained under the Mental Health Act after self-harm and aggressive behaviour. She was described by her family as academically bright with a talent for the arts and a love of musicals and shopping
There were no rules or boundaries and the report stated ‘every parent who spoke to us was unhappy with the treatment of their young person at West Lane’.
“Young people would watch TV all day in their pajamas and stay up at night to surf the internet or watch movies.
“This meant that young people had unattended access to their smartphones, and thus could access inappropriate websites, such as those for self-harm, share photos of other patients who had injured themselves, and spend hours on the internet at night.”
West Lane Hospital in Middlesbrough, where all three were treated for mental health issues, were found to have ‘unstable and overworked services’ that were among the ‘root causes’ of Christie and Nadia’s deaths. Malfunctions at West Lane Hospital in Emily’s case did not contribute to her death
One parent compared the chaos to William Golding’s novel in which a group of boys become increasingly ferocious alone on a deserted island without the civilizing influence of adults.
“It was like Lord of the Flies: they would all be in a cohort, either just watching television or running around,” the parent said.
Telephones were seen as a way for patients to communicate with family and a rule was introduced to make them available to everyone to comply with the European Convention on Human Rights, which gives the right to ‘respect for private and family life,” the report said.
Nadia Sharif (pictured) was found dead in her room at West Lane Hospital in Middlesbrough around 8.30am on Monday 5 August. Her family is now demanding answers from the hospital, where they claim she should be under 24-hour supervision.
Access to social media was a major issue that was “ill-addressed and caused mistrust and concern,” the report said.
The risk for young patients was increased by the ability to access “inappropriate” websites that support eating disorders, self-harm and suicide.
Rules meant that ‘staff could not restrict access to mobile phones’.
And staff said she was “told not to intervene in incidents of self-harm until the situation became life-threatening.”
The report from Manchester-based Niche Health and Social Care Consulting said: ‘The reality of this was that children and young people should be allowed to harm themselves before staff intervened. Patients felt they had to be alert to self-injury and did not trust staff to keep them safe.’
Some employees were seen as ‘offensive’ and their actions as ‘a form of bullying’.
Authorities failed to inform parents of incidents involving their child and there was a lack of confidence in management to deal with complaints.
Problems with staff were exacerbated when a complaint of inappropriate detention led to a review of CCTV and the dismissal of 33 staff and eight disciplinary measures. A total of 18 incidents of inappropriate restraining were identified, mainly involving three patients being dragged across the floor. No one was fired.
The report, which made 12 detailed recommendations, also criticized the industry’s watchdog, the Care Quality Commission (CQC), stating that its investigation into West Lane was ‘inaccurate’. The CQC finally closed the hospital in August 2019. It was reopened as Acklam Road Hospital and run by a different trust.
Christie Harnett took her own life on West Lane in June 2019. She had been detained 11 times under the Mental Health Act and spent 556 days in hospital in three years. Due to the lack of suitable beds, she was often placed in hotels or lodging by social services during her treatment, leading to an escalation of self-harm behavior, the report said. A total of 51 problems with her care were identified.
Christie Anne Brayley, 17, died in a bathroom at West Lane Hospital in Middlesbrough on Thursday after a two-year battle with mental health problems
Nadia Sharif took her own life in West Lane in August 2019. During her three years of mental health care, she was subject to 10 different placements and there was a “consistent and inadequate recognition of risk,” the report found. A total of 46 problems with her care were reported to various authorities.
Emily Moore died at Lanchester Road Hospital in Durham in February 2020 following treatment at West Lane. There were 200 self-harm incidents in her last 12 months. The report said her family was “increasingly concerned” that the West Lane unit “couldn’t protect her.” Investigators found 14 issues in her care, eight of which were related to West Lane.
Commenting on the report, David Jennings, chairman of Tees, Esk and Wear Valleys NHS Foundation Trust, said: ‘We would like to reiterate our deep regret for the events that contributed to the deaths of Christie, Nadia and Emily.’
He said: “This report covers a period when it was abundantly clear that there were shortcomings in both care and leadership.” Significant changes have been made since then, he said.
Margaret Kitching, the chief nurse for NHS England, North East and Yorkshire, said the report “raises extremely serious concerns” and that patients had “not received the care they deserved”.
Christie’s father Michael Harnett said the report was “shocking” because it confirmed “it happens to every patient.”
He said, “Not a single patient had anything good to say. Everything we’ve been through, not just us, everyone there has been through the same thing, every family.’