21 March 2023

A damning governance report into Tees, Esk & Wear Valleys NHS Foundation Trust (TEWV) has been published today. It follows the critical investigations into the deaths of three young women in the care of the Trust.

This concerning governance report comes despite the Trust being subject to monitoring by the NHS, healthcare watchdog the Care Quality Commission (CQC), Clinical Commissioning Groups (CCGs) and seven local authority healthcare committees.

It follows an announcement in February by the CQC that they will be bringing criminal charges against TEWV in relation to the deaths of Christie Harnett, 17, Emily Moore, 18, and a third person who died just 18 months after Christie. All three were detained mental health patients in the care of the Trust.

This ‘governance’ report uncovers the complete failure of management, leadership, substandard delivery of services within the overall governance at TEWV. The Executive Management Team were said to be ‘removed’ from West Lane Hospital for failing to identify the escalating risks associated with operations, quality and safety. For two years prior to November 2018, and the suspension of 33 nurses, there was an over-reliance on verbal summaries from the then Director of Operations. Brent Kilmurray, was the Chief Operating Officer and Deputy CEO from 2013 to July 2018, before he resigned and returned to the Trust in 2020 as Chief Executive Officer (CEO).

Incident reporting was not accurate and there was a tolerance of high numbers which were not internally scrutinised. It is evident that there was a consistent failure to put the young people at the heart of care through access to qualified, experienced and compassionate professionals. A significant theme throughout the report is that the care afforded to service users was ‘chaotic’.

The CQC were aware of the risks to the care and treatment of young persons in the 12 months prior to the hospitals closure but without investigating further. An action plan was developed by the Trust but not subject to Board scrutiny. Furthermore, there was no robust safeguarding oversight by either NHSE specialised Commissioning or NHSE/l.

There are a total of 12 Recommendations for TEWV and other agencies, some consisting of multiple components.  Each and every separate component must be subject of change and then, assurance reviewed. The report also contains quotes from staff, former patients and parents in relation to their experiences at West Lane Hospital, some of which are deeply concerning.

In short, the report highlights an unsafe environment and lack of care regime, leadership and governance given to the three girls named in the report, and indeed, many others of our most vulnerable.

Issues addressed in the report include reduced staffing, senior staff without necessary experience in child-centred care, a poor reporting culture on significant self-harm and near death incidents and inadequate incident investigations. Despite high numbers of incidents involving ligatures, the investigation found no evidence of proper risk assessments for ligatures or the removal of ligature points.

The report also highlighted how a third of all self-inflicted deaths in the UK are of people already in contact with mental health services.

In November 2022, three damning independent investigation reports were published into the deaths of Christie Harnett, Emily Moore and their friend Nadia Sharif, 17, which uncovered 119 “multifaceted and systemic” failings in West Lane Hospital in Middlesbrough, including lack of leadership, issues with succession and crisis management, and weak internal and external systems of safeguarding governance. All three deaths were self-inflicted.

Following the deaths, West Lane Hospital was closed in 2019, but was reopened under the new name Acklam Road Hospital in May 2021. Only 1 out of 3 wards has re-opened and this is managed under the Cumbria, Northumberland and Tyne and Wear Trust (CNTW) and not TEWV. The other 2 wards remain vacant, TEWV not ready yet to re-apply for their licence to the CQC to run in-patient children services. Recent inspections by the Care Quality Commission (CQC) and further deaths continue to highlight dangerous cultures and practices in TEWV units.

Between April 2017 and March 2020, the Trust recorded 357 deaths. The latest CQC inspection of secure wards at the Trust, published last year found these services still require improvement. 

The families of Christie Harnett, Nadia Sharif and Emily Moore have launched a campaign, Rebuild Trust. They are collectively calling for a public inquiry into the Tees Esk and Wear Valley NHS Foundation Trust.

There is an ongoing inquiry into the deaths of mental health inpatients in Essex, following a series of contentious deaths. However, the inquiry does not have statutory powers so is being boycotted by many families affected, who continue to campaign for deeper scrutiny.

TEWV is among the most concerning mental health Trusts, with a series of preventable deaths in their care, as was the case in Essex before the inquiry was announced in November 2020.

Deborah Coles, Director of INQUEST, said: This report highlights a catastrophic failure of leadership, regulation and oversight leading to repeated, wholly avoidable deaths.  The corporate failure to mitigate the environmental risks which could have prevented these deaths is nothing short of criminal. The scale of the systemic neglect and dangerous practices has only come about because of bereaved families and their lawyers. Far greater public scrutiny is needed on what is taking place behind the closed doors of our mental health institutions.” 

Alistair Smith of Watson Woodhouse solicitors, who represent the three families, said: "We thought the report would be bad but it is far worse than expected. The report is a damning indictment of those who ran this Trust. It lays bare the weak and ineffective leadership at the Trust and the ‘chaotic’ and substandard delivery of in-patient services to children.

This highlights not only the failures of the Trust but those supposedly scrutinising it, NHS England and CQC, who, knowing of issues, failed to robustly safeguard those children. It is now apparent more than ever that a public inquiry is needed to get to the bottom of how this has happened and continued for so long."

Statements from the families are available on request.

For further information and photos please contact Alistair Smith at Watson Woodhouse Solicitors on [email protected]Alternatively email : [email protected]; [email protected]; [email protected]. They can also be contacted on 07557592405 or 07769297642.

The families are represented by INQUEST Lawyers Group members from Watson Woodhouse Solicitors. They are supported by INQUEST senior caseworker Selen Cavcav.

Journalists should refer to the Samaritans Media Guidelines for reporting suicide and self-harm and guidance for reporting on inquests.