2 November 2022

Damning independent investigation reports 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) have been published.

The three reports uncover “multifaceted and systemic” failings in West Lane Hospital in Middlesbrough, where Christie Harnett and Nadia Sharif, both 17 years old, died and where Emily Moore, 18, had recently been moved 11 days prior to her death in Lanchester Road hospital, Durham.

All three deaths were self-inflicted. The girls had been friends and spent time together in the secure mental health unit for children at West Lane.

Issues highlighted in the reports include ineffective management, reduced staffing, lack of leadership, aggressive handling of disciplinary problems, issues with succession of crisis management, failures to respond to concerns from patients and staff alike and more.

The reports collectively identified a total of 119 ‘Care and Service’ delivery problems in respect of the service provided to the three girls.

Following the deaths, West Lane Hospital was closed in 2019, but was reopened under the new name Acklam Road Hospital in May 2021. Recent inspections by the Care Quality Commission (CQC) and further deaths continue to highlight dangerous cultures and practices in TEWV units.

In June, the Care Quality Commission (CQC) announced they will be bringing criminal charges against TEWV in relation to Christie’s death.

Between April 2017 and March 2020, the Trust recorded 357 deaths. The latest CQC inspection of secure wards at the Trust, published last week, found these services still require improvement. Despite previous critical inspections, they found more work is needed to provide safe care.

The families of the three girls 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.

INQUEST is calling for a statutory public inquiry into deaths and serious incidents in mental healthcare nationally. 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.

The parents of Christie Harnett, Charlotte and Michael Harnett said: Our beautiful Christie, just 17 years old, lost her life whilst in a hospital run by TEWV Trust. Where there was little to no care or compassion. Three years on the Trust are still being rated inadequate and are rolling out the same 'copy and paste' platitudes and apologies. A public inquiry is the only way to stop the failings continuing.”

The parents of Nadia Sharif, Hakeel and Arshad Sharif, said: “This has been awful and goes on and on. We need a public inquiry to see what went wrong.”

The parents of Emily Moore, David and Susan Moore, said:As a family who have seen with our own eyes and witnessed our daughter Emily’s horrific care amongst others, we believe a public inquiry is paramount to TEWV either moving forward or losing their licence to serve the publics mental health needs.

Even nearly three years after Emily’s death the Trust is inadequate in many of its locations and this just does not get any better. This mental health Trust is a danger to the public and cannot move on without the need for a public inquiry.”

Deborah Coles, Director of INQUEST, said: These damning reports uncover systemic failings and dangerous and coercive culture and practice within this Trust. The organisational failure to mitigate the environmental risks which could have potentially prevented these deaths is nothing short of criminal.

The reports also raise serious doubt about the effectiveness of regulators in informing and enforcing much needed changes on the ground, before preventable deaths take place.

Sadly, these are not isolated incidents, locally or nationally. INQUEST is calling for the government to urgently commission a statutory independent inquiry into deaths and serious incidents in mental health services, to ensure learning, action and accountability.”

Alistair Smith of Watson Woodhouse solicitors, who represent the three families, said: The three reports highlight the appalling and chaotic care given to the girls. They deserved much better. And three years on, as recent CQC inspections show, the Trust has not learned and not improved. It is time for a public inquiry into this Trust to determine how it got into this dire state.

Many of the tragic deaths and serious incidents were preventable and unless something is done now - it is an unfathomable reality that many more lives will be lost under this failing Trust.

There is a need for answers and for those responsible to be held accountable. A public inquiry will explore the route of the problems and force real changes to culture, policy and practice. This is the only way to ensure other families will not have to go through similar heartache and anguish. Despite what the Trust say, lessons have not been learnt as we see repeated failings time and time again.”


For further information and photos please contact Lucy McKay [email protected] and Sarah Magson/ Abigail Gowland at Watson Woodhouse Solicitors on 01642 266511 on [email protected]; [email protected]

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.

A PDF of all three investigation reports is available here or you can access the reports and the Trust's response on the TEWV website.

The independent investigation reports were commissioned by the NHS and written by Niche Consulting. They looked at the following deaths:

  • Christie Harnett, 17 years old, who died 27th June 2019 in West Lane Hospital.
  • Nadia Sharif, 17 years old, who died 5 August 2019 in West Lane Hospital.
  • Emily Moore, 18 years old, who died 15 February 2020 in Lanchester Road hospital in Durham, an adult ward where she was moved from West Lane Hospital just days before, due to her 18th birthday, on 6 February 2020.

More info on the family led campaign Rebuild Trust is available at www.rebuildtrust.co.uk