Death of teens in mental health hospital care highlight “systemic failings and dangerous and coercive culture and practice”

An independent investigation into the care and treatment of three teenage girls, provided by Tees, Esk and Wear Valleys NHS Foundation Trust, has concluded that major “multifaceted and systemic” institutional failings contributed to their deaths.

The reports, conducted by health and social care consultant Niche, found that the deaths of Christie , Emily , and Nadia occurred due to inadequate service delivery. The girls had been diagnosed with complex mental health conditions and had all been patients of West Lane Hospital in Middlesbrough.

They had all been friends, spending time together at the secure mental health unit in West Lane and later died separately over an eight-month period as a result of self-inflicted inquiries.

What did the reports find?

The investigation found that in Nadia’s case, more than 100 episodes of self-harm were recorded in the month before her death. However, this indication of high risk was never formally recognised. Additionally, there was concerning evidence of the inappropriate use of force, visible in CCTV footage which showed Nadia being ‘dragged’ down a corridor backwards.

In Emily’s case, it was alleged that staff would shout and swear at her when she harmed herself. And in the view of the investigators, the transition from children to adult mental health services did not account for Emily’s specific needs, and as such, she did not have effective care plans in place.

For Christie, the researchers found a serious self-harm incident was never adequately investigated, and as a result, no care plan was created to inform staff how to care for her and mitigate particular risk factors.

Other issues highlighted in the three reports included ineffective hospital management, reduced staffing, lack of leadership, aggressive handling of disciplinary problems, issues with a succession of crisis management, and failure to respond to patient and staff concerns. In total, 119 ‘Care and Service’ delivery problems were identified concerning the girls.

INQUEST calls for a public review of deaths and serious incidents in mental health hospitals

These reports come after Sky News and the Independent ran an exposé of five mental health hospitals last week. The investigation similarly highlighted repeated allegations of over-restraint and inadequate staffing, which they said left young people at increased risk of self-harm.

Due to the evident issues present in mental healthcare, the legal justice charity INQUEST is calling for a statutory national public inquiry into deaths and serious incidents in mental healthcare units.

In a statement, INQUEST further highlighted that while West Lane Hospital closed in 2019 following the three teenagers’ deaths, the institution reopened as Acklam Road Hospital in 2021, with recent low-grade inspections continuing to raise serious questions about the culture and practices in Tees, Esk and Wear Valley Foundational Trust.

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.”

In a statement, Tees, Esk and Wears Valleys Foundational Trust chief executive, Bren Kilmurray said:

“On behalf of the trust, I would like to apologise unreservedly for the unacceptable failings in the care of Christie, Nadia and Emily which these reports have clearly identified.

“The girls and their families deserved better while under our care. I know everyone at the trust offers their heartfelt sympathies and condolences to the girls’ family and friends for their tragic loss."

“We must do everything in our power to ensure these failings can never be repeated."

“However, we know that our actions must match our words. We accept in full the recommendations made in the reports – in fact the overwhelming majority of them have already been addressed by us where applicable to our services.”