Teenage patients 'ignored' before fatal NHS trust failures

"We knew someone would die… and nobody listened."

Laura Kenny recalls her friend Christie Harnett, who, along with Laura, was a patient at a mental health unit in Middlesbrough at the time of her tragic death by suicide. Laura reports that she and other patients had voiced concerns regarding their treatment in a unit later identified in an independent report as "chaotic and unsafe." Unfortunately, these warnings went unheeded.

"We'd been warning everyone," Laura asserts. "We wrote letters to everyone we could think of, stating that one of us was going to die."

Seventeen-year-old Christie was one of three young women who tragically ended their lives within a few months of each other while receiving care at facilities operated by the Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV), which oversees mental health services across North Yorkshire, County Durham, and Teesside.

In recent weeks, over a dozen former patients, both as adolescents and adults, have shared accounts of the inadequate level of care within TEWV. Families of individuals who died while still under the trust's care, such as Nathan Evison, who was 19 when he took his life in 2019, and Laurent McNamara, who died the following year, have also come forward with their experiences.

These individuals tell similar stories, citing a lack of compassion among staff and a dearth of effective treatment or therapy options, raising concerns that critical errors continue to persist.

In response to their shared experiences, affected individuals and numerous others have advocated for a public inquiry. While one was announced last December, there is growing disappointment among families and patients due to delays in its progression.

Despite assurances of receiving answers by the end of February, a meeting on March 31 with the Department of Health and Social Care (DHSC) failed to provide clarity on who would oversee the inquiry, the anticipated start date, or its location.

"While our clients appreciate that these matters require time, they are increasingly concerned about the ongoing care being delivered by a trust under scrutiny and the apparent absence of concrete developments in the past three months," stated Alistair Smith from Ison Harrison Solicitors.

The DHSC clarified that it is acting swiftly to appoint a chair for the inquiry, emphasizing their commitment to ensuring that the perspectives of patients and families affected by TEWV's failures are central to the investigation.

Previous investigations

An independent inquiry into the trust's management of young individuals admitted for mental health treatment has already taken place, commissioned by NHS England and published in 2023. This inquiry specifically examined Christie's death, along with those of two other young women—Nadia Sharif, 17, and Emily Moore, 18.

The report corroborated patients' allegations of excessive and inappropriate restraint techniques, revealed that staff were instructed to refrain from intervening during self-harm incidents, and documented a systemic tolerance of failures among management.

In response, TEWV issued an apology and announced substantial improvements. However, bereaved families and former patients remain skeptical, fearing that three years later, the critical lessons from these failures have gone unheeded, leaving vulnerable individuals inadequately supported.

The establishment of a statutory public inquiry has been viewed positively by former patients and families, as it promises a more thorough investigation than previous reports, equipped with legal powers to summon witnesses, gather documents, and focus on preventing the recurrence of past failures.

In 2024, TEWV faced legal repercussions from the Care Quality Commission (CQC) and was fined £215,000 for safety violations that contributed to the deaths of Christie and another unnamed woman. The trust acknowledged guilt on two charges for failing to provide safe care and treatment, which placed both women at "a significant risk of avoidable harm."

Staff responses to self-harm

Now in her twenties and pursuing a law degree, Laura Kenny reflects on her ten-year experience as a patient under the care of TEWV, which began when she was 13. Struggling with an eating disorder that led to severe underweight issues, Laura's condition evolved into episodes of self-harm and suicide attempts.

During this period, Laura frequently stayed at West Lane, a specialist mental health facility for adolescents, where Christie was also a patient. Laura recalls staff responses during self-harm incidents were inadequate, either involving harsh verbal reprimands or complete neglect of the situation.

"Their approach was to either leave you for hours, allowing headbanging or self-harming to occur, or to swiftly restrain you on the floor and administer an injection," she explains. "The aim seemed to be to simply silence you."

Michael, Christie's stepfather, shares his traumatic memories of her experiences, recounting how staff would physically restrain her, sedate her, and place her in bed without further dialogue regarding the incident—even when she was still injured.

Upon hearing of Christie's death, Laura describes her devastation.

"I think the worst part was knowing it would happen," she admits.

Christie's death was soon followed by those of Nadia Sharif and Emily Moore, both under TEWV's care. The coroner is still investigating the circumstances surrounding the three young women's deaths.

Michael has joined forces with Emily's father, David Moore, to advocate for a public inquiry. Emily, like Christie and Nadia, also took her life shortly after transitioning from West Lane to an adult institution.

David asserts that the systemic failings in care extend well beyond these three tragedies.

"It's not just one death, or two, or three—this is a systemic issue resulting in multiple deaths within the trust. It signifies a significant failure in the system," he states. "No one listened, and it's challenging to articulate, but it feels as if nobody truly cared."

Community care failures

Concerns regarding TEWV extend beyond its institutional settings. Nathan Evison's family believes that inadequacies in community care contributed to the tragic death of their son, who was only 19.

Over a six-week period in 2019, Nathan's mental health deteriorated significantly following a relationship breakdown. Residing in a remote rural area with no internet or cell service, he sought help from a community mental health team associated with TEWV.

Nathan's mother, Jess, asserts that a bed was available in a mental health unit should the team have opted to admit him for his safety. However, despite Nathan's concerning mental state, the team chose not to admit him, and he was dead within hours.

"It felt like his condition went from stable to critical in just six weeks," she explains. "He reached out for the support he needed, but it simply wasn't there."

Nathan's partner, Andrew, believes that had the community team communicated with Nathan's parents, the outcome might have been different.

"A simple phone call to inform us of his situation could have altered everything," he states. "His friends and family could have stepped in. But that connection never happened."

In Harrogate, another family grapples with the consequences of a clinical decision by TEWV that they believe went horribly wrong. Laurent McNamara, who lived with bipolar disorder, experienced significant mood swings and impulsive behaviors.

Last June, during an acute manic episode, Laurent was detained at Foss Park Hospital in York under the Mental Health Act but was unexpectedly discharged without prior warning. His father, Bill, learned of this when Laurent called to request a ride from the hospital parking lot.

Upon arriving at home, Bill contacted the ward, expressing concern for Laurent's well-being, yet he discovered that Laurent had been released while still unwell.

Tragically, within 48 hours, Laurent was found dead at home, having left the family residence during the early morning hours.

The exact circumstances surrounding his passing await a coroner's determination, but the family believes his discharge was premature, occurring while he was still experiencing the effects of his disorder.

Laurent's wife, Gemma, remarks that staff placed excessive weight on patient preferences, neglecting the reality that Laurent was not in a position to make informed decisions due to his illness.

"He didn't want to die. Had he known what would unfold, he would have certainly chosen to remain in the hospital," she states. "While they believe they are acting in the patient's best interest, they fail to recognize what is genuinely necessary."

Future prospects

TEWV's chief executive Alison Smith expressed hopes that the upcoming inquiry would serve as "an opportunity to hear and learn what we could have done better and how we can improve experiences for our patients, families, carers, and staff." She also emphasized the importance of allowing those affected to hear the trust's apology.

TEWV informed the BBC that they prefer not to comment on specific cases. The organization has ceased providing in-patient care for adolescents, redirecting such services to neighboring trusts. Recent CQC reports indicate some advancements in TEWV regarding safety measures and protocols for reporting and addressing significant incidents.

The former patients and families who have successfully advocated for a public inquiry anticipate that their many questions relating to the trust's care shortcomings will finally be addressed, ultimately leading to enhanced safety and quality of care.

Nathan's legacy

On a drizzly February day, amidst the scenic North York Moors National Park, a small footbridge spans the River Dove.

This bridge, named in honor of Nathan Evison by his former colleagues in the National Park where he was pursuing an apprenticeship, stands in a rugged, picturesque setting. It serves as a poignant reminder of the complexities surrounding mental health treatment and the dire repercussions of failures in care.

Nathan's mother, Jess, visits the bridge for the first time alongside her partner Andrew.

"The timing never felt right before, and the emotions are overwhelming, but I know he would be glad we are here."