'We knew somebody would die': Teenage patients 'ignored' before fatal NHS trust failures

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

Laura Kenny reflects on her friend Christie Harnett, both of whom were patients at a mental health unit in Middlesbrough when Christie tragically took her own life. Laura recalls that she and her peers had voiced serious concerns regarding their treatment—described later in an independent report as "chaotic and unsafe"—but their warnings fell on deaf ears.

Warning: This article contains distressing details and references to suicide and self-harm

"We had been warning everyone," Laura reveals. "We wrote letters to every authority we could contact, predicting that one of us would die."

Seventeen-year-old Christie was among three young women who, in close succession, took their lives while receiving care from the Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV), which serves a vast area including North Yorkshire, County Durham, and Teesside.

In recent weeks, we have engaged with over a dozen former patients, both adolescents and adults, who reported experiencing notable deficiencies in the standard of care provided by TEWV. We have also met with the families of young individuals who passed away outside the hospital while still under the trust's oversight. Nathan Evison was only 19 when he died by suicide in 2019, and Laurent McNamara died the following year.

Former patients and families consistently echoed sentiments of inadequate compassion from staff and the absence of substantial therapeutic interventions. Many expressed fears that similar mistakes currently endure within the system.

Families and former patients have advocated for a public inquiry, which was announced last December. However, they express disappointment over the delay in this inquiry's execution. Despite reassurances of forthcoming answers by the end of February, a subsequent meeting on March 31 with the Department of Health and Social Care (DHSC) yielded no clarity regarding the inquiry's leadership, start date, or venue.

"While our clients appreciate that these processes take time, they are understandably concerned about the quality of ongoing care from a trust under such scrutiny, especially with no substantive progress reported over the last three months," stated Alistair Smith from Ison Harrison Solicitors, as shared with the BBC.

The DHSC indicated that it is working diligently to appoint an inquiry chair. "We are committed to ensuring that the voices of patients and the families affected by failures [at TEWV] are central to this inquiry," a spokesperson affirmed to the BBC.

An independent investigation into the trust's handling of young people admitted due to mental health issues had already been conducted, commissioned by NHS England, with its main findings published in 2023. This inquiry specifically addressed Christie Harnett's death as well as those of Nadia Sharif and Emily Moore.

The findings corroborated the claims of patients regarding the use of excessive and inappropriate restraint, directives for staff not to intervene during self-harming episodes, and a general tolerance of failures by management.

In response, TEWV issued an apology and claimed to have implemented significant improvements. However, bereaved families and former patients remain skeptical, asserting that critical lessons have yet to be learned and that vulnerable individuals continue to be inadequately supported.

Many informed the BBC that they welcome the statutory public inquiry, which promises a more comprehensive investigation than the earlier report. This inquiry will have the legal authority to call witnesses, demand documents, and specifically aim to prevent the recurrence of past failings.

Ultimately, their desire is for transparency regarding the mismanagement at the Trust and to seek justice for those they have lost.

TEWV opted not to engage in an interview and stated that it would refrain from commenting on individual cases. In a statement, Alison Smith, the chief executive since September, assured that the trust would "fully co-operate with the public inquiry with honesty, openness, humility, grace, and kindness."

Three deaths in eight months

Now in her 20s and pursuing a law degree, Laura Kenny recalls her decade under the trust's care with vivid and troubling memories. Starting at age 13, an eating disorder plunged her into a perilous state of being dangerously underweight and eventually led to episodes of self-harm and suicide attempts.

During this period, Laura spent significant time as an inpatient at West Lane in Middlesbrough, a specialized mental health center for youth, where her friend Christie Harnett also received treatment. Laura describes how staff would respond to self-harm incidents by either shouting at her or Christie, or simply ignoring the situation.

"Their response involved either leaving you for hours engaged in self-harm or quickly restraining you and sedating you," she recounted, "The objective seemed to be to suppress any further trouble."

Michael, Christie's stepfather, recalls the harrowing stories Christie shared about how staff addressed her self-harm.

"They would physically pin her down, sedate her, place her in bed—then just walk away," he recalled.

Worse still, when Christie would wake up, she remarked that staff refused to discuss the incident, even when she was visibly injured.

The news of Christie's death was devastating for Laura.

"I think the hardest part was we all anticipated it happening," she reflected.

Christie's death was soon followed by those of Nadia Sharif and Emily Moore, two other young women under TEWV's care, with all three fatalities occurring within an eight-month timeframe leading up to February 2020.

A coroner is still investigating the circumstances surrounding Christie, Nadia, and Emily's deaths.

In 2024, TEWV faced prosecution from the Care Quality Commission (CQC) and incurred a fine of £215,000 due to safety failures linked to Christie's death and another unnamed woman. The trust pleaded guilty to two charges concerning their inability to provide safe care and treatment to the two women, thereby exposing them to "a significant risk of avoidable harm."

Michael has passionately campaigned for a public inquiry alongside David Moore, Emily's father. David asserts that the systemic failures extend significantly beyond the three tragic deaths.

"It's not merely one death or two; it symbolizes a multitude of failures within the trust," he stated. "There was a palpable absence of concern—it's disheartening to articulate, but it feels as if nobody cared."

'He didn't want to die'

Apprehensions about TEWV extend beyond hospital settings. The family of Nathan Evison hold the belief that the standard of community care could have contributed to the untimely death of the 19-year-old apprentice.

In a span of just six weeks in 2019, Nathan's mental health deteriorated drastically following a relationship breakdown. Living in a secluded rural cottage with no internet or mobile reception, he sought help, prompting a community mental health team from TEWV to visit him on-site.

Nathan's mother, Jess, claims a bed in a mental health facility was available, had the team decided to admit him for his safety. However, she asserts that they opted not to admit him, despite his mental health rapidly worsening. Within hours of their visit, he was dead.

"It felt like he went from perfectly fine to being critically ill in a matter of weeks," she remarked. "He reached out for support, and we saw that essential help just wasn't there."

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

"It would have taken just one phone call to inform us of what was happening that day," he explained. "His friends and family could have stepped in, but that opportunity was missed for lack of communication."

In Harrogate, another family grapples with the aftermath of a clinical decision that went catastrophically awry at the trust. Laurent McNamara, who experienced bipolar disorder characterized by erratic mood swings and impulsive behavior, was detained at Foss Park Hospital in York last June during a manic episode. Following an unexpected and sudden discharge, Laurent's father, Bill, received the first notification through a phone call from his son asking for a pickup from the hospital parking lot.

As they returned home, Bill sensed that Laurent remained unwell, prompting him to contact the ward to understand why his son had been discharged. Within 48 hours, Laurent was found dead at home, alone, after leaving his parents' residence in the early hours of the morning.

While the exact circumstances that led to his death are still under review, his family believe he was released while still experiencing a manic episode.

Gemma, Laurent’s wife, contends that hospital staff emphasized patient autonomy excessively, disregarding Laurent's impaired judgment.

"He didn't want to die. If he had been aware of the potential outcome, he would have definitely opted to stay in the hospital," she asserted.

"They believe they're acting in the patient's best interests by honoring their wishes, but they're misguided; they aren’t considering what the patient truly needs."

In her statement to the BBC, TEWV’s chief executive Alison Smith indicated that the forthcoming inquiry represents an opportunity to evaluate and enhance care practices for patients, families, and staff alike. "Most importantly, it will allow those affected to understand how deeply sorry we are for what transpired."

TEWV refrained from commenting on individual cases but confirmed that it no longer provides inpatient care for young people, delegating this responsibility to neighboring trusts. Recent reports from the CQC suggest some improvements have been made within TEWV, particularly concerning safety and protocols for reporting serious incidents.

However, former patients and families who have successfully advocated for a public inquiry anticipate answers to their pressing questions about the trust’s systemic failures, hoping that these revelations will lead to the advancement of safe and effective care.

Nathan's Bridge

On a damp February day, nestled in the North York Moors National Park, we embark on a search for a small footbridge spanning the River Dove. This bridge was named in memory of Nathan Evison by his colleagues in the National Park, where he was pursuing his apprenticeship.

We eventually locate it, set against a ruggedly beautiful landscape, its elegance unblemished even by the steady rain. A plaque bearing Nathan’s name, dulled by exposure to the Yorkshire climate, rests at one end of the bridge.

This solitary yet breathtaking structure serves as a poignant reminder of the complexities involved in managing mental health issues and the dire repercussions that incorrect treatment can yield.

Jess, Nathan's mother, shares that this marks the first occasion she and her partner, Andrew, have felt ready to visit the memorial.

"The timing hadn’t felt right until now. It stirs up a lot of emotions, but somehow, I believe he would be pleased to see us here."