A report released today into the deaths of three girls made reference to details surrounding their treatment, published in a Care Quality Commission report published November and detailed below:
An investigation into the deaths of Christie Harnett, 17, Nadia Sharif, 17 and Emily Moore, 18, identify 119 failings in health and social care which led to their deaths.
The three girls took their own lives between June 2019 and February 2020, had all been diagnosed with complex mental health needs and had been patients at West Lane Hospital in Middlesbrough.
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Nadia, who grew up in Middlesbrough, was diagnosed with an autism spectrum disorder. She had a love for theme parks and was a technically gifted Mathematician.
The report into the care and treatment of Nadia referenced the “unstable and overstretched services” in the hospital, and that the failings were “multifaceted and systemic”.
It says the organisation failure to mitigate the risks of self-harm, accompanied by a lack of support for Nadia’s individual needs were the “root causes” for her death.
Investigators also uncovered CCTV footage of Nadia being 'dragged' down a corridor backwards through access to a separate serious investigation report.
It identified 47 care and service delivery issues with her treatment.
Health minister Maria Caulfield told MPs she will examine calls for a public inquiry amid concerns over inpatient mental health services.
Ministers will make a decision “in the coming days” on whether a full public inquiry or a “rapid review” should be carried out into the failings.
Responding to an urgent question, Ms Maria Caufield told MPs: “The findings from the investigation into the deaths make for painful reading and the death of any young person is a tragedy, and all the more so when that young person should have been receiving care and support.
“My thoughts and I’m sure the thoughts of this whole House are with their families and friends, and I want to apologise for the failings in the care that they received.”
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“On the issue of a public inquiry, I am not necessarily saying there won’t be a public inquiry but it needs to be on a national basis and not just on an individual trust basis, because as we’ve seen in maternity very often when we repeat these inquiries they produce the same information and we need to learn systemically about how to reduce these failings.
“The issue I have with a public inquiry is they’re not timely, they can take many years, and we’ve clearly got some cases now which need some urgent review and some urgent action.
“So I will look at her request, but I am taking urgent advice – as is the Secretary of State – because we take this extremely seriously and one death from a failing of care is one death too many.”
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