A damning report has detailed a health trust’s campaign of alleged bullying and failure to protect patients before the tragic death of three teenagers.

The independent investigation into concerns around the mental health provision at West Lane Hospital, Middlesbrough described the staff response to self-harm as “negative and punitive”, while some patients were dragged along the floor in an “excessive and inappropriate” form of restraint. 

An insufficient leadership structure and lack of support created a care environment which was often described as “chaos”, the report said. 

The facility, which is part of the Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV), was closed in August 2019 by the Care Quality Commission (CQC) after a deteriorating spiral of poor care. But this was not until after the tragic deaths of Christie and Nadia, whose deaths were as a result of the care provided at West Lane Hospital, the report stated.

Read more: Teenagers died after 'appalling' care at Durham and Middlesbrough hospitals

Christie Harnett, 17, of Newton Aycliffe, had complex mental health needs as well as autism and had been receiving treatment at West Lane at the time of her death on June 27, 2019. Nadia Sharif, 17, from Middlesbrough, had a diagnosis of autistic spectrum disorder and died on August 9, also at West Lane. 

Emily Moore, 18, had been an inpatient at the same hospital until July 2019, and then moved to Ferndene, managed by a different trust. The Shildon teenager was transferred to Lanchester Road, Durham in February 2020 when she turned 18 but died one week later. 

The findings of the investigation, released on Tuesday, stated how the use of restraint was “excessive, inappropriate, and ultimately damaging to patients, as well as staff”, with some patients dragged along the floor.

The Northern Echo: The hospital closed in 2019 but has since reopened under the new name Acklam Road The hospital closed in 2019 but has since reopened under the new name Acklam Road (Image: The Northern Echo)

After a young person complained of being inappropriately restrained in November 2018, a review of CCTV footage from the preceding four weeks found 18 incidents of inappropriate restraint, predominantly involving three patients being dragged along the floor.

This resulted in 33 members of staff being removed from duty and eight subsequently disciplined. Meanwhile, 13 of the 33 staff were alleged to have observed but failed to prevent the inappropriate restraints. They were initially put on special leave and then suspended, but nine staff remained. 

Patients and families said they were not safe under the trust’s care. Young people interviewed by inspectors said they felt the environment facilitated self-harm, while staff were accused of being intentionally negative and bullying. 

“The typical response to self-harm and suicidality was described by several interviewees as negative and punitive,” the report added. 

Read more: The failures that led to death of three girls at Durham and Middlesbrough hospitals

There was a lack of structure among staff, due to an inconsistent workforce, as family and carers felt they could not safely raise concerns about the care. The report also found there was a “fundamental and consistent failure” to inform parents about incidents involving their children.

It added: “This risk was often exacerbated by a lack of staff, and particularly skilled staff, in order to respond with appropriate methods when young people were self-harming.”

It is recommended that all future concerns must be reported and reviewed frequently. When there has been a death at the TEWV Trust, families must be given appropriate and compassionate family liaison and support, the report added. 

In response to the report, David Jennings, chair of Tees, Esk and Wear Valleys NHS Foundation Trust, said: "We would like to reiterate how deeply sorry we are for the events that contributed to the deaths of Christie, Nadia and Emily. 

“Brent Kilmurray, our chief executive, and I have met each of the young women’s families to apologise to them in person. I thank them for allowing us to do that. I cannot begin to imagine how painful it has been for them. 

“This report covers a period of time where it was abundantly clear there were shortfalls in both care and leadership. Over the last three years, how we care for people, how we involve patients, families and carers, and our leadership and governance structure have changed significantly.

“We will continue to work hard to make sure we deliver safe and kind care to the people we support, as they have every right to expect.”