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: 

The treatment three girls received before they tragically took their own life has been exposed shocking failures in NHS mental health services.

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.

Emily, from Shildon, was an inpatient under the care of TEWV Adult Services (Tunstall Ward) when she took her own life. She loved shopping and animals and took great care in looking after her pet guinea pigs.

The report said issues at West Lane cannot be seen to have been immediate contributory factors in her death, but added that Emily’s care plans in Newberry Ward in West Lane were “fragmented, incomplete and inconsistent”.

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Emily alleged that staff "would shout and swear at her when she harmed herself" – a time when she needed support the most – while at the Ferndene facility.

It said the two systems issues that had a direct impact on Emily’s death were the transition from CAMHS (Children and Adolescent Mental Health Services) to Adult Services which was based entirely on age and did not take Emily’s clinical needs into consideration, and the failure to address the low-level ligature risks identified in en-suite bathrooms on Tunstall Ward in 2019.

A total of 24 care and service delivery problems were identified during Emily’s care before her death.

The Northern Echo:

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.”

Read more: 'Failures' exposed at West Lane Hospital before deaths of three girls

Read more: Andy McDonald MP's inquiry call into Tees, Esk and Wear Valley Trust

Read more: Shocking comments about patient treatment West Lane Hospital

“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.”