TEWV fined £200k after Christie Harnett and Patient X deaths

The trouble-hit Tees, Esk and Wear Valleys (TEWV) NHS mental health trust will have to pay the six-figure sum after the deaths of Christie Harnett and an unnamed mum, known as Patient X, at its hospitals in Middlesbrough in 2019 and 2020.

It failed to adequately risk assess patients' self-harm and suicide risk, or implement effective ways to reduce those risks, the court heard.

Christie, from Newton Aycliffe, was 17-years-old when she died at West Lane Hospital in June 2019 while under TEWV’s care.

The court was told TEWV "failed to adequately identify her high risk of self-harm and or set up appropriate ways in which the risk was to be managed by staff".

It also heard Christie had made numerous attempts to end her own life by various methods.

The sentencing comes after her death and treatment were the subject of an NHS England, along with the death of Emily Moore.

A total of 120 faults and failures were found in care and service delivery across a number of agencies were found over the treatment provided to them.

Prosecutor Jason Pitter KC said: “The trust failed to put in place appropriate risk assessment and consequential risk control and mitigation measures and failed to ensure that staff were safely equipped or informed to know how to manage Christie's self-harm risk.

Christie Harnett (Image: THE NORTHERN ECHO)

"Those failures, we say, that they amounted to a failure to provide safe care and treatment and exposed her to a significant risk of avoidable harm."

Patient X, who will never be named due to an indefinite reporting restriction, was treated at the trust’s Roseberry Park Hospital where she died in 2020.

The court was told that on the day Patient X was found staff were carrying out observation checks on the ward and failed to check her bathroom for 20 minutes when she wasn't seen in her room.

The staff member reported she was in her room at 12pm, but it wasn't for another 15 minutes before they returned to the office to ask a colleague where X was.

Mr Pitter added they continued to search for Patient X after they went back to her bedroom at 12.20pm, adding: "This time X's hand could be seen under the shower curtain. A staff member entered and found X in the bathroom."

The prosecutor added the trust had accepted there were “various issues” in relation to X’s care plan.

"The location of all patients should be known to staff but not all patients need to be kept within eyesight. In this case, her whereabouts were not known”, he said.

District Judge Marie Mallon fined TEWV £200k. She said: "The court extends its condolences to the families of both [Christie and Patient X].

"The trust will be sentenced on the basis that its failures exposed Christie and Patient X to a significant risk of avoidable harm. It will not be sentenced on the basis that its failures caused their deaths."

She slashed a fine the trust, and therefore the taxpayer, could have had to foot by 90 per cent due to it being publicly funded, and reduced it again by a third as the trust pleaded guilty to the two charges of failing to provide safe care.

It came after TEWV's counsel Paul Greaney KC warned of a serious impact on services if a big fine was imposed.

He told the court: "There will be a serious adverse impact on the service and patient care if the fine is significant."

Last September the trust admitted two charges of breaching the health and social care act in relation to each of their deaths and was before Teesside Magistrates Court today for sentencing.

Christie’s stepfather Michael said in a victim impact statement: “I never got to see her turn 18, or even 21. We will never get to see her become a mother. I will never get to walk my daughter down the aisle.

"We have had them stolen from us because the place that was meant to keep her safe, in my opinion, totally failed her."

Speaking outside court after the hearing he added: "What we wanted in the end was them to be proven guilty. We didn't want the fine to affect service users and by the sound of it a big fine would have - it's strained and bad enough as it is. The main thing was their guilty plea."

"None of their apologies have ever seemed personal. She [Beverley Murphy] gave the apology but at the end of the day she's only been there a few months. Why get her to apologise to us? 

"From our dealings with them personally it's all been the same. We've offered in meetings to help them out as best as we can and things have been suggested but they never came back for any help from us.

"Their rating has gone up and five years on you'd hope things would have gotten better but I think it's still bad it 'requires improvement'"

Christie’s sister, Ellis Brayley, said her mental health “declined rapidly” after she was admitted to the hospital, adding: “I can’t even bring myself to say the name of the place because it fills me with so much anger.”

The families of Emily Moore and Nadia Sharif, another teenager who died while in the care of TEWV, joined Christie's family at court to hear the sentence being passed.

Meanwhile, Patient X’s mum said: "I feel like I haven't just lost my daughter but my daughter's family lost their family unit which I have fought so hard to keep together.

"I have never had anyone come to my house or sit me down and say what happened or sorry. My daughter is dead and it's like she's a number on a piece of paper.

"My daughter deserved better. She deserved to be cared for. The trust, in my opinion, owed it to her and children.

"I haven't had a full night's sleep in the last three years."

In a statement read in court, TEWV Chief Nurse Beverley Murphy said: "On behalf of the trust I would like to say to the families of Christie and service user X how sorry we are for the incidents that occurred while their relative was in the care of the trust.

"We are so sorry that these incidents that occurred while their relative was in the care of the trust.

Recommended reading:

• LIVE: TEWV NHS Trust fined thousands after Christie Harnett and Patient X deaths
• Family and trust reacts after TEWV found not guilty of unsafe care

• TEWV found not guilty of unsafe care in run up to patient's death

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"The trust accepts the responsibility that comes with providing care and treatment. On this occasion, the standard of care provided fell short of that which we would expect."

Mitigating, Paul Greaney KC said the leadership of the trust had “changed beyond recognition” since Christie and Patient X had died and listed a host of improvements which had been made, including the trust’s overall CQC rating being upgraded from ‘inadequate’ to ‘requires improvement’.

Brent Kilmurray, TEWV's CEO, swiftly left court after the sentencing, not stopping to speak to media, but released a statement saying: “As we made clear in court today, we are deeply sorry for the events that led to these tragedies.    

“We didn't provide the care these two people deserved, and the guilty pleas reflect that. Of course, that is no consolation to Christie’s family and friends, and the loved ones of the other patient, for which I offer our heartfelt apologies.   

“The CQC has acknowledged in our latest inspection that improvements have since been made, however now is not the time for this. Today is about us being accountable, and our thoughts are with the families at this incredibly difficult time.”