Staff allowed young patients at a failing mental health hospital to harm themselves and access suicide websites amid “chaotic” ward conditions, a damning independent investigation has revealed.
The report was ordered after three teenagers, Christie Harnett, 17, Nadia Sharif, 17, and Emily Moore, 18, took their own lives over an eight-month period before the covid pandemic following treatment at West Lane Hospital. in Middlesbrough.
Staff shortages and inadequate training, as well as a lack of leadership, meant that child and adolescent mental health wards often appeared “chaotic and unsafe” to staff and patients.
A “least restrictive practice” policy meant that young patients with complex problems were largely left on their own, skipping education lessons to goof off and surf harmful Internet websites.
The report revealed that young patients “were allowed to decide whether to attend lessons and were not always prevented from bringing inappropriate high-risk and potentially lethal items onto the wards.”
Nadia Sharif, 17, had been in the trust’s care for five years before she was diagnosed with Asperger’s syndrome and took her own life.
Emily Moore, 18, was also treated at West Lane Hospital but was transferred to Lanchester Road Hospital in Durham on her 18th birthday, where she died in February 2020.
Christie Harnett, 17, was initially referred to the NHS Trust’s eating disorders team. She was later detained under the Mental Health Act after self-harm and aggressive behavior.
Rules and boundaries were lacking and the report commented that ‘every parent who spoke to us was unhappy with the treatment of their youngster at West Lane’.
“Young people would be in their pajamas all day watching TV during the day and staying up late at night on the Internet or watching movies.
“This meant that young people had uncontrolled access to their smartphones, thus being able to access inappropriate websites such as self-harm websites, share photos of other patients who have self-harmed, and spend hours on the Internet at night.”
West Lane Hospital in Middlesbrough, where the three were treated for mental health problems, was found to have “unstable and overburdened services”.
One parent compared the chaos to William Golding’s Lord of the Flies novel, in which a group of children on a deserted island grow increasingly wild without the influence of adults.
“It was like Lord of the Flies: everyone would be in a cohort, either just watching TV or running around,” the father said.
The phones were seen as a way patients could communicate with families and a rule making them available to all was introduced to comply with the European Convention on Human Rights, providing a right “to respect for private and family life.” “, according to the report.
Nadia Sharif was found dead inside her room at West Lane Hospital in Middlesbrough at around 8:30am on Monday August 5, 2019.
Access to social media was a major issue that was “mishandled and caused mistrust and concern,” according to the report.
The risk for young patients was increased by the ability to access “inappropriate” websites that endorse eating disorders, self-harm and suicide.
The rules meant that “staff could not restrict access to mobile phones.”
And staff said they were “told not to intervene in self-harm incidents until the situation became life-threatening.”
The Manchester-based Niche Health and Social Care Consulting report stated: “The reality of this was that children and young people would be allowed to cause harm to themselves before staff intervened. Patients felt they had to watch out for others.” -doing harm and didn’t trust the staff to keep them safe.’
Some staff members were seen as ‘abusive’ and their actions as ‘a form of intimidation’.
Authorities failed to inform parents of incidents involving their children and a lack of trust in management to deal with complaints.
The staffing problems were exacerbated when a complaint about inappropriate restraint led to a CCTV review and 33 staff members being removed from duty and eight subsequently disciplined. In total, 18 incidents of inappropriate immobilization were identified, predominantly in which three patients were dragged across the floor. Nobody was fired.
The report, which made 12 detailed recommendations, also criticized industry watchdog the Care Quality Commission (CQC), saying its scrutiny of West Lane “lacked rigor”. The CQC eventually closed the hospital in August 2019. It was reopened as Acklam Road Hospital and run by a different trust.
Christie Harnett took her own life on West Lane in June 2019. She had been detained under the Mental Health Act 11 times, spending 556 days in three years in hospital detention. The lack of proper beds meant that social services often placed her in hotels or accommodation during her treatment, leading to an escalation in self-harm behaviour, according to the report. In total, 51 problems with her care were identified.
Christie Harnett, 17, died in a bathroom at West Lane Hospital after a two-year struggle with mental health issues.
Nadia Sharif took her own life on West Lane in August 2019. During her three years of care by mental health services, she was subjected to ten different placements and there was “consistent and insufficient recognition of risk,” according to the report. . In total, 46 problems were identified with her care at various agencies.
Emily Moore died at Lanchester Road Hospital in Durham in February 2020 after receiving treatment at West Lane. There were 200 self-harm incidents in her last 12 months. The report says her family was “increasingly concerned” that the West Lane ward was “unable to keep her safe.” Investigators found 14 problems in her care, eight of which were related to West Lane.
Commenting on the report, David Jennings, Chairman of the Tees, Esk and Wear Valleys NHS Foundation Trust, said: “We would like to reiterate how deeply we regret the events that contributed to the deaths of Christie, Nadia and Emily.”
He said: “This report covers a period of time where it was very clear that there were deficiencies in both care and leadership.” Since then significant changes have been implemented, he said.
Margaret Kitching, NHS head of nursing for England, North East and Yorkshire, said the report “raises extremely significant concerns” and that patients “have not received the care they deserve”.
Christie’s father, Michael Harnett, called the report “shocking” as it confirmed that “it was happening to all patients”.
He said: ‘No patient had anything good to say. Everything we went through, it wasn’t just us, it was everyone who went through the same thing, all the families.
