Two suicidal patients took their own lives after receiving inadequate care from a hospital that ran “chaotic and dangerous” wards.
Christie Harnett, 17, and a young mother identified as Patient X, both took their own lives while in the care of Tees Esk and Wear Valley NHS Foundation Trust.
Despite repeated attempts by both men to self-harm, the Trust admitted in court today that it had failed in its duty to provide safe care and treatment.
In Christie’s case, she had made ten attempts to hang herself using a ligature in the two years before her death at West Lane Hospital in Middlesbrough, North Yorkshire.
But her carers still failed to monitor her properly or remove objects which could have been used as ligatures, Teesside Magistrates’ Court heard.
Christie Harnett (pictured), 17, and a young mother identified as Patient X, both took their own lives while in the care of Tees Esk and Wear Valley NHS Foundation Trust.
In Christie’s case, she had attempted to hang herself using a ligature 10 times in the two years before her death at West Lane Hospital.
On June 23, 2019, following numerous suicide attempts, Christie successfully committed suicide by hanging herself in a shared bathroom.
Another patient raised the alarm when water was seen running under the locked door and the teenager was discovered a short time later by staff. She later died in intensive care without regaining consciousness.
Jason Pitter, KC, prosecuting for the Care Quality Commission, said:
“Between the ages of 15 and 17, Christie spent 603 out of 752 nights in hospital.
“She was hospitalized on 10 occasions and detained under the Mental Health Act on 11 occasions. There were numerous incidents of self-harm, including 19 by neck ligation.
The Trust observed that incidents of self-harm were “increasing in degree and frequency” but had still not carried out a proper risk assessment.
Mr Pitter said: “The risk assessments for Christie failed to adequately identify the high risk of self-harm and in particular the high risk of ligation. The risk of self-harm was underestimated by staff and the risks were not mitigated as much as they could have been.
“Essentially, the Trust failed to put in place appropriate risk assessments and resulting risk control and mitigation measures, and staff were unable to ensure their safety. “
In its investigation, the CQC found: “Christie’s care plan should have identified the risk of ligation and strategies to minimize it. »
The commission also found that the Trust failed in its supervision of Christie and in removing material that could have been used as ligatures.
Patient
She was admitted to the unit on November 7 after discovering suicidal thoughts.
The next day, she was found semi-conscious by staff after using a ligature to attempt suicide.
Tributes paid to teenagers who tragically died in crisis psychiatric hospital
Patient
On November 19, a staff member looked in his room and saw the bathroom door was open with the light on, but did not check inside.
Instead, she assumed the room was empty and continued to tour the wards for another 15 minutes before questions were asked about Patient X’s whereabouts and his room was searched.
Mr Pitter said: “As he entered the bathroom his hand was visible under the shower curtain. The ligature was removed and emergency care administered without success.
He said the Trust had classified Patient looked in his room.
He added: “The observation sheets demonstrate an inadequate and inconsistent approach to the conduct of observations and a failure to embed its supportive observations procedure among its staff.
Family members spoke of the trauma of losing their loved ones in statements read in court.
Michael Harnett, of Newton Aycliffe, County Durham, Christie’s stepfather, spoke of a happy, smiley girl who loved to sing and take to the stage in school productions.
However, he said visiting him at West Lane Hospital haunted his parents and younger brother.
Mr Harnett said: “Seeing cuts, scratches and marks on her and the bloodstained walls where staff had not cleaned her was traumatic for us as adults, not to mention her younger brother .
“From the moment his heart beat its last beat, a part of us was ripped away and we will never be the same.”
Christie’s older sister Ellis, 23, said: “I felt like I was supposed to protect her and I will always feel like I let her down because I couldn’t protect her.
“But it wasn’t my job to keep him safe, it was theirs, the Trust’s, and in my opinion they failed him.”
On June 23, 2019, following numerous suicide attempts, Christie successfully committed suicide by hanging herself in a shared bathroom (file photo).
Patient X’s mother said his death traumatized her children in different ways.
She said: “The youngest was not able to understand and always thought his mother would be able to come home.” Even now, they still think their mother might come home.
“It’s heartbreaking to have to tell a young child that their mother is now a star in the sky.”
She added: “The trust should have done better. They owe it to her and her children who now have to fight throughout life without their mother.
Paul Greaney, KC, of the Trust, said it had changed “beyond recognition” since the deaths.
He said: “The court will condemn an organization very different from that which existed at the time of the events. This is an organization that is making real progress and is determined to learn from the deaths of Christie and service user X.’
Mr Greaney continued: “The Trust recognizes that it exposed Christie and service user X to a significant risk of avoidable harm, but it should not be convicted on the basis that its failures caused their deaths.
“This is not a case where nothing was done, this is a case where systems were in place but those systems failed.”
In March last year, a damning independent investigation found staff allowed young patients at West Lane to self-harm and access suicide websites in “chaotic and dangerous” conditions on wards .
The report was ordered after three teenage girls – Christie, Nadia Sharif, 17, and Emily Moore, 18 – took their own lives over an eight-month period from June 2019.
A “least restrictive practice” policy meant that young patients with complex problems were largely left to their own devices, skipping classes to lounge around and surf harmful websites on the Internet.
The report found that young patients were “allowed to decide whether they attended classes and were not always prevented from bringing high-risk and potentially fatal inappropriate items into wards”.
The report from Manchester-based Niche Health and Social Care Consulting said: “The reality was that children and young people would be allowed to harm themselves before staff intervened. Patients felt they needed to be considerate of others. -harmful and did not trust staff to keep them safe.
In February, the trust was released following a trial at the same court for breach of custody of Emily Moore, to the fury of her family.
For mental health support, contact the Samaritans on 116 123, email them at jo@samaritans.org or visit samaritans.org to find your nearest branch.
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