'We knew somebody would die': Teenage patients 'ignored' before fatal NHS trust failures

"We knew idiosyncratic would die… and cipher listened."

Laura Kenny is remembering her person Christie Harnett.

Both were patients astatine a intelligence wellness portion successful Middlesbrough erstwhile Christie took her ain life.

Warning: This nonfiction contains distressing details and references to termination and self-harm

"We'd been informing everyone," says Laura. "We wrote letters to everyone we could deliberation of saying 1 of america is going to die."

In fact, 17-year-old Christie was 1 of 3 young women who, wrong a fewer months of each other, took their ain lives portion patients successful hospitals tally by the Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV) - which covers the full of North Yorkshire, County Durham and Teesside.

In caller weeks we person spoken to much than a twelve erstwhile patients, admitted arsenic young radical oregon arsenic adults, who accidental they experienced failures successful the modular of attraction astatine TEWV.

We person besides met the families of immoderate of those who died distant from hospital, but inactive nether the trust's care. Nathan Evison was 19 erstwhile helium killed himself successful 2019 and Laurent McNamara died past year.

All person akin stories - describing a deficiency of compassion among unit and an lack of immoderate meaningful attraction oregon therapy. Many fearfulness mistakes are inactive being made.

Those we spoke to, and hundreds more, pushed for a nationalist inquiry. One was announced past December, but families and patients are disappointed by delays successful mounting it up.

Despite having been promised answers by the extremity of February, they accidental a gathering connected 31 March with the Department of Health and Social Care (DHSC) near them nary nearer to knowing who mightiness pb the investigation, erstwhile it mightiness commencement and wherever it mightiness beryllium held.

"While our clients admit these things instrumentality time, they are disquieted astir the continued attraction being offered by a spot nether scrutiny and how, successful 3 months, determination appears to beryllium nary steadfast developments," Alistair Smith, from Ison Harrison Solicitors told the BBC.

The DHSC says it is moving "at pace" to corroborate who should seat the inquiry.

"We are committed to ensuring the voices of patients and the families affected by failures [at TEWV] are astatine the bosom of this inquiry," said a spokesperson successful a connection to the BBC.

There has already been 1 autarkic enquiry into the trust's attraction of young radical admitted to infirmary with a intelligence wellness problem. Commissioned by NHS England, it published its main study successful 2023.

In particular, it looked astatine Christie's death, arsenic good arsenic those of 2 different young women - 17-year-old Nadia Sharif, and Emily Moore who was 18.

The findings backed up patients' claims of excessive and inappropriate restraint, that unit were told not to intervene successful episodes of self-harm, and that failures were tolerated by managers.

TEWV past apologised and said important improvements had been introduced, but bereaved families and erstwhile patients fearfulness that, 3 years on, the lessons from these failures person not been learned, and that susceptible radical person been severely fto down.

Former patients and bereaved families person told the BBC they invited the statutory nationalist inquiry, which volition beryllium a overmuch much elaborate probe than the erstwhile report, with ineligible powers to telephone witnesses, summon documents and a absorption connected preventing past mistakes from being repeated.

But astatine heart, they accidental they privation to get answers astir what went severely incorrect astatine the Trust and to spot immoderate measurement of justness for those they person lost.

TEWV declined to beryllium interviewed and said it would not remark connected idiosyncratic cases.

In a statement, Alison Smith, main enforcement since past September, said the spot would "co-operate afloat with the nationalist enquiry with honesty, openness, humility, grace and kindness".

Three deaths successful 8 months

Laura Kenny, present successful her 20s and studying instrumentality astatine university, has vivid and disturbing memories of the decennary she spent arsenic a diligent nether the trust's care.

From the property of 13, an eating upset near her dangerously underweight. Her information rapidly spiralled into episodes of self-harm and termination attempts.

During this time, Laura spent a batch of clip arsenic an in-patient astatine West Lane successful Middlesbrough, a specializer intelligence wellness centre for young people. Her friend, Christie Harnett was besides treated there.

Laura says unit would respond to incidents of self-harm by either shouting astatine her oregon Christie, oregon conscionable disregard what was happening.

"Their absorption would beryllium to either permission you for hours headbanging oregon self-harming, oregon to conscionable restrain you precise rapidly to the level and inject you," she says. "The thought was to benignant of conscionable unopen you up."

Christie's stepfather, Michael, has unspeakable memories of what she told him astir the staff's effect to her self-harming.

"They would virtually conscionable pin her down, sedate her, enactment her successful bed, and past that was it."

He adds that erstwhile Christie yet woke up, she told him unit would not speech done the incident, adjacent if she was inactive covered successful humor from her injuries.

Laura says the infinitesimal she heard Christie had died was horrific.

"I deliberation the worst happening was that we knew it was going to happen," she says.

Christie's decease was followed by that of Nadia Sharif and Emily Moore, 2 different young women nether the trust's care. All 3 deaths occurred wrong an eight-month play up to February 2020.

A coroner is inactive to find the circumstances astir Christie, Nadia and Emily's deaths.

In 2024, the spot was prosecuted by the Care Quality Commission (CQC), and fined £215,000 for information failings contributing to the deaths of Christie and different unnamed woman.

The spot pleaded blameworthy to 2 charges of failing to supply harmless attraction and attraction to the 2 women, exposing them to "a important hazard of avoidable harm".

Michael has campaigned for a nationalist enquiry alongside Emily's father, David Moore.

Emily took her ain beingness conscionable aft she was transferred from West Lane Hospital to an big facility.

David says helium believes the failures successful attraction person extended acold beyond the deaths of the 3 young women.

"It's not 1 death, 2 deaths, 3 deaths, it's multiple, aggregate deaths successful the trust. It's conscionable a large nonaccomplishment successful the system," helium says.

"Nobody listened astatine all. And it's hard to say, but it feels similar cipher cared."

Concerns astir TEWV spell further than its hospitals.

The household of Nathan Evison judge the modular of attraction offered to those successful the assemblage whitethorn person led to the 19-year-old apprentice's death.

Over a play of conscionable six weeks successful 2019, Nathan's intelligence wellness declined rapidly aft the breakdown of a relationship.

He lived successful an isolated agrarian cottage with nary net and telephone signal. After helium had asked for help, a assemblage intelligence wellness squad from TEWV visited him there.

Nathan's parent Jess says a furniture successful a intelligence wellness portion had seemingly been available, had the squad wanted to admit him for his ain protection.

But the squad chose not to admit Nathan, she says, contempt his intelligence wellness having spiralled retired of control. Within a fewer hours helium was dead.

"It was similar helium went from 0-60 successful six weeks," she says. "I don't deliberation helium had immoderate help. And helium did the close thing, helium went and asked. We've seen that enactment for him conscionable wasn't there."

Her spouse Andrew feels that if the assemblage squad had communicated with his parents, things mightiness person turned retired differently.

"They lone had to ringing america up and archer america what was going connected that day," helium says. "His friends would person gone, we would person gone, helium could person travel here. But it ne'er happened, for that 1 telephone call."

In Harrogate, different household is besides coping with the fall-out from a objective determination astatine the spot that seems to person gone catastrophically wrong.

Laurent McNamara lived with bipolar upset - characterised by utmost shifts successful mood, and impulsive, sometimes reckless, behaviour.

Last June, during a manic episode, helium was detained astatine Foss Park Hospital successful York nether the Mental Health Act. But then, unexpectedly and without warning, helium was discharged.

The archetypal his begetter Bill knew was erstwhile Laurent phoned to inquire if helium could beryllium picked up from the infirmary car park.

Bill says his lad intelligibly inactive appeared to beryllium unwell, truthful erstwhile they arrived home, helium rang the ward to inquire wherefore his lad had been released.

Within 48 hours, Laurent was recovered dormant astatine his home, alone, having slipped retired of his parents' location successful the tiny hours of the morning.

Exactly what happened is inactive to beryllium determined by a coroner, but his household judge helium was discharged portion inactive successful the grip of a manic episode.

Laurent's woman Gemma says infirmary unit placed excessively overmuch accent connected the patient's wishes, but Laurent was acold excessively sick to cognize what was champion for him.

"He didn't privation to die. If he'd known what was going to happen, helium would person decidedly stayed successful hospital," she says.

"So they deliberation they're doing bully by doing what the diligent wants, but they're not, due to the fact that they're not reasoning what they really need."

The forthcoming enquiry would beryllium "an accidental to perceive and larn what we could person done amended and however we amended the experiences for our patients, families, carers and staff," said TEWV main enforcement Alison Smith successful her connection to the BBC.

"Importantly it volition besides alteration those who person been affected to perceive however atrocious we are."

The spot told the BBC it does not privation to remark connected idiosyncratic cases.

It nary longer provides in-patient attraction for young radical - they are treated by neighbouring trusts. More caller reports by the CQC suggest determination person been immoderate improvements astatine TEWV, including astir information and policies to study and enactment connected superior incidents.

But the erstwhile patients and families who person present won their combat for a nationalist enquiry anticipation their galore questions astir the trust's attraction failures tin yet beryllium answered, and that it volition pb to safer, amended care.

On a bedewed February day, precocious successful the North York Moors National Park, we are looking for a tiny footbridge implicit the River Dove.

It was named aft Nathan Evison by his erstwhile colleagues successful the National Park, wherever helium was completing his apprenticeship.

We yet find it, acceptable successful a rugged scenery of hills and moors, and adjacent the dependable rainfall can't disguise its beauty.

Nathan's sanction is conscionable astir disposable connected a small plaque astatine 1 extremity of the bridge, worn dull by the Yorkshire upwind successful the years since his death.

But this lonely and beauteous span is simply a reminder that treating intelligence wellness problems is simply a analyzable situation that tin person catastrophic consequences if things spell wrong.

Nathan's mum, Jess, tells maine this is the archetypal clip she and her spouse Andrew person felt capable to visit.

"The time's conscionable not been right. And it is rather emotional, but I cognize he'd beryllium chuffed that we're here."