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Family say teenager Christie Harnett was failed on ‘colossal scale’ as NHS trust fined £200k

A County Durham teenager who took her own life at an NHS mental health hospital was “failed on a colossal scale”, her family have said.

Tees, Esk and Wear Valleys NHS Trust (TEWV) has been fined £200,000 after admitting failures in the care of two patients, Teesside Live reports. Teenager Christie Harnett, and another patient, who cannot be named for legal reasons, died while under the care of the trust.

Christie, 17, died after being found unconscious in a bathroom at the Newberry Centre at West Lane Hospital, Middlesbrough, in June 2019. A mum, referred to as Service User X – after a judge ruled her name could not be reported – died in November 2020, three days after being found unconscious in the bathroom of her room at Roseberry Park Hospital, also in Middlesbrough.

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  • On Friday, the mental health trust responsible for their care was fined at Teesside Magistrates’ Court after pleading guilty to two offences of failing to provide safe care and treatment to people who were exposed to a significant risk of avoidable harm. The Care Quality Commission (CQC), which brought the prosecution, said the trust failed to mitigate the known risks the patients were exposed to following previous self-harm incidents.

    The court heard Christie had been diagnosed with a “complex and emerging mental health disorder” and had spent almost two years in hospital – 603 out of 672 nights in the run up to her death.

    ‘Worst period of our lives’

    In a victim impact statement, Christie’s father Michael Harnett paid tribute to her. He said: “2007 is the year that Christie came into my life. I will always remember the first time I met her she was a smiling five year old. From day one I was amazed that no matter what happened she had that massive smile and infectious laugh.

    “The day Christie went into hospital started the worst period of our lives. Not only was Christie’s life more difficult but so was ours. We could not go on family holidays, had very few days out and the days we did get were always dictated by what leave she was allowed, depending on how she behaved.”

    Mr Harnett said it wasn’t unusual for the family to travel to see her, only to be turned away – with NHS bosses citing that she had misbehaved. He added: “To be turned away and have to watch your daughter try and climb over the fence to see you because she wasn’t allowed was heart breaking. Seeing her with cuts, scratches, marks around her neck and the walls of her room stained by blood where staff hadn’t cleaned it properly was traumatizing.

    “The only way we now get to see Christie’s smile or hear her sing is in pictures and videos. We never got to see her turn 18 or even 21. She is never going to drive the baby blue Fiat 500 she desperately wanted, we will never get to see her become a mother and I will never get to walk my daughter down the aisle.”

    Christie’s grandmother Casey Tremain said she believes her granddaughter was failed on a “colossal scale”. She said: “In my opinion she was failed on a colossal scale not just once but failed time and time again. My granddaughter would have been 22-years-old living her best life but instead she is forever 17 because in my opinion people didn’t care for her. I will always believe that her life meant nothing to the people who should have been helping her.”

    Prosecutor Jason Pitter KC said Christie had been detained under the Mental Health Act on 11 occasions from the age of 15, and that there were “numerous self-harm incidents in that time”.

    She fatally harmed herself in a communal bathroom on the ward on June 23, 2019, and was found by a healthcare assistant after a service user saw water running under the bathroom door. An investigation revealed a number of failings in her care, including a failure to adequately identify the high risk of self harm and set out appropriate ways this was to be managed by staff, Mr Pitter said.

    The trust failed to respond to previous ligature incidents involving Christie in March and May, and put in place appropriate measures, it was said. Risk assessments and care plans failed to prevent Christie using the bathrooms without any additional risk control, such as removal of items she could use to attempt to tie a ligature, Mr Pitter said.

    ‘The risk of self-harm had been underappreciated’

    In its response under caution, the trust accepted that “in relation to the use of the ward bathroom the risk of self harm had been underappreciated by staff and risks were not mitigated as fully as they could have been”.

    The court heard Service User X had a history of depression and anxiety and was admitted to hospital following an overdose in 2020. On the day of her death, a staff member doing a care observation round looked round her bedroom door, but did not go into the bathroom, and wrongly reported there was no-one in the room before completing her round.

    The staff member then tried to find out where Service User X was, and returned to the room with another employee. This time they entered the bathroom and found Service User X unconscious, the court heard.

    In a victim impact statement, Service User X’s mother said: “The death of my daughter isn’t like anything you can begin to comprehend. I wouldn’t wish the pain, anger, and sheer distress on my worst enemy. I know I have to be strong for her children. She has left behind amazing children all of which are so different but still so much like my daughter. The only glimmer of hope in all of this is that a part of her lives on in them.”

    Paul Greaney KC, mitigating on behalf of the trust, said it wished to apologise to the families of Christie and Service User X, and read a statement from its chief nurse – Beverley Murphy – saying how sorry the trust was for the incidents and that the care on these occasions “had fallen short of that which we would expect”.

    “This is not a case where nothing was done. There were systems and these systems failed,” Mr Greaney said. “Staff on those wards did care for Christie and Service User X.” He told the court the leadership of the trust “has changed beyond all recognition” since then and it was “determined to learn the lessons arising out of Christie and Service User X”.

    New appointments have been made in the following executive roles:

    • Chairman
    • Medical director
    • Chief nurse
    • Director of people and culture
    • Assistant chief executive
    • Executive director of corporate affairs and involvement
    • Executive director of therapies
    • Executive director of finance, information and estates

    Mr Greaney said the money to pay the fine would have to be diverted from funds “that would otherwise be used to support patient care”. Following sentencing, Brent Kilmurray, chief executive at Tees, Esk and Wear Valleys NHS Foundation Trust said: “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.”

    Last month, the mental health trust was acquitted of failures in Emily Moore’s care. She was just 18-years-old when she died while being treated at Lanchester Road Hospital in Durham in 2020. TEWV stood trial at Teesside Magistrates’ Court accused of failing to provide care and treatment in a safe way resulting in harm or loss.

    However, the trust, which provides services across County Durham and Teesside, was acquitted. On the opening day of the trial, the court heard how Emily was found in the bathroom during a routine observation having self-harmed. She tragically died two days later after suffering a hypoxic brain injury.

    Responding to the verdict, Emily’s dad, David Moore, said: “I think it’s what we expected to be honest with you but it’s not what we agree with. The care wasn’t there for Emily, right from day one. Whatever they said, in our hearts it wasn’t what we saw, what we felt and what we heard. Justice has not been served in Emily’s case.”

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