Deaths in care: What happened to the patients failed by a mental health trust

A solicitor says there "will be more deaths" at a mental health trust prosecuted for failing a teenager and mother who took their own lives while under its care.

Alistair Smith represented the families of patients who died while being cared for by the Tees, Esk and Wear Valleys NHS Foundation Trust.

His warning follows the sentencing of the trust on Friday which saw it ordered to pay a fine of £200,000 after pleading guilty to failing to provide safe care and treatment to Christie Harnett, 17, and Patient X.

Teesside mental health trust fined £200,000 over deaths of two women in its care

Christie, from Newton Aycliffe, took her life in June 2019 while being cared for at West Lane Hospital, in Middlesbrough.

Patient X took her life while on an adult ward at Roseberry Park Hospital, in the same city, in late 2020.

Their grieving mothers told ITV News Tyne Tees what happened.

What happened to Christie Harnett?

When Christie Harnett was admitted to West Lane Hospital in 2017 with an eating disorder, her mother hoped she would get better.

But that did not happen and two years later she took her own life there. 

Charlotte Harnett, Christie's mother said: "I didn't want her to be in hospital. As my child, I wanted to look after her. I wanted to make it better.

"As the weeks went on and she was getting worse and worse and worse, I didn't know what to do. I didn't know who to turn to.

"I was asking staff members why she'd been allowed to self-harm."

In March 2019, Christie tried to take her own life using taps in her bathroom at the hospital and was put on life support. 

Just days earlier she told her family she felt unsafe.

"She actually sent a message saying, 'I'm going to end up dead, if I'm honest'," continued Charlotte.

"They'd been told, they've been warned that she wasn't of the right frame of mind. They said, 'don't worry, we’ll up her obs(ervations), we'll keep someone with her. We'll keep a good eye on her'.

"And later on, I got a phone call to say she's in hospital. You need to get there now."

Family 'affected for rest of their life' by death of Christie Harnett, 17, in mental health care

Christie's grandmother Casey Tremain remembers the horror unfolding.

"I had a lot of missed calls on my phone, I knew it was something serious," she told ITV News Tyne Tees. "I rang Charlotte, and she said, Christie's in intensive care on life support.

"I couldn't understand how it got to that point, how her being in hospital being monitored has allowed that to happen. It didn't make sense."

Christie did recover and went back to West Lane. But her family said things were only getting worse.

Back at the hospital, Charlotte described witnessing "girls walking around, blood dripping down their faces, marks on their arms, which had been cutting".

She feared the worst would happen to her teenage daughter - a child who was "funny", who "loved singing dancing, clothes, make up" and who was "like sunshine" in her family's lives.

"I told the staff," Charlotte explained. "I said something needs to be done because someone's going to end up dead. And they didn't listen."

In June 2019, Christie made another attempt on her life in a bathroom at West Lane. She died four days later on 27 June.

Like in March, Christie had hurt herself using taps in the bathroom - taps the trust had been warned were a risk in January of that year.

"I remember Charlotte saying to me that she wasn't coming back this time," said Casey. "And I was saying to Charlotte, 'don't say it, don't say it'.

"She's not here because she was failed and it hits you in random moments. You can be out and smell a perfume and it will trigger me.

"The smell, a sound, a song. And she's not here."

Charlotte continued: "I didn't ever think that I would lose a child, and I have. And it's horrible."

What happened to Patient X

In August 2019 West Lane Hospital was shut down following the death of another patient - Nadia Sharif, from Middlesbrough.

Three months later the trust's chief executive Colin Martin announced his retirement.

By June 2020 the trust had a new boss, Brent Kilmurray, who had previously worked at the trust in a senior role . 

It was under his leadership that a second patient, Patient X died, and whose death the trust is also been prosecuted over. 

She has been referred to as Patient X to protect her identity in order to safeguard her children.

Patient X's mother told ITV News Tyne Tees: "She wanted to get better - she wanted to come home to her children. She was a good mum. She was my baby."Patient X died on an adult ward at Roseberry Park Hospital in Middlesbrough in late 2020.

Like Christie, she took her own life using taps in a bathroom.

"I think they should be ashamed of themselves. I think what they've put these families through is absolutely ridiculous.

"When this court case is over, they walk away and forget all about it. We are left with the aftermath of the decisions that weren't made properly."

Timeline of events

• March 2019: Christie Harnett makes attempt on her life using taps in her bathroom at West Lane Hospital and is put on life support

• June 2019: Christie Harnett tries to take her life again using taps in her bathroom at West Lane Hospital and dies four days later

• August 2019: West Lane Hospital shut down following death of another patient, Nadia Sharif

• December 2019: Chief executive Colin Martin announces retirement

• June 2020: Brent Kilmurray appointed as chief executive

• Late 2020: Patient X takes her life using taps in her bathroom at Roseberry Park Hospital and dies

Urgent calls for change

Alistair Smith has been representing many families who lost loved ones under the care of Tees, Esk and Wear Valleys NHS Foundation Trust, including Christie Harnett and Patient X.

He told ITV News Tyne Tees: "The care must have been absolutely appalling, because it's not easy to bring a prosecution of a trust and it isn't done often.

"And so the substandard care must be so low to reach the criminal standard."

Former West Lane staff told they were 'being silly’ after warning management about patient deaths

In the case of Christie Harnett he believes the police should reinvestigate what happened at West Lane Hospital.

"I was quite surprised that the police didn't prosecute for corporate manslaughter, on the basis that she died in exactly the same way as she had suffered very serious injuries three months prior to it," he explained.

"And on the basis of the environment at West Lane. The more you knew about it the more you struggled to believe what went on."

Almost five years on from Christie’s death, there are concerns things are not getting better. 

The latest inspection by the Care Quality Commission shows it is a trust that still 'requires improvement'.

Following the sentencing of the trust over the deaths of Christie and Patient X, there are renewed calls for its chief executive to step down.

In a message to Brent Kilmurray, Mr Smith urged: "Please resign. Please do the honourable thing.

"If you do that it gives the trust a better chance of improving which is what all the people, all the patients want for this trust."

Asked if Mr Smith thought patients at the trust are now safe, he answered "no".

Asked if Mr Smith thought there would be more deaths, he answered "yes".

Charlotte, Christie's mother, said her death had "destroyed" the lives of the family - including her five other children.

She and Christie's grandmother Casey say "someone needs to be held accountable".

"If failings took a life anywhere else, people would be held to account," added Casey.

Their feelings are echoed by Mr Smith and the mother of Patent X.

Mr Smith said: "There’s a lot of people in senior management jobs who failed, nothing’s happened to them and there's been no personal accountability for that."

While Patient X's mother added: "They’re not just numbers, They’re not just nameless faces. They are family members, they are mothers, they are daughters. Please just remember that."

For many years, Christie’s mother said she carried the guilt of her daughter’s death. But now she knows she was not to blame: 

"No matter what I did it wouldn't have changed anything," she said. "It wasn't my fault. It was their fault."

The Trust's CEO, Brent Kilmurray, has also given a own statement, which reads: "As we made clear in court today, we're 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's no consolation for Patient X and Christy's loved ones, for which I offer our heartfelt apologies.

"The CQC has acknowledged in our latest inspection that improvements have been made since then, however today is about being accountable and our thoughts are with the families at this incredibly difficult time."

The Trust has also confirmed Mr Kilmurray will not be resigning.

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