"We knew somebody would die": Teenage patients ignored before NHS trust failures
"We knew somebody would die… and nobody listened."
Laura Kenny recalls her friend Christie Harnett, both of whom were patients at a mental health unit in Middlesbrough when Christie took her own life.
Laura states that she and other patients had raised concerns about their treatment at the unit—later described in an independent report as "chaotic and unsafe"—but their warnings were not heeded.
"We'd been warning everyone,"Laura says.
"We wrote letters to everyone we could think of saying one of us is going to die."
Seventeen-year-old Christie was one of three young women who, within months of each other, died by suicide while patients in hospitals managed by the Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV), which serves North Yorkshire, County Durham, and Teesside.
In recent weeks, more than a dozen former patients—admitted as young people or adults—have spoken about experiencing failures in care standards at TEWV.
Families of some who died outside hospital but remained under the trust's care have also shared their experiences. Nathan Evison, aged 19, died by suicide in 2019, and Laurent McNamara passed away last year.
All accounts describe a lack of compassion among staff and an absence of meaningful treatment or therapy, with many fearing that mistakes continue.
Those interviewed, along with hundreds more, have advocated for a public inquiry. One was announced in December, but families and patients express disappointment over delays in its establishment.
Despite assurances of answers by the end of February, a meeting on 31 March with the Department of Health and Social Care (DHSC) did not clarify who would lead the investigation, its start date, or location.
"While our clients appreciate these things take time, they are worried about the continued care being offered by a trust under scrutiny and how, in three months, there appears to be no firm developments,"said Alistair Smith of Ison Harrison Solicitors to the BBC.
The DHSC stated it is working "at pace" to confirm the inquiry chair.
"We are committed to ensuring the voices of patients and the families affected by failures [at TEWV] are at the heart of this inquiry,"a spokesperson told the BBC.
An independent inquiry into the trust's treatment of young people admitted with mental health problems was commissioned by NHS England and published its main report in 2023.
This inquiry examined Christie's death and those of two other young women—17-year-old Nadia Sharif and 18-year-old Emily Moore.
The findings corroborated patients' claims of excessive and inappropriate restraint, staff being instructed not to intervene in self-harm episodes, and managerial tolerance of failures.
TEWV issued an apology and stated that significant improvements had been implemented. However, bereaved families and former patients fear that, three years later, lessons remain unlearned and vulnerable individuals continue to be let down.
Former patients and families welcome the statutory public inquiry, which will be more detailed than the previous report, possess legal powers to summon witnesses and documents, and focus on preventing recurrence of past mistakes.
At its core, they seek answers about what went wrong at the Trust and some measure of justice for those lost.
TEWV declined interview requests and would not comment on individual cases.
Alison Smith, the trust's chief executive since September, stated it would "co-operate fully with the public inquiry with honesty, openness, humility, grace and kindness."
Three deaths in eight months
Laura Kenny, now in her 20s and studying law at university, has vivid, distressing memories of the decade she spent as a patient under the trust's care.
From age 13, she suffered from an eating disorder that left her dangerously underweight, which escalated into episodes of self-harm and suicide attempts.
During this period, Laura was frequently an in-patient at West Lane in Middlesbrough, a specialist mental health centre for young people. Her friend Christie Harnett was also treated there.
Laura describes staff reactions to self-harm incidents as either shouting at patients or ignoring the behavior.
"Their reaction would be to either leave you for hours headbanging or self-harming, or to just restrain you very quickly to the floor and inject you,"she says.
"The idea was to sort of just shut you up."
Christie's stepfather, Michael, recalls what she told him about staff responses to her self-harming.
"They would literally just pin her down, sedate her, put her in bed, and then that was it."
He adds that when Christie woke up, staff would not discuss the incident with her, even if she was still covered in blood from injuries.
Laura describes the moment she learned of Christie's death as horrific.
"I think the worst thing was that we knew it was going to happen,"she says.
Christie's death was followed by those of Nadia Sharif and Emily Moore, two other young women under the trust's care. All three deaths occurred within eight months up to February 2020.
A coroner is still determining the circumstances surrounding the deaths of Christie, Nadia, and Emily.
In 2024, the trust was prosecuted by the Care Quality Commission (CQC) and fined £215,000 for safety failings contributing to the deaths of Christie and another unnamed woman.
The trust pleaded guilty to two charges of failing to provide safe care and treatment, exposing the women to "a significant risk of avoidable harm."
Michael has campaigned for a public inquiry alongside Emily's father, David Moore.
Emily took her own life shortly after transfer from West Lane Hospital to an adult facility.
David believes care failures extend beyond these three deaths.
"It's not one death, two deaths, three deaths, it's multiple, multiple deaths in the trust. It's just a big failure in the system,"he says.
"Nobody listened at all. And it's hard to say, but it feels like nobody cared."
'He didn't want to die'
Concerns about TEWV extend beyond its hospitals.
The family of Nathan Evison believes the standard of community care may have contributed to the 19-year-old apprentice's death.
Over six weeks in 2019, Nathan's mental health rapidly declined following a relationship breakdown.
He lived in an isolated rural cottage without internet or phone signal. After requesting help, a TEWV community mental health team visited him.
Nathan's mother, Jess, says a mental health unit bed was apparently available, but the team chose not to admit him despite his deteriorating condition. Within hours, he died.
"It was like he went from 0-60 in six weeks,"Jess says.
"I don't think he had any help. And he did the right thing, he went and asked. We've seen that support for him just wasn't there."
Her partner Andrew believes that communication with Nathan's parents might have changed the outcome.
"They only had to ring us up and tell us what was going on that day,"he says.
"His friends would have gone, we would have gone, he could have come here. But it never happened, for that one phone call."
In Harrogate, another family copes with consequences of a clinical decision at the trust that appears to have gone catastrophically wrong.
Laurent McNamara, who lived with bipolar disorder characterized by extreme mood shifts and impulsive behavior, was detained at Foss Park Hospital in York under the Mental Health Act during a manic episode last June.
Unexpectedly and without warning, he was discharged.
His father Bill first learned of this when Laurent called to ask for a ride from the hospital car park.
Bill says Laurent still appeared unwell, so upon arriving home he called the ward to inquire about the discharge.
Within 48 hours, Laurent was found dead at home, having left the house in the early morning hours.
The coroner is still investigating, but the family believes Laurent was discharged while still manic.
Laurent's wife Gemma says hospital staff placed excessive emphasis on patient wishes, though Laurent was too ill to make informed decisions.
"He didn't want to die. If he'd known what was going to happen, he would have definitely stayed in hospital,"she says.
"So they think they're doing good by doing what the patient wants, but they're not, because they're not thinking what they actually need."
TEWV chief executive Alison Smith described the forthcoming inquiry as an opportunity to learn how to improve experiences for patients, families, carers, and staff.
"Importantly it will also enable those who have been affected to hear how sorry we are,"she said.
The trust declined to comment on individual cases.
TEWV no longer provides in-patient care for young people, who are now treated by neighboring trusts.
Recent CQC reports indicate some improvements at TEWV, including safety and incident reporting policies.
However, former patients and families who secured the public inquiry hope it will answer their many questions and lead to safer, improved care.
Nathan's Bridge
On a rainy February day in the North York Moors National Park, a small footbridge over the River Dove is sought.
Named after Nathan Evison by his former National Park colleagues, where he was completing an apprenticeship, the bridge is set amid rugged hills and moors.
Despite steady rain, its beauty remains evident.
Nathan's name is visible on a small plaque at one end, weathered by years since his death.
This solitary bridge symbolizes the complexity of mental health treatment and the catastrophic consequences when care fails.
Nathan's mother Jess and partner Andrew say this is their first visit.
"The time's just not been right. And it is quite emotional, but I know he'd be chuffed that we're here,"Jess said.
