A governance report into Tees, Esk & Wear Valleys NHS Foundation Trust (TEWV) was published on 21st March 2023, following independent investigation reports in November 2022 into the deaths of three teenage girls who were detained mental health patients in the care of the Trust.

The report is a system-wide independent investigation into concerns and issues raised. Commissioned by NHS England and undertaken by Niche Health and Social Care Consulting, it found “clear synergies” between care failings delivered to all three teenage girls who died.

The governance report uncovered the failure of management, leadership and substandard delivery of services within the Trust. It found a “consistent failure to put the young people at the heart of care”. Incident reporting was found to be not accurate and a theme throughout the report is that the care afforded was “chaotic”. There are a total of 12 recommendations made, including staff training, communication between various care agencies, and liaising with families after the death of a patient.

Issues highlighted in the report include reduced staffing, senior staff not having necessary experience in child-centred care, poor reporting of significant self-harm and near-death incidents, inappropriate restraint incidents and inadequate incident investigations. Despite a high number of incidents which involved ligatures, the report found that there was no evidence of proper risk assessments for ligatures in place or the removal of ligature points. The report included that young people talked about how the environment “facilitated self-harm”, a risk often exacerbated by a lack of skilled staff.

In February 2023, it was announced that the CQC will be bringing criminal charges against TEWV in relation to the three deaths.

Deborah Coles, Director of INQUEST, a charity providing expertise on state related deaths, said: “This report highlights a catastrophic failure of leadership, regulation and oversight leading to repeated, wholly avoidable deaths. The corporate failure to mitigate the environmental risks which could have prevented these deaths is nothing short of criminal. The scale of the systemic neglect and dangerous practices has only come about because of bereaved families and their lawyers. Far greater public scrutiny is needed on what is taking place behind the closed doors of our mental health institutions.”

Calls for a full statutory inquiry into inpatient mental health settings

Sadly these issues are not limited to West Lane Hospital. Over the last months and years there have been a number of reports of unsafe care, abuse of patients and excessive restraint in mental health wards.

Following the BBC Panorama report in October 2022 which revealed a “toxic culture” of abuse at the Edenfield Centre in Prestwich, there have been growing demands for a public inquiry into both the mental health unit at Prestwich, as well as mental health provision in England and Wales as a whole.

How Farleys can help

Here at Farleys, we have extensive experience of representing clients at inquests into the death of a loved one. We have represented a number of families whose family members have died whilst an inpatient, including those at the Prestwich facility.

We understand the distressing, daunting nature of the proceedings and will support clients throughout with down to earth, expert advice. To discuss legal representation at an inquest, please call our team today on 0845 287 0939, email us, or contact us through the online chat below.