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A mental health unit criticised over the deaths of three teenagers was “chaotic and unsafe”, a report found.

An independent inquiry found “excessive and inappropriate” restraint was used at Middlesbrough’s West Lane Hospital.

The report also found self-harm was “facilitated” with staff told not to intervene unless it could be fatal, while “insufficiently curious” leaders tolerated safety failures.

Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV) apologised.

It said significant changes had been made.

The report followed the deaths of Christie Harnett, Nadia Sharif, both 17, and Emily Moore, 18, who took their own lives in an eight-month period up to February 2020 under the trust’s care.

West Lane, which closed following the deaths, provided specialist child and adolescent mental health services, including treatment for eating disorders.

Tuesday’s report, commissioned by NHS England and undertaken by Niche Health and Social Care Consulting, found “clear synergies” between care failings delivered to all three.

It is the latest in a series of reports which identified failings.

The report’s authors spoke to former patients, their parents and staff as well as the families of the three teenagers who died.

It found a “consistent failure to put the young people at the heart of care”.

Young people interviewed said the care environment “facilitated self-harm” and they did not feel confident that they were safe.

A key theme of powerlessness was identified from patient interviews, the report said.

Patients spoke of being treated with a lack of dignity, with one saying staff made them feel “that I’m just a waste of a bed”.

Another spoke of being restrained by male staff “when I was completely naked”.

Some verbal interactions were described as judgemental, and at times abusive.

“I was called a maniac, a stupid little girl – lots of comments like that,” said one patient.

“I was told, if you really wanted to kill yourself, you would be dead by now.”

Every parent spoken to as part of the investigation was unhappy with the care of their young person, the report’s authors said.

Many felt “undermined” with reports of failures to inform them of incidents involving their children and one described feeling “manipulated into not making more fuss about things”.

The use of restraint at the hospital was excessive, inappropriate, and ultimately damaging to patients, as well as staff.

Staff were struggling to cope with the complexity and demands of the patient cohort, the report found, and little support was given to staff to assist in de-escalating situations, which is likely to have contributed to an over-reliance on restraint.

West Lane was often described as a “closed culture” and there was insufficient curiosity within corporate governance regarding the culture there, the report said.

And there was no evidence there was a collaborative effort by the trust or its partners to ensure there was a robust safeguarding framework in place to protect children and young people.

The report made 12 recommendations which included dealing with complaints, staff training, communication between various care agencies and liaising with families after the death of a patient.

It recommended NHS England reviewed progress within six months to a year.

By Fiona Trott, BBC North of England Correspondent

From NHS England and the Care Quality Commission, right down to the hospital itself, the report finds weaknesses in mental health provision at every level – and patients at West Lane weren’t protected.

One parent told me it made her feel like a terrible mother. A patient said he still can’t trust people because of the trauma he suffered.

When you hear this, you understand why this report means so much to them. It says they weren’t listened to and their concerns and complaints were justified.

Their next question is: “How was this allowed to happen in the first place?”

They’re reading a report which says incident reporting at the hospital gave a false impression of what was going on and the board was overly accepting of verbal reassurances on quality and safety.

That’s why – after years of letter writing to prime ministers, the Parliamentary Ombudsman or Freedom of Information requests – some families are still calling for a judge-led inquiry.

TEWV chairman David Jennings said it was “deeply sorry” and they had met the families of the three young women and apologised.

“This report covers a period of time where it was abundantly clear there were shortfalls in both care and leadership,” he said.

“Over the last three years, how we care for people, how we involve patients, families and carers, and our leadership and governance structure have changed significantly.

“We will continue to work hard to make sure we deliver safe and kind care to the people we support, as they have every right to expect.”

Margaret Kitching, the chief nurse for NHS England, North East and Yorkshire, said: “We continue to closely monitor the trust’s progress to ensure all of the recommendations are fully addressed.”

Miss Harnett, from Newton Aycliffe, County Durham, took her own life at West Lane Hospital in June 2019 and Miss Sharif, from Middlesbrough, died there two months later.

Miss Moore, also from County Durham, took her own life in February 2020 at Lanchester Road Hospital. She had previously been treated at West Lane in 2018 and 2019.

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