Three teenage women have died by suicide whilst in the care of a single NHS trust, with ex-patients now claiming their warnings about hazardous environments went unaddressed. The deaths occurred within months of each other at hospitals run by Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV), which serves North Yorkshire, County Durham and Teesside. An independent investigation thereafter described the psychological care facility in Middlesbrough as “chaotic and unsafe”. In spite of assurances, relatives and ex-patients say a official investigation revealed in December has stalled, with uncertainty regarding who will lead the investigation or when proceedings will commence. The trust now faces mounting pressure as numerous former patients describe a history of inadequate care and lack of empathy by staff members.
A Cycle of Preventable Loss
Laura Kenny’s memory of her experience at the Middlesbrough psychiatric facility is deeply affected by the death of her friend Christie Harnett, a 17-year-old who died by suicide whilst under the trust’s care. Laura and other patients had repeatedly raised complaints about their care, submitting letters to anyone they believed might listen. “We recognised somebody would die… and nobody listened,” Laura remembers with evident frustration. Yet their warnings proved tragically accurate. In the space of just months, three young women died by suicide whilst being treated by TEWV hospitals, each death constituting a shortcoming that might have been prevented had the alarm bells been acted upon.
The deaths of Christie Harnett, Nathan Evison, who was 19 when he died in 2019, and Laurent McNamara, who died last year, share a pattern of systemic neglect. Former patients and families recount a recurring pattern: staff showing a lack of compassion, an lack of substantive therapeutic support, and concerning responses to psychiatric emergencies. At the West Lane Hospital, now called Acklam Road Hospital, staff would allegedly shout at or simply ignore patients undergoing self-harm. These accounts present a portrait of an institution fundamentally ill-equipped to provide the specialised care that at-risk adolescents urgently required.
- Three young women took their own lives whilst receiving TEWV’s care within months of each other
- Former patients described staff yelling at or dismissing incidents of self-harm
- An independent report characterised the Middlesbrough unit as “disorganised and unsafe”
- Over a dozen former patients reported inadequate care and absence of empathy from staff
Alerts Unheeded Inside Hospital Settings
The most troubling aspect of the TEWV failures is not merely that care did not reach acceptable standards, but that patients themselves understood the danger and raised their worries repeatedly. Laura Kenny and her other patients at the Middlesbrough unit took the extraordinary step of writing letters to anyone they thought might intervene, explicitly warning that deaths were likely to occur if conditions did not improve. These were not unclear objections about discomfort or minor inconveniences—they were urgent appeals from defenceless individuals who grasped the gravity of their situation. Yet despite these explicit, well-expressed concerns from the very people most affected, institutional inertia prevailed. No meaningful action was taken, no urgent review was triggered, and no preventive actions were implemented.
The neglect on these alerts amounts to a profound breach of responsibility by those responsible for safeguarding. When those receiving care identify that their surroundings poses a life-threatening danger, organisational leaders has an binding responsibility to take immediate and thorough action. Instead, the trust evidently failed to address these warnings completely. The three deaths that occurred subsequently were not unforeseen events; they were outcomes that had been explicitly forecasted by those dealing with the service failures in person. This gap between alert and action speaks to a troubling culture within TEWV where service user perspectives were not simply dismissed but consciously overlooked, even when they carried warnings of life-and-death consequence.
Staff Responses Which Intensified Suffering
Beyond neglect, reports by ex-patients reveal active harm perpetrated by personnel responsible for providing care. When service users suffered self-injury—a manifestation of their emotional anguish demanding empathetic response—staff responded by raising their voices to them or merely overlooking the occurrences entirely. Such responses are contrary to core standards of mental health support and suggest a fundamental misunderstanding of the illnesses being managed. Rather than calming situations, or providing therapeutic support, employee reactions appear designed to embarrass and exclude vulnerable individuals to a greater extent. These testimonies paint a picture of an environment where the very people seeking help met with hostility instead.
The standalone review’s depiction of the unit as “chaotic and unsafe” takes on new meaning when examined in light of these employee conduct. A disorderly setting combined with unsympathetic responses creates circumstances where at-risk adolescents cannot heal. Rather than discovering safety, patients faced unpredictability and judgement. For young people contending with severe mental health conditions, such treatment compounds their distress rather than alleviating it. The lack of empathy from those in caring roles represents not merely occupational shortcoming but a betrayal of the core confidence that underpins the therapeutic relationship.
Social Care Failures Outside Hospital Settings
The failures within TEWV extended far beyond the confines of hospital wards. Patients discharged into community care found themselves navigating a system equally fragmented and unresponsive to their needs. For young people moving from inpatient treatment to outpatient support, the continuity of care that should have ensured stability instead became a further cause of vulnerability. Families report that scheduled reviews were missed, liaison between services broke down, and individuals dealing with serious mental health conditions were lacking adequate oversight or intervention. The trust’s duty did not end at hospital discharge; yet for many former patients, assistance disappeared precisely when they required it most.
Those under community-based support faced distinct vulnerabilities because their difficulties often occurred away from formal oversight. Without routine ward monitoring, concerning indicators could worsen without intervention. Former patients and their relatives describe a trend in which individuals flagged concerns about their wellbeing, yet responses remained insufficient and tardy. The transition from hospital to community amounted to not a step towards independence but rather a dangerous shortfall in the protective framework. For vulnerable young people still dealing with acute mental health conditions, this gap proved catastrophic. The trust’s community-based services seemed to function in separation from the hospital services, generating dangerous disconnects in patient care pathways.
Nathan Evison: A Plea Left Unheeded Unanswered
Nathan Evison was nineteen years old when he died by suicide in 2019, whilst under the care of TEWV’s community services. His family’s testimony reveals a young man facing serious mental health challenges who continually asked for assistance, only to meet with apathy among the very professionals tasked with supporting him. Despite being a patient of the trust, Nathan’s deteriorating condition seems to have been inadequately monitored or tackled. The safeguards designed for his protection broke down completely, resulting in a grieving family seeking explanations about what went wrong and why their son’s requests for help went unanswered.
Nathan’s passing was not an one-off occurrence but part of a concerning trend within TEWV’s community services. His case demonstrates how young people can slip through the gaps in the system, their concerns neglected until it is beyond recovery. The trust’s neglect in offering sufficient assistance or intervention during his closing months represents a serious violation of duty. For Nathan’s family, the loss deepens the suffering that he experienced whilst alive—the knowledge that assistance existed but not given. His death stands as a stark reminder of the consequences when mental health services fail their most vulnerable users.
Laurent McNamara: Released During Crisis
Laurent McNamara passed away last year whilst under TEWV’s community care, another young individual whose life ended whilst the trust held accountability for their wellbeing. Laurent’s case, like Nathan’s, uncovers gaps in how the trust oversaw and assisted individuals in the community. Families outline a pattern wherein hospital discharge did not translate into comprehensive outpatient support. Instead, people found themselves dealing with complex mental health conditions with inadequate professional assistance. Laurent’s death raises pressing concerns about the trust’s community services and whether adequate safeguards existed to identify and respond to individuals in crisis.
The loss of Laurent McNamara represents another failure in a system that consistently failed to safeguarding those it supported. His family, like Nathan’s and Christie’s, has been left to contend with profound grief alongside the understanding that institutional failures contributed to their loved one’s death. These cases together show that TEWV’s problems were not confined to hospital units but extended throughout its whole service. Adolescents discharged into the community received inadequate monitoring, support, and intervention. The trust’s responsibility went further than institutional settings, yet its local provision proved similarly incapable or reluctant to provide the care these at-risk young people desperately needed.
The Prolonged Wait for Justice and Accountability
Families and former patients have experienced months of frustration as efforts to establish a public inquiry into TEWV’s failures have stalled. Despite being promised concrete answers by the close of February, a meeting with the Department of Health and Social Care on 31 March yielded no concrete progress regarding who might chair the investigation, when proceedings could begin, or where hearings would be held. The prolonged timescales have left those affected in limbo, uncertain whether their voices will ultimately be listened to and whether widespread failings will be thoroughly investigated. For families continuing to grieve the loss of their loved ones, the extended lack of clarity compounds their anguish and raises concerns about whether justice will ever be achieved.
Solicitors acting representing affected families have expressed growing concern about the speed of developments. Alistair Smith from Ison Harrison Solicitors noted that whilst clients recognise such matters require time, they continue to express concern about continued care being provided by a trust facing ongoing investigation. Nearly three months have elapsed since the inquiry was announced, yet no substantive developments have emerged. The Department of Health and Social Care maintains it is progressing rapidly to confirm the inquiry chair and remains committed to putting patient and family perspectives at the centre of the investigation. Yet, for those awaiting answers, the progress continues at a disappointing pace.
- Inquiry process into TEWV revealed in December but continues without confirmed leadership or commencement date.
- Families fear institutional failures continue whilst inquiry delays persist without resolution.
- DHSC pledged to patient involvement but has missed initial deadline for investigation confirmation.
A Structure That Needs to Be Reformed
The testimonies of previous service users at TEWV paint a damning picture of a mental health provision fundamentally broken in its approach to vulnerable young people. Employee conduct to self-harm incidents ranged from shouting at patients to entirely disregarding their distress. The lack of meaningful therapy or compassionate care left teenagers and young adults feeling abandoned at their most desperate moments. These were not isolated incidents but structural breakdowns embedded within the organisation’s practices and ethos. The external review’s characterisation of the unit as “chaotic and unsafe” captures the reality experienced by those who sought help only to become additionally harmed by the very institution meant to protect them.
Whilst the slow-moving review moves at a snail’s pace, questions loom over whether the trust persists in repeating the same lapses that claimed three young lives. Families and former patients express deep worry that inadequate safeguards stay in effect and that no lessons have been absorbed. The mental health emergency facing young people across the NHS requires immediate intervention, not protracted investigations that extend over months without resolution. Until TEWV implements comprehensive change in its staffing, training, and treatment protocols, vulnerable patients remain at risk. The families of Christie Harnett, Nathan Evison, and Laurent McNamara merit more than promises—they warrant solid evidence that the system that disappointed those they cared for has finally been repaired.