It has come to light that a mental health trust mispronounced the names of two teenagers who passed away while under its care in a report seen by one of their families.
In the eight months leading up to February 2020, Christie Harnett, Emily Moore, and Nadia Sharif perished.
The trust accidentally referred to Nadia as "Christie" at one point, making her Middlesbrough-born parents, who received the report, "angry and upset.".
For the "appalling" mistake, Tees, Esk and Wear Valleys NHS Trust expressed regret.
I'm incredibly sorry for what happened in that case, said Brent Kilmurray, the trust's current chief executive who was not in his position when the teenagers died.
Given everything that transpired, that was a serious error, and I want to apologize to Nadia's family once more. ".
The three teenagers had a combined history of severe mental health issues.
The NHS found numerous shortcomings in their care and treatment during investigations into how they passed away after harming themselves in the same way.
Nadia, from Middlesbrough, and Christie, from County Durham, both passed away at the age of 17 in West Lane Hospital.
It was discovered that it was "unstable and stretched" at the time. There is now another mental health trust that offers services to children and young people.
Also from County Durham, Emily passed away in February 2020. She had been in West Lane, but after some time there, she was transferred to a different hospital run by a neighboring trust. After turning 18, she was then transferred to a unit for adults run by Tees, Esk, and Wear Valleys.
It was discovered that the decision to switch to adult services was "entirely" based on age and did not take her clinical needs into account.
David Moore, Emily's father, claimed that he had fought tooth and nail to keep her from being moved.
I actually pleaded with you on my hands and knees at our most recent meeting, pleading with you not to send her to the Tees, Esk, and Wear Valley, he recalled.
Investigators heavily criticized the trust for failing to recognize the threat that each of the three young women posed by using the same method of self-harm. All three young women died after using this technique.
A public investigation is now desired by the families of all three teenagers.
With a hearing set for February 21 at Teesside Magistrates' Court, the trust may also face prosecution in connection with Christie's passing. A hefty fine might be imposed if it is found guilty.
The trust issued an apology for shortcomings in the three young women's care and treatment and claimed that since they passed away, it had spent £8 million and hired an additional 700 staff members in order to increase patient safety.
