Three young women died at NHS trust in months. Patients say staff ignored their warnings.

Laura Kenny spent a decade as a patient at West Lane Hospital in Middlesbrough, a mental health centre for young people run by the Tees, Esk and Wear Valleys NHS Foundation Trust. She was 13 when an eating disorder left her dangerously underweight. Her condition spiralled into episodes of self-harm and suicide attempts.

While at the hospital, Laura watched her friend Christie Harnett receive care that she says fell dangerously short. "We knew somebody would die… and nobody listened," Laura now recalls. "We'd been warning everyone. We wrote letters to everyone we could think of saying one of us is going to die."

Christie was 17 when she took her own life. Within an eight-month period up to February 2020, two other young women treated at the trust also died by suicide. Nadia Sharif was 17. Emily Moore was 18. All three deaths occurred while the young women were under the trust's care.

Laura says staff would react to self-harm incidents by either shouting or ignoring what was happening. "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 Harnett, heard similar stories from his stepdaughter. "They would literally just pin her down, sedate her, put her in bed, and then that was it," he says. When Christie woke up, staff would not talk through the incident, even if she was still covered in blood from her injuries.

More than a dozen former patients and families spoke to the BBC about their experiences at the trust, which covers all of North Yorkshire, County Durham and Teesside. All reported a lack of compassion among staff and an absence of meaningful treatment or therapy. Many fear mistakes are still being made.

An independent inquiry commissioned by NHS England examined the trust's treatment of young people admitted with mental health problems. Its main report, published in 2023, looked specifically at Christie's death and those of Nadia and Emily. The inquiry found that staff used excessive and inappropriate restraint, that staff were told not to intervene in self-harm episodes, and that managers tolerated these failures.

In 2024, the Care Quality Commission prosecuted the trust for safety failings. The trust pleaded guilty to two charges of failing to provide safe care and treatment, exposing two women to "a significant risk of avoidable harm". The trust was fined £215,000.

Despite these findings, families and former patients say the lessons have not been learned. They pushed for a public inquiry, which was announced last December. A public inquiry has greater legal powers than a standard review—it can call witnesses, summon documents, and recommend changes to prevent future failures.

However, families are frustrated by delays. They were promised answers by the end of February, but a meeting on 31 March with the Department of Health and Social Care left them without clarity on who might lead the investigation, when it might start, or where it might be held. "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," Alistair Smith, from Ison Harrison Solicitors, told the BBC.

The Department of Health and Social Care said it is working "at pace" to confirm who should chair the inquiry. A spokesperson stated: "We are committed to ensuring the voices of patients and the families affected by failures at TEWV are at the heart of this inquiry."

Concerns about the trust extend beyond its hospitals. Nathan Evison was 19 when he died in 2019. His mother Jess says a community mental health team from the trust visited him after he asked for help during a mental health crisis. A bed in a mental health unit had apparently been available, but the team chose not to admit him.

Nathan lived in an isolated rural cottage with no internet or phone signal. Within a few hours of the team's visit, he was dead. "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."

Nathan's stepfather Andrew believes a single phone call might have changed the outcome. "They only had to ring us up and tell us what was going on that day. His friends would have gone, we would have gone, he could have come here. But it never happened, for that one phone call."

In another case, Laurent McNamara lived with bipolar disorder, which is characterised by extreme shifts in mood and impulsive, sometimes reckless behaviour. Last June, he was detained at Foss Park Hospital in York under the Mental Health Act during a manic episode. He was then unexpectedly discharged without warning.

His father Bill says Laurent still appeared unwell when they arrived home. Bill rang the ward to ask why his son had been released. Within 48 hours, Laurent was found dead at his home, alone. His family believes he was discharged while still in the grip of a manic episode.

Laurent's wife Gemma says hospital staff placed too much emphasis on what the patient wanted, when Laurent was far too ill to make that decision. "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."

The trust declined to be interviewed and said it would not comment on individual cases. Alison Smith, chief executive since last September, stated in a written response: the trust would "co-operate fully with the public inquiry with honesty, openness, humility, grace and kindness". She added that the inquiry "would be an opportunity to hear and learn what we could have done better and how we improve the experiences for our patients, families, carers and staff. Importantly it will also enable those who have been affected to hear how sorry we are."

The trust no longer provides in-patient care for young people—neighbouring trusts now treat them. More recent reports by the CQC suggest there have been some improvements at the trust, including around safety and policies to report serious incidents. But families and former patients hope the public inquiry will finally answer their questions about what went wrong and lead to safer care.

A small bridge over the River Dove in the North York Moors National Park bears Nathan Evison's name. His former colleagues in the National Park, where he was completing an apprenticeship, named it in his memory. A plaque at one end of the bridge carries his name, worn dull by Yorkshire weather. It stands in a lonely, beautiful landscape—a reminder that mental health care failures can have catastrophic consequences.