Summary of Findings and Recommendations from the Independent Review of Tees, Esk and Wear Valley’s NHS Foundation Trust

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The following provides a summary of the findings and recommendations identified by an independent review of the Tees, Esk and Wear Valley’s NHS Foundation Trust, in relation to the deaths of three teenage girls who were within the service over a period of time.

In November 2022 an independent investigation report was released in relation to these cases and from these 120 failings in care were identified throughout the three cases. In March 2023, a subsequent report was released in relation to “A system-wide independent investigation into concerns and issues raised relating to the safety and quality of CAMHS provision at West Lane Hospital, Tees, Esk and Wear Valley’s NHS Foundation Trust.”

In this article, we highlight some of the governance issues identified in the system-wide investigation and share some of the key recommendations provided across the three investigations that should be considered by all mental health services.   

Governance Issues identified within Tees, Esk and Wear Valley’s NHS Foundation Trust

In March 2023, the independent review published a system wide independent investigation report of the CAMHS provision Tees, Esk and Wear Valley’s NHS Foundation Trust. Below are details of some of the governance issues identified as part of the review. These issues included:

Key Recommendations from the Investigation

Below we have summarised some of the key system-related recommendations identified in the independent review.


Incident Management

Risk Management

Complaint Management

Care Plans and Restraint

How can HCI help?

At HCI, we help providers of health and social care make intelligence driven decisions to attain, manage and improve quality, safety and regulatory compliance. We work with Mental Health Services to support the development of comprehensive Quality and Safety Management Systems that encompass many of the key system areas identified in this review such as Governance Structures, risk management, audits, incident management and complaint management.

HCI also work with mental health services to conduct independent serious incident reviews, including complaint investigations, systems analysis and look back reviews. We offer a structured review process which is developed and implemented with a service user / patient focus, working to identify the system issues that may exist and identify the actions required to drive a culture of safety within the organisation.

For more information contact HCI at 01 629 2559 or

Contact Us

For more information contact or Phone +353 (0)1 6292559.