Firstly, I want to send my heartfelt condolences to the families of Christie, Nadia and Emily. They have experienced the worst possible loss and hurt and unimaginable pain.

Whilst these reports will provide them with some greater understanding about what happened to their loved ones, they make for incredibly hard reading.  The reports are littered with instances of how these young women were so catastrophically failed.

It is clear, reading the reports into each of the girls’ deaths, that opportunities were missed with tragic consequences. The reports reveal organisational failure to mitigate the risks of self-harm and multifaceted and systemic failings including reduced staffing, low morale, ineffective management of change, lack of leadership, aggressive handling of disciplinary problems, issues with succession and crisis management, and failures to respond to concerns from patients and staff alike

There’s evidence of poor risk assessments, delays in responding to red flags and care protocols that were inappropriate and “open to misinterpretation”.

There is another report still to come – a fourth report which will apparently deal with broader issues and in all likelihood will not be published until the New Year.

I am immensely disappointed about that further delay. I don’t know what that critically important fourth report will conclude, but in the final analysis these families need three things: Truth, Justice and Change.

We have the three individual reports. I am confident that the truth has been established in those reports, but the families need to have all their questions answered, and it is up to them to judge whether they have all the answers they need and want.

What remains to be secured is justice. There has to be accountability for the decision making and systemic failures that played such a huge part in theses appalling deaths.

And ultimately there needs to be radical and far-reaching change. We will never totally eradicate the risk of such events but it is plain that so much more could have been done and should have been done to prevent such dreadful loss of these young lives.

The publication of the three individual reports is not the end of the matter. In fact, they are just the start. These reports published today, and the one that is still to come, have to be the catalyst for a comprehensive review of mental health provision for our children and young adults. There are major societal and cultural issues that we have to get a grip on and those who have suffered such dreadful losses have to be empowered in that process to ensure their voices are heard.

There are major issues around the duty of candour, whistleblowing and transparency and, such is the crisis in public accountability, there needs to be an emphatic legislative response to address the issues these tragedies, and sadly far too many others, have brought to light.

We owe it to Christie, Nadia and Emily.

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