A County Durham teenager died after spending more than 18 months in mental health treatment without being able to access the specialist therapy doctors believed she needed, an inquest has heard.
Emily Moore, 18, from Shildon, was found unresponsive in a bathroom at Lanchester Road Hospital in Durham, run by Tees, Esk and Wear Valleys (TEWV) NHS Foundation Trust, on February 13, 2020.
She was placed on life support but sadly died two days later, on February 15, shortly after her 18th birthday.
The inquest, before a jury at County Durham and Darlington Coroner’s Court, opened today (June 22) after a six-year campaign by Emily’s family for a full hearing into her death.
Jurors heard that Emily had been under the care of child and adolescent mental health services since early 2017, when staff at Sunnydale/Greenfield school raised concerns after finding diary entries in which she wrote about wanting to end her life.
She was referred to consultant psychiatrist Dr Shakeel Ahmed and was initially diagnosed with depression.
Emily was prescribed antidepressant medication up to the maximum dose, received weekly appointments and support from crisis services, but her condition did not improve.
The court heard she continued to experience a persistently low mood, feelings of hopelessness and repeated thoughts of wanting to end her life.
Dr Ahmed told the jury Emily often described feeling “stuck” and “hopeless”, and believed she would “never get better”.
Her mental health was further affected by family difficulties, including the death of her grandmother and her mother becoming unwell, which Emily blamed herself for.
Despite ongoing treatment, Emily had multiple attempts to end her life and was repeatedly assessed as being at “high risk”.
About a year into her care, after medication and cognitive behavioural therapy (CBT) had limited effect, she was reassessed and found to have traits of a personality disorder.
The court heard that therapies considered most appropriate for her presentation, including cognitive analytic therapy (CAT) and dialectical behaviour therapy (DBT), were identified but were not available within the team treating her at the time.
A possible atypical autism diagnosis was also considered but not pursued further after the team and her parents agreed there were not enough clear signs to support it.
By March 2019, Dr Ahmed concluded Emily had reached the limit of what could safely be managed in the community.
She was detained under section two of the Mental Health Act and admitted to West Lane Hospital in Middlesbrough, then run by TEWV, for assessment. Dr Ahmed said it was “not expected to be a short admission” and she remained in inpatient care from that point.
West Lane Hospital has since been permanently closed following serious concerns about the safety of its young patients.
Just days before her death, Emily was moved to Lanchester Road Hospital in Durham.
On February 13, 2020, the just-turned 18-year-old was found unresponsive in a toilet on the ward. She was taken to hospital but was pronounced dead on February 15 at 12.11pm.
Paying tribute, her parents David and Susan described Emily as a “very bright girl” with “her whole future ahead of her, full of love and life”. They said she was a “well-liked pupil with a large group of friends” and that they “miss Emily every single day” and that she would be “always in our hearts and never forgotten”.
The Northern Echo previously reported that Emily’s family have been waiting six years for answers and feared an inquest to deliver them would never happen after the Tees, Esk and Wear Valleys (TEWV) mental health trust, which cared for her initially, said one was not needed after it was cleared in the criminal courts of giving Emily unsafe care.
An independent report published in November 2022 identified 24 care and service delivery problems in Emily’s care before her death.
The Care Quality Commission (CQC) also brought criminal proceedings against the trust in relation to her death in 2024, but TEWV was cleared in court of giving unsafe care at Lanchester Road. The trust initially suggested that meant an inquest was not needed.
Senior Assistant Coroner for County Durham and Darlington, Crispin Oliver, concluded last year that an inquest should take place.
TEWV has always said it will cooperate fully with the inquest and that its thoughts are with Emily’s family.
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In total, 119 errors were found in the care of Emily, Christie Harnett, 17, and Nadia Sharif, 17, between June 2019 and February 2020. David and his wife Susan have spent years campaigning for change at TEWV alongside dozens of other families who lost loved ones in its care.
In December, their calls for a public inquiry were answered by then-Health Secretary Wes Streeting, but six months on, a chair is yet to be named.
The inquest, before a jury, is set to last four weeks.
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