A County Durham teen was found unresponsive in the bathroom of her hospital room just ten minutes after a worker called to check on her, but thought she was elsewhere, an inquest heard.
A healthcare assistant who went to check on Emily Moore at Lanchester Road Hospital in Durham on February 13, 2020 told a jury she thought the 18-year-old was somewhere else when she didn't see her through the room's window at 2.20pm.
But at 2.30pm when she called again, a bathroom curtain had been pulled and Emily was found unresponsive in the shower.
The Shildon teenager was placed on life support but died two days later, while under the care of the scandal-hit Tees, Esk and Wear Valleys (TEWV) NHS Foundation Trust.
Crook Coroners Court heard on Wednesday (July 8) how Emily's dad David phoned the ward hours earlier to "give staff a heads up" about the date, and after seeing a concerning social media post his daughter had written. February 13 marked the birthday of Emily's friend Christie Harnett, who died in June 2019 while at TEWV's West Lane Hospital.
But healthcare assistant Michelle Hutchinson told the inquest she “could not recall a time” she had been briefed on Mr Moore’s concerns.
Jurors were told that a care plan put Emily on “enhanced observation”, but that was not consistently followed.
Staff were expected to watch her “constantly” between 6pm and 10am, and Emily was allowed one hour in her room after lunch and one hour after teatime. During those periods she was to be checked every 15 minutes, and then expected to spend most of her time in communal areas.
Ms Hutchinson said she had gone into Emily’s room at about 1.50pm and spent around 15 minutes with her, telling the jury there was “no indication of any distress” during their conversation.
Her notes stated Emily was still on her bed at 2.15pm but five minutes later she looked through the window, saw that Emily was not on her bed and that the bathroom curtain was open, and did not enter the room.
She said: “I thought Emily might have come back out of the room into the communal area.”
The family’s barrister, Anna Morris KC, asked: “When you saw through the hatch Emily was not in her room, why did you not go into the bathroom?”
Ms Hutchinson replied she had “no concerns at that point” and felt Emily had “engaged well” with her earlier, believing she had gone into the activity room. The jury heard the ensuite could not be clearly seen from the viewing visor in the bedroom door.
When Ms Hutchinson checked again at about 2.30pm, the bathroom curtain had been pulled.
She said: “I thought she was in the shower, so I went in to check on her and Emily was then found.”
Asked whether she had considered the birthday as a possible trigger, Ms Hutchinson said: “I thought it could trigger something, so I did not ask about it.”
Jurors heard that during a formulation meeting on February 11, shortly before Emily’s move to Tunstall ward, she described replaying the “traumatic” events of her friend’s death on a daily basis and feeling guilty about what had happened.
The jury has previously heard how Emily had been left “traumatised” by her time at TEWV’s West Lane Hospital in Middlesbrough.
In July 2019 she was moved to Ferndene Hospital in Prudhoe, run by Cumbria, Northumberland, Tyne and Wear (CNTW) NHS Foundation Trust, where her mood “significantly improved”. Clinicians told the inquest they had wanted to keep her under CNTW’s care but there were “no available beds” for an out‑of‑area adult patient when she turned 18.
Emily only arrived on the Tunstall ward a week earlier on February 6, two days after turning 18. Her move from children’s services to adult mental health care has previously been described as “the least worst option available”, following more positive treatment at Ferndene Hospital in Prudhoe.
Expert witness Dr Francesca Denman, a consultant in psychotherapy specialising in personality disorders, said Emily “felt guilty and not deserving of care” and was highly sensitive to any suggestion she might be rejected.
She said “neither the ward nor Emily quite stuck to" the care plan, and that for Emily that could be “symbolic” of how much staff cared.
She said: “If you are told you are allowed an hour alone and no one is seeking to reinforce that, patients may “see it as proof they deserve to die because people do not care enough to follow the care plan through”.
Counsel for the inquest, Bridget Dolan KC, asked Ms Hutchinson whether the timings of the 15‑minute checks had to be strictly kept.
Ms Hutchinson said there were “no instructions to adhere to the timings if they had changed”.
The jury heard staff had “no indication how long Emily should be in her room on her own”, as they were “not aware there was a limit” in her care plan.
Ms Hutchinson said she “could not recall” being told about those restrictions but believed she had carried out the checks as requested.
In her first week at Tunstall ward, the jury heard there were “no episodes at all of self‑harm” from Emily until the fatal act on February 13.
She was taken to hospital and was pronounced dead two days later, at 12.11pm on February 15.
The inquest continues.
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