A series of care failings contributed to the death of a County Durham teenager under the care of a scandal-hit mental health hospital, a jury has found.
Emily Moore, 18, from Shildon, was found unresponsive in her en-suite bathroom at Lanchester Road Hospital in Durham, on February 13, 2020.
She died two days later, shortly after her 18th birthday, while under the care of Tees, Esk and Wear Valleys (TEWV) NHS Foundation Trust.
After a four-week inquest at Crook Coroners’ Court, the 11 jurors found that, although Emily had carried out the fatal act which ended her life, there was “no way” to determine where she intended to end her life.
Following 16 hours of deliberation, the jury identified multiple contributing factors, including her mental ill-health, the impact of losing a close friend, and her experiences within mental health services.
In a conclusion read to the court, the jury said: “Her mental ill-health, emerging emotionally unstable personality disorder, her treatment and trauma throughout interactions and admissions within mental health services, the impact of losing her support network, including the death of a close friend, deviations from agreed engagement plans, being left to ruminate, and risk management in the ensuite were all contributing factors to her death.
“We find the timelapse of visual checks and time spent searching the ward without initially entering the room for confirmation of Emily’s presence significantly increased the risk of fatality.
“Although Emily intentionally [committed the act], there is no way to determine her true intention on the day of the incident.”
Senior Assistant Coroner Crispin Oliver thanked the jury for their careful consideration, adding he was satisfied that “overarching matters will be dealt with” by an upcoming public inquiry.
The inquest heard Emily first began struggling with her mental health at 15 and was later diagnosed with emerging emotionally unstable personality disorder (EUPD).
In 2019, she was sectioned and admitted to TEWV’s West Lane Hospital in Middlesbrough, where the jury heard she was “traumatised” by her experiences.
The hospital closed later that year. The inquest heard the care she received there was “incomplete, fragmented and not structured” to her needs, leading to ongoing difficulties.
In July 2019, Emily was moved to Ferndene Hospital in Prudhoe, run by Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust (CNTW), where her mood “significantly improved”, jurors were told.
Her father, David Moore, 57, described the care at Ferndene as “chalk and cheese” compared with West Lane.
Emily turned 18 on February 4, 2020, and moved two days later to the adult Tunstall ward at Lanchester Road Hospital, under TEWV’s care.
Clinicians told the inquest they had hoped she could remain under CNTW, but there were “no available beds” for an out-of-area adult patient.
On the morning of February 13, Mr Moore contacted the ward at around 11am after seeing a concerning social media post from his daughter which read “until we meet again”.
The inquest heard the death of a close friend in June 2019, while both were patients at West Lane Hospital, had a significant impact on Emily.
Later that day, Emily was found unresponsive in her ensuite bathroom. The jury heard there had been a number of failings, including the call from her father not being logged and staff initially believing she was elsewhere on the ward during her 15 minute checks.
She was taken to hospital but died on February 15 at 12.11pm.
The inquest comes after a six-year campaign by Emily’s family for answers surrounding her death.
The family had previously feared an inquest would never take place after Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV) said one was not needed, after it was cleared in the criminal courts of providing unsafe care.
The Care Quality Commission (CQC) also brought criminal proceedings against the trust in relation to her death in 2024, but TEWV was cleared of giving unsafe care at Lanchester Road.
An independent report published in November 2022 identified 24 care and service delivery problems in Emily’s care before her death.
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TEWV, chief nurse Beverley Murphy said: “We can’t begin to imagine how difficult this continues to be for Emily’s family and friends. We would like to express how deeply sorry we are and recognise the impact this has had on all who knew and loved Emily. Our thoughts remain with them.
“We thank the coroner and the jury for their thoroughness and fully accept their findings and recommendations.”
In December last year, the family’s calls for a public inquiry were answered by then-Health Secretary Wes Streeting, but seven months on, a chair is still yet to be named.
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