A grieving County Durham father said it is “a shame people had to die” after a jury found a catalogue of failings in his daughter’s care contributed to her death.
Emily Moore, 18, from Shildon, was found unresponsive in her ensuite bathroom at Lanchester Road Hospital, 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 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, there was “no way” to determine her true intention to end her life.
David Moore said he felt a mix of “anger and emptiness” following the conclusion.
Speaking outside court, Mr Moore said: “The jury saw everything, they heard everything, and they came back with that decision. It is what we have been saying for so many years - the treatment, the trauma, it all contributed.
“But the truth has finally come out and Emily deserves that.”
However, asked how he now felt after a six-year fight for answers, he said: “I do not know how we feel yet. I just feel a bit lost. I do not know what to feel, apart from anger at the trust.
“I hope they have learned lessons and they change things because if they do not, there will be more action from other families.
“They have let everyone down. They have let the public down.”
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.
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 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.
After sitting through four long weeks of evidence detailing repeated failings in his daughter’s care, Mr Moore described it as “horrendous”.
He said: “It is just horrendous, the things that you hear.
“Even nurses admitting to things that should not have happened. They denied all these allegations and questions that we had for them.
“They have come out and told the truth, and I admire that, but they should have been truthful from the very start. It has taken six and a half years to get the truth out of them.
“Nobody should have to wait that long.”
Despite the conclusion of the inquest, Mr Moore said the family’s fight for their daughter is “far from over.”
He said their focus will now turn to the upcoming public inquiry which was announced in December last year.
Mr Moore said: “We will also keep fighting for our daughter and for other families, because this will happen again, the fight is far from over.
“People are fed up with the trust. They need to get their act right, not just here but nationwide, things need to change in mental health for everyone.
“It is just a shame people have to die for this.”
The inquest comes after a six-year campaign by Emily’s family for a full hearing into 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.
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On behalf of 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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