Jury retires in teen's hospital death inquest

This article contains details of suicide and self-harm

A jury in the inquest of a teenager who died while under the care of a highly criticised mental health trust has retired to consider its verdicts.

Emily Moore, 18 and from Shildon, died in February 2020 while a patient at Tees, Esk and Wear Valleys NHS Foundation Trust's (TEWV) Lanchester Road Hospital in Durham.

An expert previously told jurors failings in her care under TEWV were a factor in her death, including her traumatic time at Middlesbrough's West Lane Hospital which Emily complained about and her father called a "hell-hole".

The inquest heard Emily was diagnosed with emerging emotionally unstable personality disorder (EUPD) after beginning to experience mental health problems aged 15.

She was sectioned in March 2019 due to the high self-harm risk she posed to herself, the jury in Crook heard, with the final 11 months of her life spent in hospitals.

Emily spent four months at West Lane Hospital, where she said she was treated "like dirt" and which clinicians admitted was a traumatic and unsafe place, before being moved to Ferndene in Prudhoe, run by Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust (CNTW).

She was "100%" happier there, but had to return to TEWV's care and an adult ward at Lanchester Road after turning 18 in February 2020, jurors have heard.

On the morning of 13 February, her father David called the hospital to express his concern for his daughter after she published an alarming post on Facebook.

The message was to mark what would have been the 18th birthday of a friend who had died while the pair were patients at West Lane together and ended with the words "until we meet again", jurors heard.

Her father was told staff would keep an eye on Emily, but the call was not recorded as it should have been and hours later she fatally injured herself in her room, the inquest heard.

Senior assistant coroner for County Durham and Darlington Crispin Oliver told the 11 jurors they would have to consider how Emily died and in "what circumstances".

He said the six men and five women would have to reach their conclusions on the "balance of probabilities", meaning they found an event was "more likely than not" to have occurred.

Factors they "may wish to consider" include whether Emily's time at West Lane Hospital "had an adverse impact" upon her and if her move from child to adult services was "appropriately planned and managed", the coroner said.

Jurors might also want to look at Emily's care at Lanchester Road and the actions of 13 February, Oliver said, as well as any impact of her friend's death.

The coroner said jurors should also "take account of the passage of time", with Emily's death occurring more than six years ago, and "memories can fade or become distorted".

He said jurors should "strive" to reach a unanimous decision and there was "no pressure of time".

The inquest heard West Lane Hospital was ordered to be closed by the Care Quality Commission a month after Emily left due to safety concerns for the patients.

A timeline of Emily's care:

• February 2017 - medication and therapy begins for 15-year-old Emily following repeated self-harm and apparent suicide attempts
• January 2018 - Emily voluntarily admits to TEWV's West Lane Hospital for a month as treatment at home is proving ineffective
• February 2018 onward - Emily completed school and passed her GCSEs but her self-harm and nihilistic thoughts escalated with her increasing impulsive acts putting her at high risk of death
• March 2019 - Emily sectioned and readmitted against her will to West Lane's Newberry ward, where she is diagnosed with EUPD
• July 2019 - Emily is moved to Ferndene, a more secure unit in Prudhoe run by Cumbria, Northumberland Tyne and Wear NHS Foundation Trust (CNTW)
• 6 February 2020 - two days after turning 18, Emily is moved to the Tunstall ward at TEWV's Lanchester Road Hospital, a facility for adults
• 13 February 2020 - Emily is found unconscious having injured herself
• 15 February 2020 - Emily is declared dead at University Hospital North Durham having never regained consciousness

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