Emily Moore died shortly after her 18th birthday
This article contains details of suicide and self-harm
An 18-year-old woman who died while under the care of a widely criticised mental health service did not receive the treatment she was entitled to, an inquest has heard.
Emily Moore, from Shildon, fatally injured herself in February 2020 while detained by Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV).
A jury was informed that Emily was one of three young women who died after receiving treatment at West Lane Hospital in Middlesbrough. Her experiences at the hospital added to her trauma and may have contributed to her death.
A senior nurse brought in to address problems stated that the issues identified in a review of Emily's death were already known to management months before Emily became a patient.
Emily, who had been diagnosed with emotionally unstable personality disorder (EUPD), died days after turning 18 and after being transferred to TEWV's Lanchester Road Hospital near Durham, the inquest held in Crook was told.
Jurors heard about the potential impact of her treatment at West Lane, where she was detained from March to July 2019 and complained of being treated "like dirt".
Emily Moore was a patient at Lanchester Road Hospital on the outskirts of Durham
The court heard that an independent review found several failings in Emily's care at West Lane, including:
- Deficiencies in the assessment and management of the risk she posed to herself
- A widespread misunderstanding regarding when and how to restrain patients
- Gaps in psychological services resulting in unavailable treatments
- Significant and frequent staff shortages
Alison McIntyre, a matron brought in to address problems in November 2018, told jurors she immediately had concerns and that all issues raised by the review were already known by managers and directors before Emily was admitted.
Emily complained that staff did not intervene to stop her self-harming, swore at her, and made remarks such as she "liked" being ill, the inquest heard.
When asked by Bridget Dolan KC, counsel for the coroner Crispin Oliver, if there was a "fundamental truth" in Emily's complaints, McIntyre responded,
"Yes."
An expert concluded that if Emily's account was accurate, her experiences would have "more than minimally contributed" to her fatal actions in February 2020, Dolan stated.
McIntyre added that any young person subjected to such treatment would be traumatised and suffer a "profound" impact on their recovery.
When asked,
"Do you accept Emily didn't get the care she was entitled to and deserved?"
Dolan inquired.
The inquest also heard that Emily's father, David, raised concerns, some of which McIntyre described as "justified" and reflective of the "cultural" issues already known to management.
'Closed culture'
Jurors learned that McIntyre was initially brought in to investigate a complaint regarding a patient being dragged across the floor by staff on Westwood ward, a locked unit for the most challenging patients.
A review of CCTV footage revealed multiple similar incidents, described by another TEWV executive as "abhorrent." The inquest heard that 33 of the ward's 49 staff were suspended for either inappropriately restraining patients or witnessing such actions without reporting them.
McIntyre described Westwood as "in crisis" and noted that she observed regular poor restraint practices on the hospital's two other wards: Newberry, where Emily was housed and restrained on four occasions, and Evergreen, a specialist unit for young people with eating disorders.
She stated there was a "closed culture" issue but that improvements were occurring until May 2019, when 29 suspended staff returned and "destabilised" progress.
About half of the returning staff maintained that they had done nothing wrong and that their suspensions were unnecessary and unfair, McIntyre said.
Although there were some "really committed, caring and compassionate staff," the narrative of unfair suspensions "permeated" the workforce, causing staff to become "fearful" of criticism or suspension for their own actions, she explained.
McIntyre indicated that the problem was less about staffing levels and more about staff skill, with issues from Westwood affecting other wards.
The inquest previously heard that the Care Quality Commission ordered the hospital's closure in August 2019.
In July 2019, Emily was transferred to Ferndene in Prudhoe, a more secure unit operated by Cumbria, Northumberland Tyne and Wear NHS Foundation Trust.
She was moved to an adult ward at Lanchester Road two days after her 18th birthday and died within a week, jurors were told.
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- Teen treated 'like dirt' before hospital death
- Teen's care caused family 'sorrow and frustration'
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