Staff failed to note teen’s dad’s concerned call
This article contains details about suicide and self-harm
The inquest heard staff at a mental health hospital failed to record a father’s anxious call to his teenage daughter hours before she fatally injured herself.
Emily Moore, of Shildon, County Durham, died in February 2020 while under the care of Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV) Lanchester Road Hospital in Durham.
Jurors heard his father called the ward on the morning of February 13 to say he had written a post about it on Facebook, but no notes were taken about it, as should have been the case.
The nurse who answered the call said she had spoken to Emily but had no concerns. Jurors also heard that clinicians lacked “clarity” about what might have triggered Emily’s self-harm.
Jurors heard that Emily began experiencing mental health problems in 2017, when she was 15, resulting in her sectioning off and an emerging diagnosis of emotionally unstable personality disorder (EUPD) in March 2019.
He spent four months at TEWV’s West Lane Hospital in Middlesbrough. his father was described as a “hell hole”And Seven months in Ferndene in PrudhoeIt was run by Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust (CNTW) before he was forced to move to Lanchester Road when he turned 18.
The inquest heard she arrived at Lanchester Road’s 20-bed women-only Tunstall ward on February 6, two days after her 18th birthday.
Emily Moore died just days after her 18th birthday [Family handout]
On the morning of February 13, his father David Moore saw a worrying Facebook post he had made to mark the 18th birthday of a friend who had died while they were together in West Lane.
The jury heard the post ended with the phrase “until we meet again”, with Emily saying she had previously felt guilty about her friend’s death, which could have been a trigger for self-harm.
Tunstall ward manager Daniel Scott told jurors the nurse who received the call should have recorded it and passed the information on to colleagues so they could keep a closer eye on Emily.
Anna Morris KC, representing Emily’s family, said there was no note of this in Emily’s engagement journal, which Scott confirmed.
“Would you expect it to have been recorded?” Morris asked.
“I would expect it to be recorded,” Scott replied, adding that he didn’t know why it wasn’t recorded.
Emily was transferred to Lanchester Road Hospital days before her death [Google]
In her statement read to the investigation, the nurse who answered the phone in the middle of the morning said that she did not note this due to other demands on the ward, but told her colleagues.
She said she went to talk to Emily, but the teenager seemed to be in a good mood, so the nurse did not speak to her directly about the phone or her friend so as not to upset or disturb her.
The nurse said at the time that she had no concerns about Emily’s presentation.
The inquest heard Emily was found unconscious in her room shortly after 14:00 GMT and died two days later.
The jury had previously heard Emily’s move to Lanchester Road was approved just a week before the incident, as doctors had said. unusual and relevant.
Consultant clinical psychologist Dr. Sonia Pace told the inquest that it was “the norm” for clinicians to lack information about patients and that her staff were experts at quickly assessing patients and creating risk management plans. That’s what they did in Emily’s case, he said.
He said it would be “useful” to “take time” and find out more about Emily before her transfer, but on February 10 he had a phone call with the teenager’s psychologist in Ferndene who gave him important information.
The next day a meeting was held with Emily and her family to determine a care plan, at which it was decided that monitoring of Emily would be reduced “very gradually” to hourly staff duties throughout the day rather than “constant.”
Pace said it was “really unclear” what would trigger Emily to self-harm, with jurors hearing that she might seem fine but then have a major incident.
But Pace said he still felt he knew enough to make an “appropriate” care plan for Emily.
Emily Moore died while in the care of Tees, Esk and Wear Valleys NHS Foundation Trust [Supplied]
The inquest also heard that a warning about potential self-harm hotspots in mental health hospitals was issued by the Care Quality Commission (CQC) following the death of a patient elsewhere in the country in September 2018.
Jurors heard that TEWV was in the process of implementing proposed changes at the time of Emily’s death, but site manager Simon Adamson said it was a “very complex” work program and the Tunstall ward had not yet been dealt with.
The inquest heard Emily’s fatal injury involved the use of a risk point identified by the CQC which has not yet been corrected.
The investigation continues.
Follow BBC North East X And Facebook and BBC Cumbria on X And Facebook and they are both open side door And instagram.
