The parents of a County Durham woman who died under the care of one of the region's NHS trusts have hit out at the system that failed her following an inquest into her death. Emily Moore had been under the care of the Tees, Esk and Wear Valleys NHS Trust at the time of her death on February 15, 2020.
Emily had been a patient at West Lane Hospital in Middlesbrough, though had moved to an adult ward at Lanchester Road Hospital at the time of her death. The Shildon woman was just 18 and had spent much of the prior three years under the care of the NHS trust.
Findings of the inquest
Emily's care - or lack thereof - at West Lane has previously been examined by a range of agencies. In 2022 a report commissioned by independent consultants for NHS England found that across Emily's case and two others - those of Christie Harnett and Nadia Sharif, who had both died at West Lane in the months prior to Emily's own death - there had been a shocking 119 issues with their care.
Christie died on June 27 and Nadia died on August 9 - both were 17. All three young women had spent time on Newberry ward at the hospital.
At an inquest which concluded in July, six years on from Emily's death, a jury found how West Lane Hospital had been so "chaotic and unsafe" that "many staff were relieved on its closure". At the inquest, questions were raised as to how a Care Quality Commission inspection in 2018 had rated the hospital as "good" - just a year before the issues were so bad that it required closure.
The jury at the inquest also highlighted factors which had contributed to Emily's death. The jury verdict included: "Based on evidence provided, her mental ill-health, Emerging Emotionally Unstable Personality Disorder, her treatment and trauma throughout interactions and admissions within mental health services, the everlasting impact of losing her support network including death of a close friend, deviations from agreed engagement plans, being left to ruminate and availability/ risk management of low level ligature points accessible in the ensuite were all contributing factors to her death."
The jury added that the "timelapse of visual checks" and "time spent searching the ward without initially entering [her] room" had "significantly increased the risk of fatality".
'The frustration goes on'
Now Emily's parents have told ChronicleLive how the indignities their daughter faced had not stopped with her devastating death - even in recent weeks her death certificate was issued only for it to contain the wrong dates.
Speaking with ChronicleLive, David and Susan Moore shared their conviction that lives were still being endangered at the NHS trust, as full accountability remains out of reach.
They said: "The frustration goes on. No apology from the trust regarding the matter of failures in her care and the staff who failed her. How can you fail a patient so badly yet keep your job? This should not be the case - we would like to see every member of staff in the courtroom that gave evidence and [was] still working for TEWV dismissed."
David said he attempted, thus far unsuccessfully, to get answers from the CQC, too. He said: "I have written 3 emails since Emily's inquest to the CQC asking for an explanation of why West Lane was given a 'good' rating by them [in] late 2018 when staff were amazed this was its rating and thought it would be closed down [and] it was [closed down] nine months later and staff mentioned they were relieved when it closed!"
"The CQC have yet to answer why this was the case yet alone acknowledge my emails." ChronicleLive understands the CQC are seeking to meet with David and Susan.
David added, citing that the dates on Emily's death certificate were three years out, how: "We have found that every corner we have turned, we have been met with no compassion or respect."
'It all came out'
He said the family - and others - were now considering what further legal avenues may be available to them. David said: "Staff have, under oath, said that West Lane Hospital was unsafe and should not have admitted any further patients from 2018. Our daughter was one of them - and now she is not alive due to failures directly related to the trust. There are several other families who are now looking at the situation and are seeking legal advice moving forward."
David said the stress of fighting the trust for more than seven years had left him off work and he added: "The trust just do not care about patients [or] families and we have had no written communication in the way of an explanation or apology to say why things went so badly wrong."
He added how his family had seen that "everything they denied over the years [...] all came out at our beautiful Emily's inquest".
The promised public inquiry
David and Susan have also questioned why there still - eight months after it was announced by then-Health Secretary Wes Streeting - is not a chair in place to lead the promised public inquiry into services at Tees, Esk and Wear Valleys NHS Trust. They said: "As a family, we feel it's taken far too long to appoint a chair to the public inquiry."
"How can this take nine months yet a new prime minister starts and he announces 159 new walk in mental health care centres in his third week in office? Lives are at risk and service users are still being failed daily by TEWV. This needs urgent action."
The Department for Health and Social Care said the process to appoint a chair was "at an advanced stage". It is understood that the department has consulted with the Lady Chief Justice about finding a suitable candidate.
A spokesperson for the department said: "We remain committed to ensuring the voices of patients and the families so badly let down by Tees, Esk and Wear Valleys NHS Foundation Trust are at the heart of this inquiry."
"We are moving as quickly as possible to identify and appoint the most suitable chair so families and patients can receive the answers they deserve. This process is at an advanced stage, and we will be providing an update on this soon."
In July, the pending inquests into the deaths of Nadia Sharif and Christie Harnett were both suspended - pending the public inquiry. Coroner Crispin Oliver said this was to avoid duplication of inquiries.
How the NHS trust responds
The Tees, Esk and Wear Valleys NHS Trust's 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."
CQC officials told ChronicleLive it would not be appropriate to comment prior to meeting David and Susan.
