Staff failed to note teen's dad's concerned call
Family handoutThis article contains details of suicide and self-harm
Staff at a mental health hospital failed to make a record of a father's concerned call about his teenage daughter hours before she fatally injured herself, an inquest has heard.
Emily Moore, from Shildon, County Durham, died in February 2020 while under the care of Tees, Esk and Wear Valleys NHS Foundation Trust's (TEWV) Lanchester Road Hospital in Durham.
Jurors heard her father called the ward on the morning of 13 February to say she had written a concerning Facebook post, but no note of it was made as it should have been.
The nurse who took the call said she spoke to Emily but had no concerns. Jurors also heard clinicians did not have "clarity" on what could trigger Emily's self-harm.
Jurors have heard Emily began experiencing mental health problems in 2017 when she was 15, resulting in her being sectioned in March 2019 and diagnosed with emerging emotionally unstable personality disorder (EUPD).
She spent four months at TEWV's West Lane Hospital in Middlesbrough, which her father described as a "hell-hole", and seven months at Ferndene in Prudhoe, run by Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust (CNTW), before having to move to Lanchester Road when she turned 18.
She arrived at Lanchester Road's 20-bed female only Tunstall ward on 6 February, two days after her 18th birthday, the inquest heard.
Family handoutOn the morning of 13 February, her father David Moore saw a concerning Facebook post she had just published commemorating what would have been the 18th birthday of a friend who died when the pair were at West Lane together.
The post ended with the line "until we meet again", the jury heard, with Emily having previously said she felt guilty for her friend's death which could be a trigger for self-harm.
Daniel Scott, manager of the Tunstall ward, told jurors the nurse taking the call should have made a record of it and passed the information to colleagues so they could keep an extra eye on Emily.
Anna Morris KC, representing Emily's family, said there was no note of it made in Emily's daily engagement log, which Scott confirmed.
"Would you expect it to have been recorded?" Morris asked.
"I would expect it to be recorded," Scott replied, adding he did not know why it had not been.
GoogleIn a statement read to the inquest, the nurse who took the mid-morning call said she did not make a note of it due to other demands on the ward, but she said she did tell colleagues.
She said she went to speak to Emily but the teenager seemed in a good mood so, to avoid upsetting or unsettling her, the nurse did not talk to her directly about the call or her friend.
The nurse said she had no concerns about Emily's presentation at the time.
The inquest heard Emily was found unconscious in her room shortly after 14:00 GMT and was declared dead two days later.
The jury previously heard Emily's move to Lanchester Road was only confirmed a week before it happened which doctors said was unusual and concerning.
Consultant clinical psychologist Dr Sonia Pace told the inquest it was "the norm" for clinicians to have no knowledge of patients arriving at the ward with staff adept at quickly assessing them and forming risk management plans, which she said they did in Emily's case.
She said it would have been "helpful" to "have time" and know more about Emily before her transfer, but she had a phone call on 10 February with the teenager's psychologist at Ferndene which gave her important information.
The following day a meeting was held with Emily and her parents to determine a care plan, at which it was decided to "very gradually" reduce observation of Emily from "constant" to hourly staff engagements during the day.
Pace said there "wasn't really clarity" about what would trigger Emily to self-harm, with jurors hearing she could appear fine but then have a major incident.
But Pace said she still felt she knew enough to make an "appropriate" care plan for Emily.
SuppliedThe inquest also heard an alert for potential self-harm spots in mental health hospitals had been issued by the Care Quality Commission (CQC) in September 2018 following the death of a patient elsewhere in the country.
Jurors heard TEWV was in the process of implementing the recommended changes at the time of Emily's death, but estates manager Simon Adamson said it was a "very complex" programme of works and Tunstall ward was yet to be dealt with.
The inquest heard Emily's fatal injury included the use of a risk spot identified by the CQC and which was yet to be corrected.
The inquest continues.
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