A jury is hearing evidence at Crook Civic Centre as the inquest into the death of Emily Moore examines the circumstances surrounding her care and death while she was under the care of Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV).
Emily, from Shildon, died in February 2020 aged 18. Her death has been the subject of years of investigations, legal proceedings and scrutiny of mental health services in the North East. The inquest is expected to hear evidence from healthcare professionals, experts and members of Emily’s family over several days.
This blog will be updated throughout the hearing as evidence is presented.
Background: Who was Emily Moore?
Emily Moore was an 18-year-old from Shildon who had been receiving support from mental health services before her death in February 2020.
She had been under the care of Tees, Esk and Wear Valleys NHS Foundation Trust and had received treatment at facilities operated by the trust. Her death came during a period when serious concerns were being raised about patient safety within parts of the organisation.
The Care Quality Commission later brought a prosecution against TEWV relating to Emily’s care. The trust was found not guilty of the specific charge following a trial at Teesside Magistrates’ Court in 2024, although concerns about aspects of her care had previously been acknowledged.
In February 2025, a coroner ruled there was sufficient evidence for a full jury inquest into Emily’s death to resume.
What is this inquest examining?
The purpose of the inquest is to establish who Emily was, and how, when and where she came by her death. Jurors may also hear evidence about the care and treatment she received, and whether any wider factors contributed to the circumstances of her death.
The hearing is taking place before a jury at Crook Civic Centre.
Rolling Updates
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June 22: Inquest Opens
The jury inquest into the death of Emily Moore opened at Crook Civic Centre. Jurors were introduced to the background of the case and heard how Emily, from Shildon, died in February 2020 aged 18 while under the care of mental health services. The hearing began examining the circumstances surrounding her treatment, including her contact with Tees, Esk and Wear Valleys NHS Foundation Trust and the care she received in the years before her death.
The inquest is expected to hear evidence from clinicians, managers and other professionals as it seeks to establish the circumstances leading up to Emily’s death.
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June 23: Evidence Continues
The inquest continued before a jury at Crook Civic Centre, with further evidence heard about Emily Moore’s care and treatment in the years leading up to her death.
The jury heard evidence about Emily Moore’s experiences at West Lane Hospital, where she was admitted in March 2019 after community treatment failed to reduce the risk she posed to herself.
Consultant psychiatrist Dr Melanie Willetts told the inquest criticism of the Middlesbrough hospital was “fair” and accepted there had been significant problems before its closure.
Jurors were shown a letter Emily wrote after leaving the unit in which she described it as understaffed and claimed staff treated patients without compassion, sometimes dismissing self-harm incidents as attention-seeking behaviour.
Dr Willetts said Emily’s account did not surprise her and acknowledged there had been staffing shortages, low morale and what she described as “compassion fatigue” among workers.
The jury also heard evidence from former TEWV executive director of nursing Elizabeth Moody, who said managers had been aware of issues at West Lane from 2018 and that staff had become “burned out” as problems escalated.
The hearing was told the hospital never fully recovered from a series of operational difficulties before its closure in August 2019.
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June 24: Hearing Continues
The jury heard further evidence about Emily Moore’s treatment at West Lane Hospital, with witnesses accepting she did not receive the standard of care she deserved.
Jurors were told an independent review identified a number of failings in Emily’s care, including shortcomings in assessing and managing the risk she posed to herself, gaps in psychology provision, substantial staff shortages and a misunderstanding among staff about the use of restraint.
Alison McIntyre, a senior nurse brought in to address problems at West Lane in late 2018, said all of the issues highlighted by the review were already known to managers before Emily was admitted. When asked whether there was a “fundamental truth” in Emily’s complaints about her treatment on the ward, McIntyre replied: “Yes.”
The court heard Emily had complained that staff failed to intervene when she self-harmed, swore at her and suggested she “liked” being ill. Jurors were told an expert had concluded that, if Emily’s account was accurate, her experiences at West Lane would have “more than minimally have contributed” to the actions that led to her death in February 2020.
Asked directly whether Emily had received the care she was entitled to, McIntyre told the hearing: “Yes” when asked if she accepted Emily did not get the care she deserved. She added that any young person exposed to those experiences would likely be traumatised and that it would have a “profound” impact on their recovery.
The jury also heard evidence from Christina Clark, who was brought in to manage the Newberry Centre shortly before Emily’s admission. Clark said she had been aware there were concerns at the hospital but “did not understand how bad it was” until she arrived. Staff were described as fearful following the suspension of colleagues, while the ward itself was said to be “very chaotic”.
Clark agreed that Emily’s care plan was incomplete and inadequate and said staff had been inconsistent in their approach to her treatment, something she believed would have caused harm. Describing conditions on the ward, Clark told jurors: “It almost felt like we were fighting fire on a daily basis.” She added: “It felt unsafe,” and said when the decision was taken to close West Lane Hospital, “I felt relieved.”
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June 25: Clinical Psychologists Give Evidence About Emily’s Treatment
The jury heard evidence today from two clinical psychologists about Emily’s treatment whilst she was a patient at West Lane Hospital.
Dr Amanda Wild, a consultant clinical psychologist who was brought in to improve services at the hospital, told the jury she had repeatedly raised concerns with senior managers about safety on the wards before Emily’s admission. She described a lack of compassionate culture, poor communication between staff and management, and days that were “floridly chaotic”, saying there was often a real sense of uncertainty about whether the hospital could operate safely.
Dr Wild explained that, although some progress had initially been made, conditions deteriorated following the return of a number of staff members in May 2019. She said she warned directors that staff were being forced to make “impossible decisions” and believed it was “not safe to remain open”. The jury heard that, despite those concerns being raised, the situation did not improve sufficiently before the hospital was later closed by the Care Quality Commission in August 2019.
The inquest also heard evidence from Dr Caroline Wyatt, a clinical psychologist, who spoke about the impact of Emily’s experiences during her admission. Dr Wyatt said Emily had described being restrained and administered tranquilising medication against her will on multiple occasions. She also told the jury that inconsistent approaches to managing Emily’s self-harming behaviour were likely to have reinforced Emily’s belief that she was misunderstood and not cared for, although she acknowledged that achieving complete consistency in a ward environment was extremely difficult.
The inquest continues.
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June 29: Father tells inquest children’s mental health hospital was a “hell-hole”
The inquest into Emily Moore’s death today heard emotional evidence from her father, David Moore, who described the children’s mental health unit where she was first treated as a “hell-hole” and claimed staff failed to provide the care she desperately needed. He told jurors that while Emily was detained at West Lane Hospital in Middlesbrough in 2019, he witnessed staff spending time on social media, booking holidays and drinking coffee rather than caring for patients. He alleged Emily self-harmed on numerous occasions while under one-to-one observation, said staff “put her down” and called her names, and told the court he repeatedly challenged clinicians about her care. He also revealed he staged a protest outside the hospital with a banner reading: “This hospital is slowly killing my daughter, listen to the parents.”
The court heard Emily’s condition improved significantly after she was transferred to the more secure Ferndene unit in Prudhoe, with her father describing the difference between the two hospitals as “chalk and cheese”. However, after turning 18 she was transferred back into the care of Tees, Esk and Wear Valleys NHS Foundation Trust at Lanchester Road Hospital. Mr Moore told jurors he contacted staff on the morning of 13 February 2020 after seeing a concerning social media post by Emily commemorating a friend who had died at West Lane, saying it did “not sit right” with him. He said staff reassured him they would “keep an eye on her”, but less than four hours later he was told to go to University Hospital of North Durham after Emily had fatally injured herself.
Jurors also heard statements from Emily’s friends and former patients at West Lane, who described the unit as “awful”, claiming staff were uncaring and that vulnerable young people often felt responsible for protecting one another from self-harm. One former patient said she did not feel safe on the ward, while another recalled there was “no routine” and that Emily’s condition visibly deteriorated. The inquest has previously heard that senior managers at West Lane had been warned about problems at the unit and that it has been accepted Emily did not receive the standard of care she deserved.
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June 30th: Inquest hears Emily Moore feared return to TEWV despite improvements at specialist unit
Today’s inquest heard evidence that Emily’s mental health improved significantly after she was transferred from Tees, Esk and Wear Valleys NHS Foundation Trust’s (TEWV) troubled West Lane Hospital to Ferndene, a specialist adolescent unit run by Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust (CNTW).
Consultant psychiatrist Dr Cathlene Seller told jurors Emily arrived at Ferndene in July 2019 “very, very depressed”, but over the following months became “happy” and “normal”, with incidents of self-harm reducing in both frequency and severity. Dr Seller said the structured routine at Ferndene, including education and clear daily timetables, had a positive impact on Emily, while consistent restrictions to prevent self-harm helped her feel safe because she knew staff cared about her wellbeing.
Jurors heard Emily’s emotionally unstable personality disorder (EUPD) remained a chronic condition and that her risk of serious self-harm was still “quite extreme” at times, meaning she continued to require inpatient care. As she approached her 18th birthday, clinicians explored several options for her future, including returning home and a specialist residential placement, but neither was considered suitable. Although Emily’s family wanted her to remain under CNTW’s care, no adult beds were available because she was an out-of-area patient, leaving a move to TEWV’s Lanchester Road Hospital as what clinicians described as the “least worst option”.
Dr Seller told the court that Emily would have preferred not to leave Ferndene and accepted it was fair to say she was concerned about returning to TEWV after her previous experiences at West Lane. Because of those concerns, Ferndene staff recommended she remain under eyesight or one-to-one observation following her transfer to Lanchester Road on 6 February 2020. The jury also heard a thank-you card Emily wrote to one of her nurses before leaving Ferndene, in which she described arriving at the unit as a “quiet nervous” girl because of the “trauma” she had experienced at West Lane. She wrote that she had believed nurses were “meant to tell me off”, but that staff at Ferndene had shown her “people do care” and had saved her life on many occasions.
The inquest has previously heard that, a week after her transfer to Lanchester Road, Emily fatally injured herself despite her father warning staff about a concerning Facebook post just hours earlier.
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July 2nd: Inquest hears Teenager’s hospital move ‘unusual and concerning’
Today’s hearing examined Emily Moore’s transition from child to adult mental health services, with clinicians telling the inquest the move did not follow national guidance for a patient with emerging emotionally unstable personality disorder (EUPD).
Consultant psychiatrist Dr Eman Arebi described Emily’s transfer to Lanchester Road Hospital two days after her 18th birthday as “very unusual”, saying she and colleagues had been “concerned” after being told of the admission only a week beforehand and without the joint planning or consultation that would normally take place. Dr Arebi said patients with EUPD rely heavily on stable therapeutic relationships and should be introduced gradually to a new team during a period of stability, rather than being transferred solely because they have reached adulthood.
Clinical psychologist Dr Rachel Smith agreed, telling jurors Emily’s relationships with staff were vital in helping her feel validated and emotionally soothed, while feeling dismissed or criticised could trigger self-harm. She said Emily’s transition was marked by uncertainty, including a breakdown in trust between her family and TEWV following her previous admission to West Lane Hospital, with her parents wanting her to be placed anywhere other than in a TEWV bed.
The jury heard Emily’s preparation for the move was limited beyond a single visit to Tunstall Ward eight days before her admission, despite guidance recommending carefully managed transitions. Jurors also heard Emily was placed on constant observations when she arrived at Lanchester Road. These were reduced after 72 hours without incident, despite evidence that during her final month at Ferndene she had self-harmed on six occasions requiring restraint or rapid tranquillisation.
The inquest further heard Emily’s father phoned the ward on the morning she fatally injured herself after seeing a concerning Facebook post, but Dr Arebi said she was never told about the call and would have spoken to Emily had she been made aware of his concerns.
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July 6th: Inquest Hears Concerns Raised by Emily’s Father Were Not Recorded
Today’s inquest heard evidence about the hours leading up to Emily Moore’s fatal injuries. This included a telephone call from her father raising concerns about her wellbeing, that was not recorded in her clinical notes by staff at Lanchester Road Hospital.
The jury heard that on the morning of 13 February 2020, Emily’s father, David Moore, contacted the Tunstall Ward after seeing a Facebook post Emily had published marking what would have been the 18th birthday of a friend who had died while they were both patients at West Lane Hospital. The post ended with the words “until we meet again”, and jurors heard Emily had previously spoken about feeling guilty over her friend’s death, which clinicians told the jury could have acted as a potential trigger for self-harm.
Ward manager Daniel Scott accepted that the nurse who took the call should have documented the conversation and shared the information with colleagues so staff could increase their observations of Emily. However, no record of the call was made. When questioned by counsel to the inquest, Mr Scott said he would have expected the information to have been recorded but was unable to explain why it had not been.
The inquest also heard further evidence about Emily’s care following her transfer to Lanchester Road Hospital just days before her death. Consultant clinical psychologist Dr Sonia Pace told the jury that although it would have been helpful to have had more notice before Emily’s arrival, she was able to gather information from clinicians at Ferndene Hospital and meet with Emily and her parents to develop a care plan.
Dr Pace told the jury there “wasn’t really clarity” about the specific circumstances that could trigger Emily to self-harm, explaining that she could appear settled before experiencing a significant incident without obvious warning signs. Despite this uncertainty, Dr Pace said she believed the care plan, which included a gradual reduction in Emily’s level of observation, was appropriate based on the information available at the time. Dr Pace also told the jury that, based on the information available to staff at the time, Emily’s actions that day could not have been predicted.
Jurors also heard evidence about ligature risks within the hospital environment. The court was told that a national Care Quality Commission safety alert had been issued in 2018 identifying potential ligature points in mental health settings following the death of another patient elsewhere in the country.
Although Tees, Esk and Wear Valleys NHS Foundation Trust had begun a programme of work to address these risks across its sites, estates manager Simon Adamson told the inquest that the work had not yet been completed on the Tunstall Ward because of the complexity of the programme. The jury heard the ligature point involved in Emily’s death had previously been identified, but the necessary safety work had not yet been carried out.
The inquest continues.
Latest Position
The inquest remains ongoing. This page will be updated with witness evidence, legal submissions, findings and any significant developments as they are heard in court.
If you have been affected by any of the issues raised in this article, support is available.
You can contact Samaritans free of charge, 24 hours a day, on 116 123, or visit www.samaritans.org for information about the support they offer. Information and support are also available from Mind at www.mind.org.uk. If you or someone else is at immediate risk of harm, call 999 or attend your nearest Accident & Emergency department.
