A jury at an inquest has laid bare how repeated failings in mental health care delivered by Tees, Esk and Wear Valleys NHS Foundation Trust left Emily Moore exposed to fatal risk.
Emily, aged 18, was found unresponsive at Lanchester Road Hospital in Durham on 13 February 2020. She died two days later. The inquest, held at Crook Civic Centre, concluded on 17 July 2026 after four weeks of evidence and a six-year campaign by her family.
The jury delivered a narrative conclusion. It found Emily died after carrying out the act which led to her death, but it could not be determined whether she intended to end her life. Her mental ill health and diagnosis of emerging emotionally unstable personality disorder formed part of the picture. So too did the treatment and trauma experienced during interactions with mental health services, the lasting impact of bereavement including the death of a close friend, departures from agreed engagement plans, time spent alone on the day of the incident, and the availability of means of self-harm in her room.
Yet the verdict went further. It identified specific institutional shortcomings that materially worsened her situation. Admission to West Lane Hospital in Middlesbrough proved a significant contributing factor. The jury described the environment there as chaotic and unsafe. Her care was incomplete, fragmented and insufficiently structured to meet her clinical needs.
Staffing levels raised serious concerns. The availability of suitably skilled staff fell short. Psychological support disappeared after a psychologist went on maternity leave. These were not marginal issues. They left a vulnerable adolescent without the structured therapeutic input her condition demanded.
Emily had previously spent time at Ferndene Hospital, where her mood improved. The decision to transfer her to adult services at Lanchester Road came only days before the move. That left insufficient opportunity to build the therapeutic relationships judged necessary for her recovery. Expert witness Dr Francesca Denman told the inquest the transfer to an adult ward shortly after her 18th birthday was risky and appeared driven by age rather than clinical need.
