A North East hospital trust has been found not guilty in connection with the death of one of its teenage patients, a judge has today ruled.

 Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV) faced a four-day trial following the 2020 death of 18-year-old Emily Moore.

Emily died while being treated as an inpatient at Lanchester Road psychiatric hospital in Durham, in February 2020.

Prosecuted by the healthcare ombudsman, the Care Quality Commission (CQC) alleged that a “poor quality” care plan exposed Emily to unsafe care and serious risk of avoidable harm, and accused Lanchester Road of breaching regulations 12 and 22 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

But in her verdict district judge Marie Mallon, said that the “overwhelming evidence” from the defence meant that she could not find the Trust guilty of any criminal offence.

She said: “The criminal standard is a high one, and the evidence of the defence experts was overwhelming.”

Over the course of the four-day trial, the court heard from expert witnesses from the prosecution, and two expert witnesses from the defence.

Emily’s care plan – the document that outlines the needs, risks and goals to a patient’s care team - lay at the heart of the case.

The prosecution alleged that it was “poor quality”, not containing enough information about Emily’s specific risks to herself, but the defence said that the document was “fit for purpose”, and did not constitute unsafe care that exposed Emily to a significant risk of avoidable harm.

Recapping evidence from nursing expert and expert witness for the defence, Tim Bryson, the judge, outlined that he had found Emily’s care plan to be “very typical and very appropriate” with the aim of “keeping Emily safe and meeting her needs”.

Though in his evidence Mr Bryson acknowledged that the plan did contain two shortfalls, he said that “they did not expose Emily to significant risk of avoidable harm”, instead noting that the plan “facilitated safe care”.

He said: “There are almost always ways to improve a plan, but the fact that I can see ways to improve it does not mean that it was unsafe.”

He highlighted that areas of Emily’s care had represented “good practice”.

But expert witness Tim McDougall, nursing specialist for the CQC and director of nursing at Lancashire and South Cumbria NHS Foundation Trust, told the court he found the care plan “inadequate”, and believed that alongside “gaps in the records”, this contributed to unsafe care that put Emily at risk.

The judge said that Mr McDougall’s main concern with Emily’s care at Lanchester Road Hospital was that there was “lots of information in lots of different places”, stating that “if Emily’s plan had been clearer, it might have been easier for nurses to provide interventions”.

But he acknowledged that he would expect nurses to look at other documents, such as the ‘report out’ when commencing a patient's care, and nurses’ engagement with Emily during her stay on the Tunstall ward represented “good practice”.

Whilst in the witness box, defence expert Dr Francesca Denman, a consultant psychiatrist, said that “what matters is not what was recorded but what was done,” and that “telling nurses about hypotheses [in the care plan] would not have helped”.

The judge added that Dr Denman “could see that there was a plan, and that this plan was being delivered”.

After the verdict was delivered, Emily’s devastated father David Moore reacted angrily and had to be calmed by court staff.

The trust, which provides mental health care to some two million people, has already pled guilty in connection with the deaths of Christie Harnett, and Patient X, who cannot be identified due to reporting restrictions.

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Christie, 17, died whilst under the care of the since-closed West Lane Hospital, in Middlesbrough, in 2019.

Patient X died whilst being treated at Roseberry Park Hospital, in Middlesbrough, in 2020.

The sentencing hearing is set to take place at Teesside Magistrates’ Court next month. The Trust could face a hefty fine for these deaths.