Family and trust reacts after TEWV found not guilty of unsafe care

Eighteen-year-old Emily Moore died while being treated as an inpatient at Lanchester Road psychiatric hospital in Durham, in February 2020. The hospital is run by Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV).

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 after a four-day trial, district judge Marie Mallon said the “overwhelming evidence” presented by the Trust’s defence team meant she could not find the Trust guilty of any criminal offence.

In a statement after the hearing, Brent Kilmurray, the CEO of TEWV, said: “During the trial, we heard from independent expert witnesses who said that Emily’s care was safe, appropriate and compassionate.”

Emily’s father David Moore has been “fighting for justice” for four years – and after the verdict, said he “would never forget and never forgive” the trust after her death.

He renewed calls for a statutory public inquiry to look into the tragic deaths of some TEWV patients and their care.

There is an ongoing inquiry into the care of mental health patients in Essex following a series of contentious deaths. 

The CQC said they were “very disappointed” with the verdict, adding “If we find people are at risk of harm, we won’t hesitate to take action in line with our enforcement powers to keep people safe.”  

But Mr Kilmurray said: “We don’t believe that this warranted prosecution by the CQC.”

Mr Moore said: “I will never forget and I will never forgive. It’s what we were expecting – but there’s more to someone’s care than a care plan, and the trial wasn’t really about Emily’s care.

“But the fight’s not over – we’ll keep going. Four years on, I miss her every day. We’ve been fighting for years; I’ve held protests, and sit-ins at hospitals, and made Facebook groups to connect with fellow parents and patients.

“NHS England needs to take a closer look – it was highlighted in the niche report into Emily’s care that her needs should have been considered above her age. I still believe that if she hadn’t gone into that hospital she would still be here.

“These people shouldn’t be working in mental health care.”

Mr Moore again called for a public inquiry into the Trust, saying: “We are 100 per cent still campaigning for a public inquiry into TEWV; it's all that matters.”

Previously, Emily’s parents said they believe “a public inquiry is paramount to TEWV either moving forward or losing their licence to serve the public’s mental health needs.

Mr Moore also highlighted that these legal proceedings are still ongoing, with TEWV to be sentenced in connection with the deaths of two of its other patients, Christie Harnett and Patient X, as well as recent inquests into the deaths of TEWV patients, including Ty Channce and Linda Banks, both of which concluded that TEWV failures contributed to their deaths.

Reacting to the verdict, Brent Kilmurray, chief executive at Tees, Esk and Wear Valleys NHS Foundation Trust, said: “It’s hard to imagine how difficult the past few days, weeks and indeed years must have been for Emily’s family and friends.

Brent Kilmurray (Image: TEWV)

"I’d like to say again how deeply sorry we are for their loss. Sadly, nothing positive comes from this.

“We have acknowledged and apologised for unacceptable failings in Emily’s care while she was at West Lane Hospital – that remains the case. Our position on that has not changed.  

“However, this charge related to Emily’s care record at a different hospital.

“During the trial, we heard from independent expert witnesses who said that her care was safe, appropriate and compassionate, and we don’t believe this warranted a prosecution by the CQC.

“That is why we had to defend this case.”   

Ann Ford, CQC’s director of operations in the north, said: “This is a tragic case, and my thoughts are with Emily’s family who are grieving for their loss.

“We are very disappointed with this outcome, however, I hope this prosecution reminds other health and social care organisations they must provide care and treatment in a safe way that meets people’s needs.

“If we find people are at risk of harm, we won’t hesitate to take action in line with our enforcement powers to keep people safe.”  

CQC is unable to release any further information until all legal proceedings against the trust have concluded.

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.

Recommended reading: 

• 'Unsafe care' in the lead up to County Durham teen's hospital death
• 'Poor quality records and plans' in run up to Emily Moore's death
• TEWV and medical guidelines criticised after Darlington man dies

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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.