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A ‘poor’ care plan and medical records riddled with ‘gaps’ may have contributed to the ‘criminally’ unsafe care and subsequent death of a teenager at a County Durham hospital. The court heard this today.
Teesside Magistrates’ Court was told the care plan for Emily Moore, 18, during her eight days in hospital before her death in February 2020 was so poor it was “criminal”. .
Tees Esk and Wear Valleys Foundation Trust (TEWV) has been accused of failing to provide safe care for 18-year-old Emily Moore in the days leading up to her death in 2020.
Emily died in February 2020 while being treated as an inpatient at Lanchester Road Psychiatric Hospital in Durham. The hospital is run by Tees Esk and Wear Valleys NHS Foundation Trust (TEWV).
read more: ‘Poor records and planning’ leading up to Emily Moore’s death
She was under observation for 15 minutes and was able to take her own life in her room in the hospital’s Tunstall ward, despite a known history of self-harm with ligatures.
The Care Quality Commission, which is prosecuting the case, said Lanchester Road Hospital breached regulations 12 and 22 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
Expert witness Tim McDougall, CQC nursing expert and director of nursing at Lancashire and South Cumbria NHS Foundation Trust, said he felt the care planning was “inadequate” and said there were “gaps in the record”. Alongside, he said he believes this is contributing to unsafe care. It would put Emily at “risk of serious avoidable harm”.
If the plan had been written more comprehensively, McDougall believed, “nursing staff would have been given clear instructions about Emily’s known risk history, reducing the chance that Emily would be in harm’s way.” ing.
“I was expecting a risk-specific care plan that reflected guidance from NICE, Department of Health and CQC guidelines on managing ligation risks.
“Using my knowledge of the mental health care setting, it is common to rely on bank and sometimes agency staff, and sometimes strangers may pass by to care for someone.
“Having a temporary nurse come to the ward does not increase risk, but having a temporary nurse come to the ward without a care plan does.”
He added that using the available records “it was not possible to conclude that all observations were made.”
CQC prosecutor Jason Pitter KC said in his opening statement on Monday that taken together this amounted to a “criminal offence”.
However, TEWV Chief Nurse Beverley Murphy said in a written statement that agency staff filled only 2 of the 101 total staff shifts during Emily’s stay at Lanchester Road Hospital. It was outlined that these were both medical assistant roles rather than nursing. staff. Additionally she was placed on 13 shifts as a nurse at TEWV Bank.
The trust’s lawyer, Paul Greaney KC, argued the plan was “fit for its purpose” but admitted “this was not an absolute standard”.
He added: “When you’re trying to make someone better, you have to take some risk and manage that risk.”
Dr Francesca Denman, an expert at the trust, said a complete record outlining Emily’s risks could be obtained in “four or five clicks” from an electronic medical note “if you knew how to do it”.
Dr Denman said the plan developed for Emily’s care was “reasonable” and that records show multidisciplinary meetings were attended by nursing staff, doctors and Emily’s family. He added that he was “delighted” with the move, saying it showed “good practice”.
She added that the input from the conference was “fantastically comprehensive and brings things together into a single understanding.”
“Emily seems to have settled into the ward quite well.”
Dr Denman also warned of overly restricting patients, including locking Emily’s bathroom door to reduce the risk of self-harm from ligatures.
Although this would “eliminate risk,” it would create “miserable” patients.
She said: “If we put more and more patients in prison in an attempt to avoid harmful events, they can end up in a dire situation.
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“[The patient] Feeling caged and hopeless, they seek more subtle ways to harm themselves. Their relationship with staff becomes controlling and rebellious and does not help them achieve their purpose of helping.
Dr Denman added that “from the patient’s point of view, what is done is important”, but that “the purpose of documentation is to communicate information between staff” and that this contributes to the delivery of effective care. We agreed that it would contribute to
The trial continues.
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