What went wrong with Shildon teenager’s mental health care?

The issue was not so much staffing levels but rather staffing skills sets, fellow problem-solver matron Alison McIntyre said, with Emily not getting the care she deserved.

Some early improvements were noted but, in May 2019, the service took several steps backwards when 29 of the suspended staff returned.

While some accepted they had been at fault about half did not, with the narrative they had been harshly treated permeating further through the workforce.

Uncertainty about when and how to restrain young people, especially when they were actively hurting themselves, remained.

One of Emily’s complaints was about staff just watching as she self-harmed, saying they would wait for her to tire herself out.

Even experienced doctors said it was a traumatic place, and then in June 2018, Emily suffered another blow – the death of her 17-year-old friend Christie Harnett.

Inquests into the death of Christie and another patient Nadia Sharif, who died on the ward two months later, will be held at a future date, but her friend’s death had a huge impact on Emily.

As well as incalculable sadness, Emily also felt guilty about it, one of the insidious symptoms of her illness.