A vulnerable teenager died in a secure psychiatric hospital after workers were two-and-a-half minutes late checking in on her, an inquest was told.
Chelsea Blue Mooney, who suffered from anorexia and PTSD, was classified as a "high-risk patient" Cygnet Hospital in Sheffield where she required a high level of care.
She had made several attempts on her own life and was admitted to the facility under the Mental Health Act, with an employee required to look in on her every 10 minutes.
However, on April 10, 2021, the 6.30pm check on Chelsea was not carried out by a staff member until 6.32pm, an inquest heard.
A jury found there was no "justification'" for this delay.
When staff went into check on Chelsea later, she had already started to suffer from a self-inflicted cardiac arrest, Hull Live reports.
An alarm was raised, the ligatures were cut, CPR treatment given and Chelsea was taken to Northern General Hospital in Sheffield, but she didn’t recover from her injuries and was effectively brain dead.
Two days later her parents, father Stephen and mother Eileen Mooney, agreed to end her life support.
The jury inquest agreed that the two-and-a-half minutes delay contributed to Chelsea's death and also found hospital staff "did not summon help with sufficient urgency”.
Additionally, there was a delay in seeking emergency support including obtaining a "red bag" containing necessary CPR equipment such as a defibrillator, oxygen and suction machines.
The jury returned a narrative verdict stating: "As a result of insufficient care, crucially inadequate observations and the delays in emergency response, this led to her unexpected death two days later on April 12, in the Northern General Hospital, Sheffield”.
Chelsea's father Stephen Blackford says his daughter was "badly let down" and that the family were "absolutely shocked and gobsmacked" when learning of the number of times Chelsea had been able to self-harm, when she was meant to be on high-level observations.
He said: "It is just horrible that before we saw the evidence, we as a family thought that it was Chelsea who took her own life.
"We don’t dispute that she self harmed, but knowing that she was checked late and that that contributed to her death has changed the fact that she didn’t take her own life, she was let down by a system that was meant to keep her safe. It is just heartbreaking."
Speaking after the inquest, Stephen said: “We were never told about the extent of Chelsea Blue’s self-harm.
“Chelsea Blue told staff she didn’t want her parents to find out, but she was our child, she was 17. Why wouldn’t they tell us that? Communication with families needs to change, we felt disregarded.”
Coroner Abigail Combes has now asked Cygnet Hospital to provide detailed information on the number of suicide attempts made by patients using the same method as Chelsea to determine if the teenager’s death was an isolated incident.
The NHS hospital has 56 days to provide those details and the Coroner could decide to issue a Preventing Future Deaths report to ensure wider lessons are learned with regards to the provision of children and young people’s mental health services.
Chelsea Blue’s family say they hope the eventual outcome will lead to improved care and possibly save lives of other young people who struggle with mental health and self-harm.
“The service is underfunded and understaffed. They can’t give the level of care that these children need,” said Stephen.
“There was evidence that Chelsea Blue and others were managing to self-harm while on two-to-one or one-to-one observations. It seems that the system was just not working, and we believe it’s still happening.
“There needs to be more individual therapeutic care and better communication with families. Chelsea Blue said she was always bored while in hospital, these children need stimulating not just medicating,” he said.
Chelsea Blue’s mother, Eileen, said: "Self-harm needs to be reduced and not be widely accepted as it is in these wards.
"The lack of communication was dreadful, keeping that family relationship is a fundamental part of recovery for every child there. Chelsea Blue’s condition did not improve while she was there, her mental health was on a downward spiral and her self-harm escalated.
"She had a bubbly personality, and she was an absolutely lovely girl to know, but I think she was let down."
A spokesperson for Cygnet Sheffield said: “We would like to express our sincere condolences to Chelsea’s family and friends. Our thoughts are with them, especially at this difficult time.
“In Sheffield we provide a Tier 4 Child and Adolescent Mental Health inpatient service which, by its nature, supports highly complex patients. We take their care and treatment extremely seriously, and a recent inspection by the regulator, the Care Quality Commission, has acknowledged we follow best practice with respect to safeguarding.
"The service is sufficiently staffed with enough doctors and nurses and a staff team that provides a range of treatments suitable to the needs of patients and in line with national guidance.
“We respect the confidentiality of our patients, including around communication and we work pro-actively to reduce incidents of self-harm. All incidents, including the significant majority that result in no harm, are reported in line with our obligations, and we ensure any learnings are shared with staff. We will of course also provide all required information to the coroner.
“We remain in contact with some of Chelsea’s family, who joined us at the hospital to see a tree our young people had planted in Chelsea’s memory, and greatly appreciate the support they have offered to Chelsea’s many friends at the service.
“We strive to actively involve families and carers in care decisions, recognising the value this offers towards driving a positive and inclusive culture on our CAMHS wards, while also ensuring we adhere to the wishes of our patients.
“Chelsea loved animals and nature, and it is a tribute to the great friendships she developed here that so many residents and staff have been involved in planning and designing a sensory garden, which will be named The Moon Garden after Chelsea, creating a lasting memorial to her.”
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