A vulnerable teenage girl died in a secure psychiatric hospital after workers were two and a half minutes late to register her, an inquest has heard.
Chelsea Blue Mooney, who suffered from anorexia and post-traumatic stress disorder, was classified as a “high-risk patient” at Cygnet Hospital in Sheffield where she required high-level care.
She had made several assassination attempts and was admitted to the facility under the Mental Health Act, with an employee required to monitor her every 10 minutes.
However, on April 10, 2021, the 6:30 p.m. check on Chelsea was not carried out by a member of staff until 6:32 p.m., according to an investigation.
A jury found there was no “justification” for the delay.
When staff later checked on Chelsea, she had already begun to suffer from self-inflicted cardiac arrest, Hull Live Reports.
An alarm was raised, the ligatures were cut, CPR was administered and Chelsea was taken to Northern General Hospital in Sheffield, but she did not 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-minute delay contributed to Chelsea’s death and also found that hospital staff ‘did not call for help with sufficient urgency’.
Additionally, there has been a delay in getting emergency help, including getting a “red bag” containing necessary CPR equipment, such as a defibrillator, oxygen and suction devices.
The jury returned a narrative verdict stating: “Due to insufficient care, critically inadequate observations and delays in emergency response, this led to his unexpected death two days later, on April 12, at the Northern Sheffield General Hospital”.
Chelsea’s father, Stephen Blackford, said his daughter was “very disappointed” and the family were “absolutely shocked and stunned” to learn of the number of times Chelsea had been able to self-harm, when she was supposed to be at a high level. observations.
He said: “It’s just horrific that before we saw the evidence we as a family thought it was Chelsea who took their own life.
“We don’t dispute that she self-harmed, but knowing that she was checked late and that contributed to her death changed the fact that she did not kill herself, she was abandoned by a system that was supposed to keep her safe. It’s just heartbreaking.
Speaking after the inquest, Stephen said: ‘We were never made aware of the extent of Chelsea Blue’s self-harm.
“Chelsea Blue told staff she didn’t want her parents to know, but it was our child, she was 17. Why wouldn’t they tell us? Communication with families needs to change, we felt ignored.
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 these details and the coroner may decide to publish a report on the prevention of future deaths to ensure that wider lessons are learned in relation to the provision of health services mental health to children and young people.
Chelsea Blue’s family say they hope the end result will lead to improved care and possibly save the lives of other young people struggling with mental health and self-harm issues.
“The service is underfunded and understaffed. They cannot give the level of care these children need,” Stephen said.
“There was evidence that Chelsea Blue and others were able to self-harm during two-person or two-person sightings. It looks like the system just wasn’t working, and we think it’s still happening.
“We need more individual therapeutic care and better communication with families. Chelsea Blue said she was still bored in hospital, these kids need stimulation, not just medication,” he said.
Chelsea Blue’s mother Eileen said: “Self-harm needs to be reduced and not widely accepted as it is on these services.
“The lack of communication was appalling, keeping that family connection is a fundamental part of every child’s recovery there. Chelsea Blue’s condition did not improve while she was there, her mental health was in a downward spiral and his self-harm escalated.
“She had a bubbly personality and was an absolutely lovely girl to get to know, but I think she was disappointed.”
A spokesperson for Cygnet Sheffield said: “We would like to express our sincere condolences to the family and friends of Chelsea. Our thoughts are with them, especially in these difficult times.
“In Sheffield, we provide a level 4 inpatient mental health service for children and young people which, by its nature, deals with very complex patients. We take their care and treatment very seriously, and a recent inspection by the regulator, the Care Quality Commission, recognized that we follow best practice in terms of protection.
“The ward is adequately staffed with enough doctors and nurses and a team of staff who provide a range of treatments tailored to patient needs and in line with national guidelines.
“We respect our patients’ privacy, including around communication, and we work proactively to reduce incidents of self-harm. All incidents, including the vast majority that result in no harm, are reported in line with our obligations, and we ensure that any learning is shared with staff. Of course, we will 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 view a tree our youngsters had planted in memory of Chelsea, and greatly appreciate the support they have given to the many friends of Chelsea serving.
“We strive to actively involve families and caregivers in care decisions, recognizing the value this offers in fostering a positive and inclusive culture in our CAMHS services, while ensuring that the wishes of our patients are respected.
“Chelsea loved animals and nature, and it is a tribute to the great friendships it has developed here that so many residents and staff have been involved in the planning and design of a sensory garden, which will be named The Moon Garden after Chelsea, creating a lasting memorial to her.”
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