A "bubbly" teenager who died in a psychiatric hospital was " badly let down" after staff were two and a half minutes late checking on her.
Chelsea Blue Mooney was classed as a "high risk patient" and had attempted to take her own life on several occasions.
Staff had been instructed to check on her every 10 minutes and Chelsea Blue, who suffered from anorexia and complex post-traumatic stress disorder, was detained at the hospital under the Mental Health Act.
An inquest revealed the 6.30pm check on Chelsea Blue was not undertaken by staff at Cygnet Hospital in Sheffield until 6.32pm on April 10, 2021. A jury found there was no "justification'" for this delay, reports Hull Live.
When staff went into check on Chelsea Blue later, she had already started to suffer from a self-inflicted cardiac arrest.
An alarm was raised and CPR treatment was given before 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 found the two-and-a-half minutes delay contributed to Chelsea Blue'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 Blue'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 she had been able to self-harm, when she was meant to be under 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."
*If you're struggling and need to talk, the Samaritans operate a free helpline open 24/7 on 116 123. Alternatively, you can email jo@samaritans.org or visit their site to find your local branch
