A Coroner investigating the circumstances leading up to the death of a 17-year-old girl who was a patient at a mental health hospital says staff have “limited concern about the number of ligature incidents” on its ward and appear to have accepted them “as normal behaviour.”
Abigail Combes, coroner for South Yorkshire has ordered Cygnet Health Care to take action in a Report to Prevent Future Deaths which was prompted following an inquest into the death of Chelsea Blue Mooney.
In her report the Coroner says the Cygnet Hospital in Sheffield “downgraded” the seriousness of the persistent use of ligatures as an act of self-harm by its patients.
Chelsea Mooney, who suffered from anorexia and complex post-traumatic stress disorder, was classed a ‘high-risk patient’ when being treated there.
She died in 2021 after making and using ligatures in her room at the secure psychiatric unit where she was detained under the Mental Health Act.
The inquest held earlier this year was told medical records showed she had made over 200 ligature attempts on herself in the 18 months she was a patient.
She had been placed on six checks per hour – meant to be carried out by staff every 10 minutes – but on April 10th, 2021, the 6.30pm check was not undertaken until 6.32pm, when Chelsea was found with two ligatures tied around her neck.
The teenager had started to suffer a cardiac arrest; the ligatures were cut and CPR treatment was given before she was taken to the Northern General Hospital in Sheffield, but she didn’t recover from her injuries.
Two days later her parents, father Stephen Blackford and mother Eileen York, agreed to end her life support.
The inquest jury concluded Chelsea’s death was partly due to “insufficient care, and delays in the emergency response.”
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‘There was limited concern about the number of ligature incidents’
Afterwards the Coroner asked Cygnet Hospital to provide detailed information about the number of ligature attempts for all patients over the same 18-month period to determine if the teenager’s death was an isolated incident or whether a culture of highly vulnerable patients using ligatures is more widespread at the hospital.
In her Report to Prevent Future Deaths, published on the August 18th, 2022, she concludes:
“There was limited concern about the number of ligature incidents collectively across the ward” and “they appear to have been accepted as normal behaviour.”
This, she says, appears to have led to a “downgrading” of the seriousness of the use of ligatures and it would take a hospital admission before it was regarded as “a serious incident”.
The coroner also states, “It may be that this approach to ligatures also contributed to the delay in Chelsea’s final ligature being removed.”
The report says there was no record of Chelsea using ligatures prior to her admission onto the ward and her “new behaviour” of using them “should have invited professional curiosity” by staff.
They should have, she says, “sought assurance about the overall practice of ligature use, which may have led to an earlier review by Cygnet Care.”
The report also states that there was no evidence of debriefs after other incidents of ligatures being used or other self-harm attempts and “therefore crucial information about Chelsea’s state of mind, motivation and methods was missing from future planning and risk assessments.”
Read more: Mental health hospital provided insufficient care and ‘inadequate observations’
At Chelsea Mooney’s inquest in March this year her parents said they were appalled to find out about the failings in her care and said their daughter had been “badly let down”.
Until then they were unaware of the number of times Chelsea had been able to self-harm when she was meant to be on high-level observations.
Following the publication of the Report to Prevent Future Deaths her father Stephen Blackford said, “All our concerns have been addressed and hopefully things will now change and other young patients and families will not have to suffer like Chelsea and ourselves have.
“We knew we needed to fight for answers. It has been a devastating experience and loss. We just hope that Chelsea’s unfortunate death can lead to a change.
“There are certainly lessons to be learnt to improve the lives of other children and we also hope it will lead to improved communication with parents and families.”
‘I would have expected; at Chelsea’s age, that a social worker would be involved in supporting her’
In her report the Coroner, addressing the family’s concerns that they were unaware of their daughter’s self-harming while in the hospital’s care, she said hospital commissioners ought to have assured themselves about the decision not to share information with Chelsea’s family.
That decision was made by Cygnet Care based on one capacity assessment with Chelsea, said the Coroner.
“This appears to have been a blanket decision and once a capacity assessment determined that Chelsea had the capacity to make that decision there is not evidence available to me of conversations with Chelsea to establish exactly what she would and would not share with family and that the consequences of those decisions were adequately explored with her.
“I would have expected; at Chelsea’s age, that a social worker would be involved in supporting her with this decision and reviewing it regularly.
“This decision about her capacity and information sharing were also not revisited which they ought to have been regularly.”
‘This culture of acceptance of ligatures being used at Cygnet must end’
Iftikhar Manzoor, litigation executive in Civil Liberties at Hudgell Solicitors who represents the family said the Report to Prevent Future Deaths was damning.
“Chelsea’s family had no idea about the extent of their daughter’s self-harming while being looked after by Cygnet Care.
“But this report shows that not only were the hospital well aware of what was going on, but that they did so little to prevent it happening time and time again.
“Questions were not raised; staff, it seems, were accepting of a culture where young people continuously put their own lives at risk.
“Now, knowing what we do, it is obvious that it was just a matter of time before this family tragically lost their girl.
“This culture of acceptance of ligatures being used at Cygnet must end. There must be a real and serious plan to get to the root cause of such behaviour and prevent another tragic death.
“Serious questions are now rightly being asked as to how this hospital ensures the safety of young people placed into its care.”
The Coroner’s report also identified “limited confidence and clarity around the CPR” needed for Chelsea and there was also “not a clear structure of one person leading and others knowing exactly what and how to do tasks,” she concluded.
She also said Chelsea’s working diagnosis of post-traumatic stress disorder was not adequately reviewed.
Chelsea’s mother, Eileen York said she was pleased with the Coroner’s report, “It won’t bring Chelsea home, but as a family we fought in her name and highlighted what really goes on in these units.”
The Coroner has now told Cygnet Care to act on her report findings, “In my opinion action should be taken to prevent future deaths and I believe your organisation have the power to take such action,” she said.
Cygnet Care has 56 days to respond to the report outlining details of action taken or proposed to be taken and setting out the timetable for action.
In a Care Quality Commission (CQC) report published earlier this year, the Cygnet Hospital, which provides 55 beds for women and Child and Adolescent Mental Health Services (CAMHS) for male and female adolescents, it was stated that there ‘was a high number of self-harm incidents on the CAMHS wards’ and that ‘the service did not have consistent quality of staffing from day to night.’
After Chelsea’s death her family agreed to donate her organs; her kidneys, liver and heart have since been received by four people.
Our team of dedicated inquest solicitors understand that trying to come to terms with the sudden loss of a loved one can be a deeply distressing experience. This is especially true when the exact circumstances of their death is unknown or unclear.
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