Inquests & Public Inquiries
Inquest Solicitors

Mental health hospital found to provide insufficient care and ‘inadequate observations’ following the death of a teenage girl


Iftikhar Manzoor

Team Leader & Senior Litigation Executive

7 min read time

The family of a 17-year-old girl who ‘would do anything for anyone’ but died after making ligatures in her room at a secure psychiatric hospital say changes must be made ‘to a failing system’ to prevent other families from losing children struggling with mental health.

The parents of Chelsea Blue Mooney, who was classed a ‘high-risk patient’ and suffered from anorexia and complex post-traumatic stress disorder, say they are appalled by the failings in care at the Cygnet Hospital in Sheffield, highlighted at an inquest into their daughter’s death.

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 Blue had been able to self-harm when she was meant to be on high-level observations.

The inquest heard medical records showed Chelsea Blue, who was detained at the hospital under the Mental Health Act, had made over 200 ligature attempts on herself in the 18 months she was a patient from 2019 to 2021. She had also self-harmed through head-banging and swallowing objects.

She was placed on six checks per hour – meant to be carried out by staff every 10 minutes – but on April 10th, 2021, the 6.30 pm check was not undertaken until 6.32 pm, when Chelsea Blue was found with two ligatures tied around her neck. She had already started to suffer a cardiac arrest.

An alarm was raised, the ligatures were cut, CPR treatment was given and the teenager 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, agreed to end her life support.

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Family unaware of the frequency of daughter’s self-harm

Speaking after the inquest, at which a jury concluded Chelsea Blue’s death was partly due to ‘insufficient care, and delays in the emergency response’, 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.

Chelsea Blue, a talented gymnast, singer and performer from Bridlington, East Yorkshire, was described by her family as someone who ‘would do anything for anyone’ and ‘always wanting to help’. She had a history of self-harming and the inquest highlighted a catalogue of errors by staff which contributed to her death.

Coroner Abigail Combes has now asked Cygnet Hospital to provide detailed information on the total 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.

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 the lives of other young people who struggle with mental health and self-harm. Her father, Stephen said:

The service is underfunded and understaffed. They can’t give the level of care that these children need.

There was evidence that Chelsea Blue and others were managing to ligature and 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.

Chelsea Blue Mooney with her mum Eileen.

Chelsea Blue’s mother, Eileen, added:

Ligatures and self-harm need 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.

Jury identified a series of failings in care

During the six-day inquest at Sheffield Town Hall, it was revealed there had been a series of failings in the lead-up to Chelsea Blue being found that day and in the emergency response of care staff. The jury agreed that:

  • There was evidence that checks on Chelsea Blue were “inadequate” during the day and were not carried out sufficiently to ensure she was safe and well.
  • The 6.30 pm check delay of two-and-a-half minutes was “not justified” and this “contributed to her death”.
  • Hospital staff “did not summon help with sufficient urgency”.
  • 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, as well as finding and using a ligature knife.
  • There was no justification for delays in the emergency response.
  • It was unclear who was leading the CPR response, this too contributed to her death.
  • Chelsea Blue also preferred her care to be delivered by female members of staff, this impacted on the checks that day and also contributed to her death.

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 the 12th of April in the Northern General Hospital, Sheffield.

The hospital appeared to have a ‘culture of acceptance of ligatures’

Iftikhar Manzoor, litigation executive in Civil Liberties at Hudgell Solicitors, represents the family and said: “Chelsea Blue’s family were shocked and had no idea that all this was going on, and the number of times she had self-harmed.

Now, knowing what they do, they feel it was sadly always just a matter of time before they lost their girl in such tragic circumstances.

In one incident Chelsea Blue was found by hospital staff with seven ligatures in the space of two-and-half hours. On a separate occasion she ligatured four times over a short duration with the same item of clothing.

There seemed to be a culture of acceptance of ligatures at Cygnet with no real plan to get to the root cause of such behaviour. There are now quite rightly serious questions being asked as to how this hospital ensures the safety of young people placed into its care.

In a Care Quality Commission (CQC) 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 ‘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.’

Chelsea Blue Mooney.

Chelsea Blue’s family agreed to donate her organs and 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 are unknown or unclear.

Our expert inquest lawyers are experienced in helping families find out the truth. Not only will we look to obtain answers about the circumstances of how your loved one died, but we will also try to highlight any failings or acts of negligence which may have contributed to their death.

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