Chelsea Mooney death: Mental health unit had 'limited concern' over ligatures

A mental health unit in Sheffield showed "limited concern" about patients using ligatures, a coroner has said following the death of a teenager.

Chelsea Mooney, 17, died in hospital on 12 April 2021, two days after an act of self-harm involving ligatures at the city's Cygnet Hospital.

Coroner Abigail Combes said "ligature incidents... appear to have been accepted as normal behaviour".

However, Cygnet Health Care said the use of ligatures was not accepted.

An inquest in March heard that Chelsea, who had an eating disorder, had been admitted to a number of mental health inpatient units leading to her eventual admission to Cygnet in Sheffield.

While in this facility the teenager, from Bridlington, East Yorkshire, began to self-harm using ligatures which was a new behaviour.

The inquest was told that "insufficient care, crucially inadequate observations and delays in emergency response led to her unexpected death" at Sheffield's Northern General Hospital.

In her report published last week, Ms Combes said: "There was limited concern about the number of ligature incidents collectively across the ward. They appear to have been accepted as normal behaviour.

"There was no record of Chelsea using ligatures prior to her admission onto this ward. This reality for staff appears to have led to a downgrading of the seriousness of the use of ligatures."

She said staff described "when they would and would not intervene" when ligatures were being used by patients at the facility and "what would and would not constitute a serious incident".

"It may be that this approach to ligatures also contributed to the delay in Chelsea's final ligature being removed," said Ms Combes.

Following the report, Chelsea's father Steve 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."

Iftikhar Manzoor, at Hudgell Solicitors, said: "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."

A spokesperson for Cygnet said: "We have every sympathy with what Chelsea's family have endured and our commitment is as steadfast as ever to ensure children in our care receive the very best support."

They said the unit took patient care and treatment "extremely seriously" and their safety always came first.

"There is no culture of acceptance around ligatures at Cygnet Health Care," they added.

Information and support for those affected by mental health issues or self-harm is available via the BBC's Action Line.