The 17-year-old, who was classed as a 'high-risk' patient, had made 200 ligature attempts on herself in the 18 months she was a patient during 2019 to 2021 and was supposed to be checked by staff every ten minutes.
But on April 10 last year, staff found her attempting harm using items she had in her room.
She was meant to be checked on every 10 minutes but on April 10, 2021, she was checked at 6.32pm instead of 6.30pm. By this time, she had attempted harm and was already in cardiac arrest.
She was taken to Sheffield’s Northern General Hospital and her parents agreed to end her life support two days later.
Following a six-day inquest, coroner Abigail Combes has now asked the hospital to provide 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.
Chelsea’s father Stephen Blackford said 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.
He 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.
“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,” he added.
Chelsea Blue’s mother, Eileen, added: “Ligatures and 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.”
A spokesperson for Cygnet Sheffield said: “All incidents, including the significant majority that result in no harm, are reported in line with our obligations, and we ensure any learnings are shared with staff. We will of course also provide all required information to the coroner.”
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’s family agreed to donate her organs and her kidneys, liver and heart have since been received by four people.
Samaritans are there to talk, listen and will not judge anyone: calls are free to 116 123 or you can email [email protected]