Video report by Chris Kiddey
The parents of a 17-year-old girl from Bridlington who took her own life at a psychiatric hospital say changes must be made to save other families from the same heartbreak.
An inquest found that insufficient care at Cygnet Hospital in Sheffield led to the death of Chelsea Blue Mooney.
The teenager, who had a history of self-harm, was meant to be checked on every ten minutes by staff, but on 21 April 2021 an evening check was two minutes late.
When she was found, Chelsea had self-harmed and was suffering a cardiac arrest.
She died two days later at Sheffield Northern General Hospital.
An inquest jury found that "insufficient care, crucially inadequate observations and delays in emergency response" all led to Chelsea's death.
Chelsea's father, Stephen Blackford, said: "As heartbreaking as it was to hear the result, it needed to be done to make it aware that there needs to be change to a system that is failing."
Mr Blackford said Chelsea had struggled with her mental health for number of years and when she was first admitted to the hospital, 18 months before her death, the experience was "positive".
"We looked at the hospital, Chelsea found it positive, there were a couple of peers in there that she knew," he said.
"At first we thought it was okay, maybe we were going to get somewhere.
"Very quickly we realised that contact stopped, we didn't know that she was getting up to self-harm."
He told ITV News that families needed to be more involved with the care of loved ones in psychiatric hospitals.
He said: "We want awareness of the contact between families because keeping communication between families is fundamental to their recovery and when we were not involved in any of her care and her care plans how was she going to get better?"
Iftikhar Manzoor, of Hudgell Solicitors, who represented the family at the inquest, said they had "no idea" about the number of times Chelsea 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," he said.
In a statement, Cygnet Sheffield said: "We would like to express our sincere condolences to Chelsea’s family and friends. Our thoughts are with them, especially at this difficult time."
The statement said a recent inspection by the watchdog the Care Quality Commission found the hospital follow best practice on safeguarding.
"The service is sufficiently staffed with enough doctors and nurses and a staff team that provides a range of treatments suitable to the needs of patients and in line with national guidance," it added.
The latest CQC report for the hospital, published in January this year, gave it an overall 'good' rating.
A CQC spokesperson, said: "CQC inspectors have been in close contact with Cygnet Hospital Sheffield before and during the coroner’s process in relation to the death of Chelsea Mooney. They will use the information raised in the coroner’s report as part of their ongoing monitoring of the service."
Mental health support:
The Samaritans Tel: 116 123
Samaritans is available around the clock to provide support for anyone struggling to cope.
Text Shout to 85258
Shout is the UK’s first free 24/7 text service for anyone in crisis. It’s a place to go if you’re struggling to cope and need immediate help.
MindInfoline: 0300 123 3393