I lost my daughter to suicide in lockdown - she was failed by the system

Chelsea Mooney was just 17 when she died, taking her own life inside a secure mental health unit that was supposed to keep her safe. 

Lockdown had worsened her condition, with her loving parents and siblings banned from visiting her as she languished in a hospital in Sheffield, more than 80 miles from home.

The Telegraph’s three-month investigation into the handling of the pandemic has uncovered the deaths of four children - including Chelsea - inside mental health units in just a six-week period in April and May 2021. 

At the time, the UK remained in the grip of lockdown despite the successful rollout of millions of doses of the Covid-19 vaccine. By contrast, in the previous 12 months, six teenagers had died in mental health units.

The deaths in so short a period of time caused such concern among officials that they demanded a “rapid review”, an urgent investigation into the deaths to explore any systemic failings. That review, The Telegraph has now been told, never actually took place. 

Chelsea’s father Steve Blackford, 38, a merchant seaman, told The Telegraph: “Through Covid, these children that were patients became prisoners because they weren’t allowed to go out, nobody was allowed to go in.

“That lockdown had irreversible effects on so many children’s well-being in these units. The only thing that they had to look forward to was a visit or being able to go out and get some fresh air and they were suddenly made into prisoners in their own establishments.”

Chelsea, from Bridlington, Yorkshire, had a history of mental health problems, developing an eating disorder at the age of 13. She would be sectioned at two other mental health units before her admission to the Cygnet Hospital in Sheffield, where her self-harming intensified during lockdown. 

On April 10 2021, she tied two ligatures around her neck and went into cardiac arrest. She died two days later after being transferred to a general hospital, where her parents had no choice but to take the awful decision to switch off her life support. 

Four days after Chelsea died, two raucous, illegal parties took place in Downing Street on the eve of the late Duke of Edinburgh’s funeral. 

“They were having their little partygates,” said Mr Blackford. “Everybody was breaking the little rules in their own little ways. It was hard, and I felt for her. 

“I was speaking to Chelsea [on the phone] because she wasn’t allowed out and wasn't allowed to travel and her sisters would put pictures on their social media if we'd been at the park or beach and then Chelsea would be messaging me saying: ‘Why can't I come?’

“I'd ring her and say: ‘Yeah but we’re not allowed,’ and she’d say: ‘But I'm stuck in here and why can’t I come out?’ and I could hear in her voice she was getting really irate. 

“Looking back through the pink [medical] notes at that time, she was having a lot of self-harm through that period of lockdown where obviously she was getting frustrated in her own mind. She was locked in there but she was not allowed to see her family.”

The Telegraph’s investigation discovered WhatsApp messages sent to Matt Hancock, the then health secretary, a month after Chelsea’s death in which an official expressed alarm at the number of deaths in Tier 4 units. These are secure units that treat the most severely ill patients.

In his message sent on May 14 2021, the civil servant, who The Telegraph has decided not to name, informed Mr Hancock: “I’ve just sent you a note updating you on an NHSEI [NHS England and NHS Improvement] Rapid Review into the sad deaths of children in Tier 4 Mental Health units. The number of deaths for 2021/22 is already at 4, where the annual total figure for 2020/21 was 6.” 

The official then told Mr Hancock that Nadine Dorries, the minister for mental health, would meet with “NHSEI leads first thing next week to grip further” to discuss the deaths of children under the care of the Child and Adolescent Mental Health Service (CAMHS).

Three days later, Ms Dorries sent Mr Hancock a message, in which she explained that “we’ve had far more CYPs [children and young people] in T4 than before the pandemic”. She said that “pressure on paediatric beds has been huge” and that as a result she was “not alarmed” by the death toll.

In her message to Mr Hancock, she said: “The number of deaths is at 4, compared to the previous year of 2 - I’ve asked for the tier 4 data, but I’m not alarmed given the pressure we know T4 has been under. Meetibg with #### this week for more information on the two recent cases and to run a rapid inquiry.”

Mr Hancock replied: “Great. Very important.”

The Department of Health and Social Care (DHSC) has now admitted that no rapid review was ever carried out at the time. It finally launched a review in January this year to investigate “patient safety in mental health inpatient settings in England”. 

The review, which is ongoing, is being chaired by Dr Geraldine Strathdee, who is also investigating deaths of mental health patients in Essex over a 20-year period.

A DHSC spokesman said that “given the data in mid-May”, NHS England was “asked … to quickly assess the issue”. 

The spokesman said: “Officials found that the close timing of the deaths was sadly a tragic coincidence and did not represent an emerging trend. The number of deaths by suspected suicide in Tier 4 CAMHS settings across the rest of the year were consistent with previous years.”

The DHSC said NHS England “carried out multiple actions following its assessment” and that work concluded in August.

'Nothing has been done'

For Mr Blackford, it is all too late to get his daughter back. But he is appalled that no formal rapid review took place. 

“It needed looking into because it wasn’t just Chelsea that died … it was many other children and I’ve been speaking to her friends and other families that have been struggling,” he said.

“When Chelsea died, a lot of families came to me saying they were concerned and saying their children are in these units and there’s exactly the same failings, saying ‘another person’s died’.”

“They should have looked into it because it could have saved other people's lives … [but] they've just dismissed it. There are more people that have passed away and hurt themselves in these units because maybe that didn’t get looked into.”

Mr Blackford added: “It’s not going to bring Chelsea back but it could have saved somebody else's life if this report was done. 

“We've seen the failings in the lack of funding and the amount of failings across the board in the mental healthcare system, not just at inpatient hospitals where people are taking their lives.”

Mr Blackford is adamant a rapid review should have been carried out during the pandemic. “They say it’s a coincidence and the number of deaths are in line with previous years, but the deaths happened because of the same failings in care and yet nothing has been done,” he said. 

“I do believe that some very serious self-harm was an accepted culture inside the hospitals by the staff. 

“I really wish I could knock on the door of Number 10 and tell the Prime Minister ours and Chelsea’s story. And then tell him that the same situation has been happening for years prior and it’s nearly two years since Chelsea passed away and it’s still happening. 

“There have been so many young lives lost and families left devastated, and things should be changed and looked into properly.”

Chelsea, he said, had been a “bubbly” child, a keen gymnast who “was always on the move, and if she wasn’t doing that she was teaching her younger sisters to do flips. She really was an absolute gem, she was a little sunshine”.

She developed an eating disorder and then “took an overdose at school”. She was sectioned after “just slowly dwindling away” and eventually sent to the Cygnet Hospital as an inpatient at a secure psychiatric hospital. 

An inquest into Chelsea’s death found she had “performed an act of self-harm” on April 10 2021 and that “as a result of insufficient care, crucially inadequate observations and the delays in emergency response, this led to her unexpected death two days later”.

The coroner subsequently issued an official report - known as a Regulation 28 - highlighting a total of 10 “matters of concern” over Chelsea’s death.

A spokesman for the Cygnet Hospital 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. 

“We know that one death is one too many and any incident in which a service user dies is heartbreaking for everyone involved.”

“We provide a Tier 4 Child and Adolescent Mental Health inpatient service which, by its nature, supports individuals with highly complex behaviours. We take their care and treatment extremely seriously, and the latest inspection by the regulator, the Care Quality Commission, acknowledged we follow best practice with respect to safeguarding.”

The toll taken on children during the pandemic remains a cause of huge concern. The Royal College of Psychiatrists found that in a three-month period between April and June 2021 - at a time when four children died in mental health units - more than 8,500 young people were referred for urgent or emergency crisis care. That was a rise of 80 per cent on the same period a year earlier.