Chelsea Mooney
18 Aug 2022 · Coroner Abigail Combes · South Yorkshire Western
The coroner's concerns
1. inadequate review of diagnosis leading to missed autism assessment
“The diagnosis whilst described as not being fixed; was not adequately reviewed. The primary witness for Cygnet in relation to diagnosis lacked professional curiosity even when asked questions in evidence. For example dismissing the potential that [the deceased] may be hyperbolic in some of her descriptions of incidents and could that be relevant to diagnosis or treatment; evidence from the family about another member of the family with an autism diagnosis was not followed up (the evidence from Cygnet”
2. unverified trauma disclosures influencing PTSD diagnosis
“2. Whilst it is important that the young person is believed and has confidence in those with a therapeutic relationship that she will be believed when she makes disclosures; there was almost no professional curiosity about the allegations and whether they spoke to something else going on with [the deceased]. The allegations that were made were blindly accepted by the team and one example where this was problematic is that part of [the deceased]'s PTSD diagnosis was based on flashbacks. One of the flashbacks which”
3. inadequate information sharing decision process
“The decision not to share information with family was made based on one capacity assessment. This did not fully address the issues with [the deceased] of understanding the consequences of that decision and neither does it adequately break down the information which Cygnet may wish to share with family. This appears to have been a blanket decision and once a capacity assessment determined that [the deceased] had the capacity to make that decision there is not evidence available to me of conversations with [the deceased]”
4. lack of post-incident debriefing
“There was no evidence of debrief after prior incidents of ligatures or other self- harm attempts and therefore crucial information about [the deceased]'s state of mind, motivation and methods was missing from future planning and risk assessments”
5. normalisation of ligature use
“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 [the deceased] 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”
6. inadequate staff guidance for crisis response
“Male staff were nervous and uncertain of how to approach [the deceased] when they were alone. Clear guidance needed to be made available to them on how to deal with this. Although in evidence staff said that if there was an emergency they would attend even if alone this was not the case in practice as the male member of staff sought female support before recognising that [the deceased] was in crisis”