Health board 'failed' teen who took her own life, coroner finds

A coroner has criticised a health board over "essential failures" in the care of a teenager who took her own life.

Manon Jones died in March 2018 while being treated for depression at the Ty Llidiard unit at Bridgend's Princess of Wales hospital.

Coroner David Regan has now issued Cwm Taf Health Board with a prevention of future deaths report.

He recorded a narrative verdict into the 16-year-old's death at Pontypridd Coroners' Court on Friday.

Ms Jones died during a fire alarm at the unit on the 7 March, 2018.

She was checked at 21:10 GMT but was found lifeless in her bathroom at 21:18 GMT.

The coroner said he couldn't be sure she intended to kill herself so ruled out a conclusion of suicide.

"The essential failures to safeguard Manon were serious," Mr Regan said.

But he said they did not amount to "gross failure to provide basic medical attention."

A coroner criticised a health board over "essential failures" in her care

The inquest heard despite a recommendation Ms Jones be placed under one-to-one observation at Ty Llydiard, she was only being checked every 15 minutes.

The coroner was critical that the reasons for this decision were not set out in clinical records.

The inquest heard the risk assessment procedure was deficient.

Reliance on a risk assessment from a previous admission to the unit was dubbed "poor".

Mr Regan said this compromised staff's ability to decide the level of care needed.

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"There should have been one-to-one observation until a more detailed assessment of the risk to herself had been carried out, and it was a failure in her care for this not to have occurred," he said.

Clinical discussions weren't recorded, he said, so an informed view about Ms Jones' condition couldn't be communicated between staff.

The inquest heard there had been an acute worsening in Manon's condition in the week before her admission to hospital.

Coroner David Regan issued Cwm Taf Health Board with a prevention of future deaths report

During that period a knife was found in her bedroom and she took an overdose that was treated at Cardiff's University Hospital of Wales.

On being discharged she was supposed to get daily visits from the community mental health team but this didn't happen.

After the inquest a statement was issued by Ms Jones' parents, Nikki and Jeff Jones, and her sister, who cannot be identified for legal reasons.

They called her "bright, talented and dynamic", and a "real force of nature" who was "caring, loving and passionate".

Ms Jones had endured "a crippling battle" with depression and self-harm they said.

"We fully support the coroner's report to prevent future unnecessary deaths to Cwm Taf Health Board and hope it will stop other families having to go through the agonising pain of losing their child," they said.

They urged the Welsh government to implement a national system that would enable health boards to keep up-to-date electronic records that can be easily shared.

"We hope that the coroner's conclusion and findings will spark a much-needed change in mental health services for children and young people in Wales," they said.

Cwm Taf Morgannwg health board's nursing and midwifery chief, Greg Dix, said: "We accept the findings of the coroner and are truly sorry that Manon was able to take her life while in our care.

"The lessons learnt from Manon's care play an important part in informing our practice."

The Welsh government said: "We have agreed a wider improvement programme for our CAMHS (Child and Adolescent Mental Health Services) inpatient units in Wales which is supported by £1.8m additional funding.

"We are committed to increasing access to information through digital services, both between health and care settings and with the patient.

"We will continue to work with health boards to ensure the migration to digital services can be achieved."

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