A teenage mental health patient died after "serious failings" in her safeguarding, an inquest heard.
Manon Jones, 16, was a pupil at Ysgol Plasmawr in Cardiff when she died on March 7, 2018.
It has taken four years for the inquest to happen but it’s proved what parents Nikki and Jeff Jones always believed - there were "serious failings" in the care their daughter received after being admitted to a child and adolescent mental health unit run by Cwm Taf Morgannwg University Health Board.
The lack of access to Manon’s clinical records meant the level of care she received was inadequate and this has now prompted the family to call on the Welsh Government to mandate electronic NHS records.
The inquest at Pontypridd Coroner’s Court into the death the schoolgirl, heard how the teenager’s mental health deteriorated in February 2018 and there was an increase in self-harming episodes.
Following an incident at Miss Jones' family home in which the police were called, Manon was admitted to hospital. She spent a night and day at the University Hospital Wales where she was given 1:1 care because of her self-harm risk.
The next day she was transferred to the mental health unit Ty Llidiard, an inpatient child and adolescent mental health unit run by Cwm Taf Morgannwg University Health Board.
Less than 24 hours later, on the 7th March 2018 Manon was found lifeless in her bathroom after taking her own life.
During the inquest the doctor who assessed Manon on her arrival to Ty Llidiard was questioned over her decision to place Miss Jones on 15-minute observations despite having had one-to-one care before the transfer.
Today as the inquest concluded HM Area Coroner, David Regan recorded a narrative verdict confirming that Manon “ought to have been on 1:1 observation levels pending a further assessment”.
The coroner also stated he would be making a Regulation 28 report to the Cwm Taf Morgannwg health board identifying a concern that the "absence of a system allowing common record-sharing might lead to a recurrence of death"
The inquest heard how the community clinical records that had detailed Manon’s deteriorating mental health condition and self-harming behaviour were not available to Ty Llidiard, leading the coroner to find that Manon’s deterioration was significant and poorly understood.
Now the family are calling on the Welsh Government to mandate electronic NHS records so that other patients receive better and more appropriate care.
A statement issued on behalf of Manon’s parents, Nikki and Jeff Jones, and her sister reads: “Manon was a bright, talented and dynamic 16-year-old, who was a real force of nature.
"She was caring, loving and passionate but had to endure a crippling battle with depression and self-harm.
“We have always believed that there were serious failings by the psychiatrists at Ty Llidiard, in not properly assessing the level of risk that Manon posed to herself due to the rapid decline in her mental health, in the last days of Manon’s life. It has been heart-breaking to hear that more should have been done to safeguard our daughter when she so desperately needed it.
“During the Inquest, we were astonished to learn that across Wales there is no electronic system of record keeping which would have facilitated real time information in respect of Manon’s risk. 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.”
The statement continues: “We call on the Welsh Government to implement a national system that will enable Health Boards to keep up to date records electronically that can be readily accessed and shared.
“We will never recover from the horror of losing Manon. We want to remember Manon by trying to protect others and lobbying for change. We want other parents to have a really clear understanding of the risks associated with depression but real change will only happen if local mental health services can be relied upon to provide the effective critical care that is so desperately needed. 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.
“We are all very relieved that the inquest process is over and would like to thank the Coroner for his thorough consideration of all the evidence.”
Responding to the Coroner’s findings Executive Director of Nursing and Midwifery at Cwm Taf Morgannwg University Health Board, Greg Dix said: “The circumstances surrounding Manon’s death, while an inpatient at Ty Llidiard, are deeply tragic, and we express our heartfelt sympathy to her family in their devastating loss.
“As a Health Board, the safety and care of our patients is paramount. 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, ensuring the highest standard of care for all of our CAMHS patients. Our Health Board and staff will always remember Manon, and we take this opportunity to, once again, offer our sincere condolences to her family.”
A Welsh Government spokesperson said: “Our thoughts are with the family and friends following their tragic loss. The health board has accepted the findings from the Coroner’s report and is committed to ensuring the highest standard of care for all young people who need the support of mental health services.
“We have agreed a wider improvement programme for our CAMHS in-patient 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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