Inquest into the death of 16-year old Manon Jones

The two-week inquest before HM Area Coroner David Regan at South Wales Central Coroner’s Court into the death of Manon Jones, a 16-year-old schoolgirl from Cardiff, concluded today. Oliver Lewis represented Manon’s family Nikki and Jeff Jones, and Manon’s sister. He was instructed by Craig Court of Harding Evans.

Manon’s mental health had deteriorated in February 2018 and there was an increase in self-harming episodes in the community. She spent a night and day at the University Hospital Wales where she was nursed on a 1:1 basis given her risk of self-harm, and the next day she was transferred to Ty Llidiard, an inpatient child and adolescent mental health unit run by Cwm Taf Morgannwg University Health Board. There, her observation level was reduced to a check every 15 minutes.

The Coroner recorded a narrative conclusion in which he agreed with the independent expert Professor Jenny Shaw the Manon “ought to have been on 1:1 observation levels pending a further assessment”.

The Coroner found that Manon’s deterioration was significant and poorly understood, that information between clinicians was poorly conveyed and there was no clear formulation of Manon’s presentation or the reasons why 15-minute observations were considered appropriate.

He found there was no system in place for the inpatient clinicians to access the paper records of the community team, so they failed to carry out a proper risk assessment or explore the circumstances that led to the admission. The Coroner issued a prevention of future deaths report to Cwm Taf Health Board noting the lack of a single shared clinical notes system.

Manon’s family said:

“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.

However, 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.”