Inquest into the death of Manon Jones

The inquest into the death of 16-year-old schoolgirl, Manon Jones from Cardiff, ended today (Friday 28 January 2022).

Manon’s mental health 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 the mental health unit Ty Llidiard, an inpatient child and adolescent mental health unit run by Cwm Taf Morgannwg University Health Board.

Staff there performed a perfunctory assessment and there was no system in place for the inpatient team to have 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. As a result, staff incorrectly reduced the observations from continuous 1:1 observation to observation every 15 minutes.

HM Area Coroner, David Regan, recorded a narrative conclusion confirming that Manon “ought to have been on 1:1 observation levels pending a further assessment”. He also said that there is a risk that future deaths will occur unless action is taken by Cwm Taf Health Board and issued them with a Prevention of Future Deaths Report criticising the lack of a single shared clinical notes system. The Inquest heard that 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. Information between clinicians was poorly conveyed. There was no identification of a clear formulation of Manon’s presentation or the reasons why 15 minute observations were considered appropriate.

Craig Court, Partner at Harding Evans, who represents Manon’s family, issued the following statement on behalf of Manon’s parents, Nikki and Jeff Jones, and her sister.

“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.”

The family were represented at the inquest by Barrister Dr Oliver Lewis of Doughty Street Chambers.

For press enquiries, please contact Craig Court at courtc@hevans.com