Judicial review forced full inquest after initial decision overturned

A PEMBROKESHIRE teenager who took her life while suffering from a psychotic episode might still be alive today had she been prescribed anti-psychotic medication and given a proper safety plan, a coroner has concluded — more than three years after her mother successfully fought a judicial review to secure a full inquest.

Sixteen-year-old Kianna Patton was found dead at the derelict Commodore Hotel in Pembroke Dock on October 24, 2019. The inquest, which concluded on Thursday (Nov 13), found that serious failings in her mental health care “probably contributed” to her death.

Early warning signs

The inquest heard that Kianna first came to the attention of mental health services in January 2018, when her GP referred her to the Child and Adolescent Mental Health Service (CAMHS) after she reported self-harming and experiencing panic attacks.

In May 2018, she took an overdose of Tramadol and told doctors she wanted to die. She was referred again to CAMHS and prescribed antidepressants. By December 2018, she was discharged after being assessed as no longer posing a risk to herself.

By mid-2019, Kianna had left the family home to live with friends in a household where cannabis was used. Her mother, Joanne Patton, repeatedly raised concerns with both police and social services but said she was “passed from one to the other”.

Mental health relapse

In September 2019, Kianna told her GP she had been hearing voices for several months and feared she was developing schizophrenia. The GP made an urgent referral to CAMHS.

An assessment later that month classed her as “low risk”, despite her describing intense sadness and auditory hallucinations. She had stopped taking antidepressants, and there was a known family history of schizophrenia — but no anti-psychotic medication was prescribed.

On October 14, Kianna told clinicians she had thoughts about ending her life but would not act on them. On October 21, she reported hearing voices telling her to “off herself”. Two days later she went missing, and on October 24, police found her body at the abandoned hotel.

Expert criticism

Independent psychiatrist Dr Joana Sales told the inquest that while early treatment was reasonable, there was “no effective safety plan” in place in the weeks before Kianna’s death. She said the failure to prescribe anti-psychotic medication or involve a crisis team left a vulnerable teenager managing complex symptoms alone.

Dr Sales added that Kianna’s cannabis use may have worsened her psychosis, but appropriate medication could have stabilised her condition within days. A structured safety plan, she said, could have prevented her death.

Coroner’s findings

Pembrokeshire Coroner Gareth Lewis accepted those conclusions, ruling that the failure to prescribe medication and put a safety plan in place “probably contributed” to Kianna’s death.

He found that she died by hanging on October 23, 2019, her mind disturbed by untreated psychotic symptoms. The coroner noted that Hywel Dda University Health Board has since taken steps to address several of the failings identified through an internal review.

Mr Lewis said there was “no act or omission” by Pembrokeshire County Council that would likely have changed the outcome but extended his “deepest sympathies” to Kianna’s family and thanked all who took part in proceedings.

Judicial review and right to life

The full inquest only took place after Kianna’s mother launched a judicial review challenging the coroner’s original decision not to hold an Article 2 inquest — one that examines whether state bodies failed in their duty to protect life.

In June 2022, Mrs Justice Hill ruled in R (Patton) v HM Assistant Coroner for Carmarthenshire & Pembrokeshire that the earlier decision was legally flawed and must be reconsidered. The High Court found the coroner had not properly examined whether health and social services had a statutory duty to safeguard Kianna under the Social Services and Well-being (Wales) Act 2014.

The judgment was seen as a landmark case for defining how Article 2 of the European Convention on Human Rights applies to vulnerable young people at risk of self-harm.

A mother’s long fight

Mrs Patton’s determination led to renewed scrutiny of how agencies share information between health, social services, and police. The High Court’s intervention ensured that her daughter’s death was not dismissed as an isolated tragedy, but examined as evidence of wider systemic failures in child mental health care and safeguarding across Wales.

Her fight for answers is a powerful example of how one family’s persistence can expose critical gaps in public services and help drive change.

Why the judicial review matters

How a mother’s legal fight changed the inquest

The High Court in Cardiff ruled in 2022 that the first coroner’s decision on Kianna Patton’s death was wrong in law — forcing a full reinvestigation.

Mrs Justice Hill decided that the earlier ruling failed to properly consider whether public bodies had a legal duty to protect Kianna’s life under Article 2 of the Human Rights Act. That duty requires the state to have effective systems and safeguards in place to protect vulnerable people.

Why this was so important

The court said coroners must look not only at what happened to an individual, but at whether the systems meant to protect them actually worked. That means an inquest can now ask wider questions — about how health services, social services and police handled the case — not just how the person died.

What went wrong before

The original coroner decided that Article 2 didn’t apply because Kianna was living with friends and not formally “in care.” The High Court said that was too narrow. Even though she had a roof over her head, the question was whether that home was safe and suitable, given her mental health problems and cannabis use there.

If the council had a duty to provide her with different accommodation under the Social Services and Well-being (Wales) Act, that could have made her a “looked-after child,” triggering extra protection and a detailed support plan.

The ruling meant the coroner had to reopen the case and look again at whether the council, health board and police systems were strong enough to protect vulnerable teenagers like Kianna. It also required the coroner to explain decisions clearly and give reasons families can understand.

Why this matters for other families

The case sets an important precedent for Wales and beyond. It shows that when a vulnerable young person dies in the community — not in hospital or custody — the state can still be held to account if systems, communication or safeguarding break down.

It also means families in similar cases can get proper legal representation and a wider inquiry into what went wrong, rather than being told it was an isolated tragedy.

Key points

• The High Court overturned the coroner’s earlier ruling.
• Councils must show how they decide if accommodation for a child is suitable.
• Article 2 can apply even when someone isn’t detained.
• Families now have stronger rights to a full, transparent inquest.

For confidential support, Samaritans can be contacted for free around the clock 365 days a year on 116 123.