News
Coroner finds missed opportunities in death of Pembrokeshire teenager
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.
international news
UK considers military options as pressure grows to secure Strait of Hormuz
Ministers confirm talks with allies after Donald Trump calls on Britain to help protect vital oil shipping route
THE UK GOVERNMENT is examining “all options” to help secure the Strait of Hormuz as tensions in the Middle East threaten one of the world’s most important oil routes.
Energy Secretary Ed Miliband said Britain is already in discussions with allies, including the United States, about how to restore safe navigation through the narrow shipping corridor, through which around one fifth of the world’s oil supply passes.
Speaking on BBC One’s Sunday with Laura Kuenssberg, Miliband said reopening the strait was a global priority but stressed the government favours de-escalation rather than military confrontation.
“It is very important that we get the Strait of Hormuz reopened,” he said. “We are in talks with allies about how to secure that key shipping route. Any options to help the Strait reopen are being looked at.”

The comments come after US President Donald Trump called on several major powers — including the UK, France, Japan, South Korea and China — to send warships to the region to ensure the vital oil corridor can no longer be threatened by Iran.
The escalating conflict between the US, Israel and Iran has already led to attacks on shipping in the Gulf, raising fears that Tehran could attempt to block or severely disrupt the strait.
Political divisions in Westminster
The prospect of British military involvement has exposed sharp political divisions in Westminster.
Shadow energy secretary Claire Coutinho said the UK should explore deploying ships or surveillance drones to the region if doing so would protect Britain’s national interests.
She argued that keeping international shipping lanes open and protecting military assets abroad was vital for global stability and the UK economy.
However, Liberal Democrat leader Ed Davey warned Britain should not automatically follow Washington into another conflict.
He said the quickest way to stabilise oil markets and secure the route was through diplomatic de-escalation rather than military intervention.
Davey also criticised President Trump’s approach to the crisis, warning the UK should not be “at the beck and call” of an American president.

Global oil supply at risk
The Strait of Hormuz is widely regarded as one of the most strategically important shipping routes in the world.
Bounded by Iran to the north and Oman and the United Arab Emirates to the south, the narrow channel connects the oil-rich Gulf region to the Arabian Sea and global markets.
Around 3,000 vessels pass through the strait every month, carrying an estimated 20 million barrels of oil per day.
Any prolonged disruption could send global oil prices soaring and drive up fuel and energy costs in countries including the UK.
Government sources have warned the economic impact of the Middle East conflict could be “huge”, with ministers already examining measures to shield households and businesses from potential spikes in energy prices.
The developments are being closely watched in Pembrokeshire, home to the South Hook and Dragon LNG terminals at Milford Haven. Tankers carrying Qatari liquefied natural gas frequently pass through the Strait of Hormuz before reaching the UK, meaning any disruption in the Gulf could have implications for energy supplies and prices in Wales.
For now, the government insists diplomacy remains the preferred path — but with tensions rising and pressure from Washington increasing, Britain may soon face difficult choices about how far it is willing to go to secure the world’s most critical oil chokepoint.
Local Government
Changes approved to final phase of Saundersfoot housing scheme
Affordable housing proportion rises as apartment plans replaced with family homes
AMENDMENTS to the final phase of a housing development in Saundersfoot have been approved, reducing the overall number of homes while increasing the proportion of affordable properties on the site.
Morgan Construction (Wales) Limited, through agent Evans Banks Planning Limited, sought permission to reconfigure the third phase of a residential development at Whitlow, Narberth Road, Saundersfoot.
The application was recommended for approval and came before members of Pembrokeshire Coast National Park’s Development Management Committee at its March meeting.
The original scheme, granted permission in 2023 and already partly built, allowed for a total of 54 homes. Under the revised proposals the number will be reduced to 47.
A planning officer’s report explained that the development is being built in phases. Phase one consists of 16 market homes, while phase two includes 19 affordable properties.
The application concerned the final stage of the project, known as phase three.
Under the original consent, phase three would have delivered 19 one- and two-bedroom apartments located in the centre of the site. However, the revised plans replace those flats with a mix of houses.
The new layout will include two three-bedroom detached houses, three two-bedroom detached bungalows, four two-bedroom terraced townhouses and three three-bedroom terraced townhouses.
This change reduces the number of homes in phase three from 19 apartments to 12 houses.
Although the number of affordable homes across the development will remain unchanged, the reduction in market housing increases the proportion of affordable properties on the site from 35.1 per cent to 40.4 per cent.
The applicants told planners that demand for the previously approved apartments had been limited. They said there was already a considerable supply of such properties in the lower part of Saundersfoot, while demand locally appeared stronger for homes suited to young families and for older residents wishing to downsize into smaller bungalows.
The report added that without the changes the final phase of the development could remain unbuilt, leaving future residents living on a partially completed site.
Committee members agreed to grant delegated approval to planning officers, subject to the completion of legal agreements covering planning obligations.
These include provisions to secure the affordable housing in perpetuity, along with financial contributions towards library services, recreational open space and sustainable transport.
Local Government
Appeal after Tenby harbour RNLI building takeaway refused
AN APPEAL has been lodged against the refusal of plans for a takeaway food kiosk at a former lifeboat store in Tenby’s seaside harbour, despite planning officers recommending the scheme for approval.
Last March, members of the Pembrokeshire Coast National Park Authority development management committee rejected proposals to site a takeaway food kiosk at the former RNLI lifeboat store at Penniless Cove, Tenby Harbour.
The application, submitted by Ruby Goodrick, sought permission to convert the old store into a takeaway cold food outlet operating seven days a week from 10:00am to 10:00pm.
The scheme came before councillors rather than being determined under delegated powers after Tenby Town Council objected to the proposal.
Despite the objection, planning officers recommended the scheme for approval, even though it represented a departure from the adopted development plan.
An officer report said: “Whilst it is acknowledged that the proposed use would introduce a retail element to this area of the harbour, on balance officers consider that no significant harm would be caused to the character of Tenby Harbour as a result of this development.
“The use proposed occupies a relatively small floor area and would not be a destination in and of itself. Rather, it would rely on the existing footfall within the harbour.”
Speaking at the meeting in March (2025), Alistair McKay, representing Tenby Sailing Club, warned the proposal could create potential conflicts with other harbour users.
The applicant told councillors she was “more than happy” to adjust the proposed opening hours. Ms Goodrick said the business would build on the success of her mother’s former sandwich shop in the town, Truly Scrumptious.
The proposed outlet, called Truly@The Harbour, would “contribute positively to the local economy,” she said.
However, committee members raised concerns including congestion in the harbour area and the handling of waste.
Members eventually voted by 12 votes to three to refuse the application.
The applicant has now lodged an appeal with Planning and Environment Decisions Wales (PEDW).
In a statement supporting the appeal, Ms Goodrick said: “The proposal is modest in scale, does not harm the retail hierarchy, is in close proximity to the town centre, and has received no objections from the majority of the statutory consultees.”
The appeal statement adds that the refusal was based on the kiosk being outside the defined town centre boundary.
However, it argues that the building is located only around 25 metres outside the retail centre boundary and would otherwise represent a use considered acceptable within the town centre.
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