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Coroner finds missed opportunities in death of Pembrokeshire teenager

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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.

 

News

Salmon face extinction in Welsh rivers by 2030, report warns

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Environment watchdog says Wales is at a “critical tipping point” as nature declines faster than it can recover

SALMON could disappear from some Welsh rivers within the next five years, according to a stark new assessment of the nation’s environment.

The warning comes in the State of Natural Resources Report 2025, published by Natural Resources Wales (NRW), which concludes that Wales is degrading its natural resources more quickly than they can be replenished.

NRW says nearly one in five species in Wales is now at risk of extinction, with freshwater ecosystems among the most pressured. Atlantic salmon, already in long-term decline, are highlighted as being particularly vulnerable, with some river systems potentially losing the species altogether by 2030 if current trends continue.

The report describes the environment as being under “sustained and intensifying pressure”, driven by the combined effects of climate change, pollution, habitat loss and unsustainable land use. It also states that Wales is consuming more than its fair share of global natural resources, placing further strain on already fragile ecosystems.

One of the most concerning findings is that there has been no overall improvement in the resilience of Wales’ freshwater environments since 2020. Only around 40 per cent of water bodies are currently achieving what is classified as “good status”, while fish populations and river habitats continue to deteriorate.

Speaking after the report’s publication, NRW chair Neil Sachdev said restoring nature could not be left to environmental bodies alone.

“Our report shows that restoring nature is a whole-society challenge,” he said. “It demands collective ownership across public bodies, businesses, communities and citizens.

“This is not just a warning about our future; it is a reckoning with our present. If we act now, with urgency and shared ownership, Wales can lead not just in ambition, but by delivering the scale of transformation the nation needs.”

The report argues that avoiding a deepening environmental and climate crisis will require fundamental changes to how people live, including how homes are heated, how food is produced and consumed, how people travel, and how land is managed.

Despite the bleak assessment, NRW notes that some progress has been made since its previous major report six years ago. Peatland restoration projects, tighter air-quality legislation, the Sustainable Farming Scheme and the Wales Metal Mines Programme are cited as targeted interventions beginning to address long-standing problems.

Commenting on the findings, Derek Walker, the Future Generations Commissioner for Wales, warned that environmental failure would hit the poorest communities hardest.

“Nature is one of our most powerful allies – preventing flooding, reducing pollution and protecting our health,” he said. “Without urgent, coordinated action to halt and reverse this decline, we are quite literally putting lives at risk unnecessarily.”

He pointed to nature-based solutions already being used in Wales, from urban green roofs to seagrass restoration, and said every part of the public sector needed to play a role in unlocking their potential.

Responding on behalf of the Welsh Government, Deputy First Minister Huw Irranca-Davies said the report would play a key role in shaping future policy.

“Protecting and enhancing nature is essential for people today and for future generations,” he said. “Wales has made real progress, but we need to go further again.

“This report sets out how we can work together to restore nature, tackle pollution and build resilience to climate change. The Welsh Government will lead this work alongside partners across the public sector, business and communities to turn evidence into meaningful action.”

For rivers across West Wales, including those once famed for their salmon runs, the report makes clear that time is now a critical factor — with decisive action needed if iconic species are to be saved from disappearing altogether.

 

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Health

‘Parking fine or miss my appointment’ say patients pressure mounts at hospitals

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From sleeping on chairs to parking fines, patients say everyday barriers are pushing the NHS to breaking point

PATIENTS across West Wales are describing a health service under such strain that some say they now expect to be penalised simply for trying to access care.

At Glangwili Hospital, stories of patients sleeping on chairs for days due to a lack of beds have been accompanied by growing frustration over issues that begin long before anyone reaches a ward — including parking, access, and the sheer difficulty of getting through the hospital doors.

One disabled patient said they had resigned themselves to receiving a £25 parking fine in order to attend hospital appointments.

“I now accept I will be fined,” they said. “Parking is impossible, but it’s that or miss my appointment. I am too disabled to park miles away and the disabled spaces are always full.”

Others have described spending days in A&E or side rooms, unable to lie down, while waiting for a bed to become available. One patient admitted on New Year’s Day with pneumonia said they slept in a chair for four nights without a pillow or blanket before being moved, only to later discover they also had flu and should have been isolated sooner.

Across social media and in correspondence with the Herald, patients and families repeatedly stress that frontline NHS staff are not to blame — instead pointing to a system that they say is buckling under years of structural strain.

Glangwili, the largest hospital managed by Hywel Dda University Health Board, serves Carmarthenshire and is home to the county’s only accident and emergency department following the closure of A&E at Prince Philip Hospital. That closure, along with reductions in services elsewhere, is frequently cited by patients as a turning point.

Several people said the loss of local A&E and cottage hospitals has forced more patients into already stretched units, increasing ambulance reliance and long-distance travel — particularly difficult in a largely rural region.

Further west, uncertainty over services at Withybush Hospital continues to fuel anxiety, especially given the scale of reinforced autoclaved aerated concrete (RAAC) identified across the site.

Hywel Dda has acknowledged that almost 90% of Withybush is affected by RAAC, while Glangwili itself is the oldest acute hospital in Wales. The health board says more than £50 million has been spent on the two hospitals in recent years, largely to address critical safety and infrastructure risks rather than expand capacity.

Patients, however, question where that money is felt on the ground.

Some have criticised NHS procurement and management structures, while others point to social care as the missing piece. Repeated comments highlight the lack of care packages and closed care homes, which many believe are leaving medically fit patients unable to be discharged — effectively blocking beds and creating bottlenecks throughout the system.

“There’s nowhere for people to go,” one reader said. “Until social care is sorted, nothing will change.”

Concerns have also been raised about staff morale, with some alleging bullying cultures and burnout contributing to recruitment and retention problems. Again, blame is consistently directed upward rather than at nurses, doctors or porters.

Behind it all looms the long-promised new ‘super hospital’ for Carmarthenshire — first discussed in 2006 and formally launched in 2018. Eight years on, construction has yet to begin, and public confidence in the project is fading.

While Hywel Dda and the Welsh Government insist improvements are under way — including additional funding to expand capacity at Glangwili and improvements to patient experience — many patients say their reality feels far removed from official assurances.

For those attending appointments, sleeping in chairs, or weighing up a parking fine against missing care, the crisis is no longer abstract.

“It’s not politics,” one patient said. “It’s whether you get treated — and how.”

 

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Crime

Two arrested after high-value shoplifting incident in Kilgetty

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TWO men have been arrested on suspicion of shoplifting following a rapid police response to a reported high-value theft at a supermarket in Kilgetty.

Dyfed-Powys Police said officers were called to the Co-op store at around 3.35pm on Wednesday (Jan 28), after a report that a large quantity of alcohol and other items had been stolen.

Using information provided by the caller, Roads Policing Unit officers worked closely with control room staff to identify a vehicle believed to be involved. Several patrol cars were deployed, and the vehicle was located a short time later travelling east.

Police said the safety of all those involved was treated as a priority, with specialist Tactical Pursuit and Containment (TPAC) advice obtained while officers maintained constant observation of the vehicle.

The car was brought to a safe stop on a back road approaching Hendy, involving three Roads Policing Unit vehicles. No injuries or damage were reported.

Following roadside checks, two men — aged 67 and 46 — were arrested on suspicion of theft from a shop.

Both remain in police custody while enquiries continue.

Police said the swift response helped prevent further offending and demonstrated the effectiveness of specialist roads policing officers acting on real-time intelligence.

 

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