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.
News
New offshore wind leaders appointed as Pembrokeshire awaits Celtic Sea jobs boom
Equinor and Siemens Energy figures take top roles expected to influence major investment
SENIOR figures from two of the world’s largest renewable energy companies have been appointed Vice-Chairs of the UK’s Offshore Wind Industry Council (OWIC) — a move expected to have direct implications for Pembrokeshire as the Celtic Sea floating wind sector accelerates.
Melissa Read, Head of UK Offshore Wind at Equinor, and Andrew Elmes, Head of Government Affairs for Siemens Energy UK & Ireland, were confirmed in their roles by Energy Minister Michael Shanks.
Their appointments come at a critical time for West Wales, with the Celtic Sea poised for significant development and Pembrokeshire’s deep-water ports — Milford Haven and Pembroke Dock — expected to become central hubs for supply-chain manufacturing, assembly and long-term maintenance.
Equinor, Ms Read’s company, is one of the international developers bidding for floating offshore wind sites in the Celtic Sea. Success in these auctions could bring substantial inward investment to Pembrokeshire, including fabrication and marine engineering roles linked to the ongoing Pembroke Dock Marine redevelopment.
Siemens Energy, represented by Mr Elmes, is a key turbine and infrastructure supplier and is expected to play an important role in any expansion of assembly or marshalling operations along the Haven Waterway.
Announcing the appointments, Energy Minister Michael Shanks said offshore wind remained “the backbone of Britain’s clean power future” and insisted the benefits must reach “every region across the UK”. For Pembrokeshire, those benefits could include hundreds of skilled jobs, major port upgrades and a strengthened long-term role in national energy security.
Industry leaders have described the upcoming auction round for new offshore wind projects as a “crucial moment” in unlocking work packages around the Celtic Sea. OWIC’s new leadership will steer discussions on supply-chain development — an area where Welsh Government, Milford Haven Port Authority and local business groups are pressing for decisive commitments to ensure companies in West Wales can compete.
RenewableUK has said the UK could triple domestic manufacturing capacity and create up to 10,000 additional supply-chain jobs nationally by 2035 through targeted offshore wind investment. Local officials hope a significant share of that growth will be centred on the Haven Waterway.
Both Read and Elmes said they were “honoured” to take on their roles and emphasised the need for close collaboration between government, industry and local supply chains — all seen as vital to turning the Celtic Sea opportunity into real economic gains for Pembrokeshire.
News
Shocking decline in river quality sparks fresh call for ‘Clean Water Bill’
Campaigners warn crisis is hitting Pembrokeshire’s rivers as Lib Dems urge urgent action
CONCERNS over the state of Wales’ rivers have intensified this week as the Welsh Liberal Democrats renewed their call for a tough new Clean Water Bill — warning that pollution levels have reached a critical point from the Usk to the Cleddau.
The proposed legislation, drawn up by Save the River Usk (STRU) and backed by a wide coalition of environmental groups, sets out a sweeping overhaul of how Wales manages water quality. It calls for a new legal principle that no discharge should harm a water body, legally binding targets for water quality and biodiversity, and the creation of a fully independent regulator to hold polluters to account.
Impact felt across Pembrokeshire
While the campaign has been driven by ongoing problems on the Usk, environmental groups say the concerns apply equally to West Wales. The Eastern and Western Cleddau, together forming the Milford Haven waterway, have recorded repeated issues linked to agricultural run-off, sewage discharges and failing infrastructure — with local residents and businesses long frustrated by slow progress and finger-pointing between agencies.
Communities based along the Haven have frequently raised alarm over storm overflows and the effects of increased sediment and nutrient loading on shellfish, wildlife habitats and water-based tourism. Campaigners argue that Pembrokeshire’s economy, heavily dependent on its natural environment, is especially vulnerable if water quality continues to decline.
‘People across Wales have had enough of excuses’
Welsh Liberal Democrat Leader Jane Dodds said the public mood was clear.
“Communities across Wales have had enough of excuses,” she said. “People want a clean river when they walk the dog, when their children play near the water and when local businesses depend on the natural environment to thrive. A Clean Water Bill is the chance to finally set clear rules, enforce them properly and stop the decline before it becomes irreversible.”
Ms Dodds said ministers should adopt the principles set out by campaigners and bring forward legislation that “puts the health of our rivers above the convenience of polluters”.
UK-wide reforms not enough, say Lib Dems
The call comes in the wake of the UK Government’s Water (Special Measures) Act 2025, which introduced tougher sanctions for failing water companies — including bonus bans, automatic fines, criminal charges for obstructing investigations and mandatory real-time sewage reporting.
However, the Welsh Liberal Democrats argue that these measures, while welcome, do not replace the need for a Wales-specific approach with stronger statutory protections and enforcement.
STRU and its partner organisations say that without binding targets and a regulator with genuine independence, Wales will continue to lag behind in restoring its rivers to good ecological health.
Local Government
Councillors call for urgent review as flooding hits coastal communities
Motion demands assessment of drainage infrastructure after Castle Pond overflow
A MOTION on emergency flooding concerns was brought before Pembrokeshire County Council this afternoon after the Presiding Member agreed to take it as an urgent matter under section 4.18.3 (b) of the constitution.
Councillors Aaron Carey and Jonathan Grimes tabled the motion, warning that repeated and increasingly severe flooding in coastal, estuarial and river-fringe communities — particularly around the Commons and Castle Pond area — has become a “live, ongoing problem” affecting residents and businesses.
Flooding ‘overwhelming’ current infrastructure
Members were told that, according to correspondence from the council’s Coastal, Rivers & Drainage Team Manager, the barrage tipping gate at Castle Pond remains out of operation until mid-January due to mechanical faults. In the meantime, a combination of high tides, heavy rain, wind-driven tidal surges and overspill at the sluice has repeatedly overwhelmed local drainage and outfall systems.
The motion notes that while the current maintenance schedule — delayed until after the summer for recreational and biodiversity reasons — had been justified internally, it “failed to foresee” the heightened likelihood of severe winter storms and surge events, which climate change is making “more frequent and more intense”.
Call for urgent infrastructure assessment
Cllrs Carey and Grimes called on Cabinet to commission an urgent review into:
The adequacy of existing drainage, outfall and tidal-sluice infrastructure, including the barrage tipping gate, sluice system, flap valve and overall outfall capacity.
The council’s maintenance scheduling policy for coastal and estuarial flood-risk assets, with a view to ensuring that essential works are completed before the winter storm-surge period rather than postponed for non-safety considerations.
Pending the outcome of that review, the motion states that the Council should allocate emergency capital funding to repair or upgrade any barrages, sluices or outfalls considered at risk of failure or blockage, in order to protect residents, properties, highways and public amenities.
It further calls for a county-wide public flood-resilience plan, identifying all hotspots, maintenance schedules, responsible teams and timelines for upgrades, to give residents “clarity and confidence” in local flood-prevention measures.
Sinnett pressed on outfall capacity
Alongside the motion, a separate Cabinet Member question was submitted to Cllr Rhys Sinnett, the member responsible for the portfolio.
He was asked what assessment had been made of the adequacy of Pembrokeshire’s tidal outfall infrastructure in the face of current and future storm surges and rising sea levels, and whether the council would now commit to commissioning an immediate structural and risk-capacity audit.
The question seeks a report to Full Council within three months, together with proposals for funding any remedial works necessary to prevent further disruption to residents, roads and public spaces.
Image: Martin Cavaney
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