News

Coroner finds missed opportunities in death of Pembrokeshire teenager

Published

4 months ago

November 13, 2025

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

Senedd vote to ban greyhound racing hailed as ‘landmark moment’ by charities

Published

3 hours ago

March 17, 2026

Tom Sinclair

Welfare groups celebrate historic decision as pressure mounts for UK-wide ban

ANIMAL welfare charities have welcomed the Senedd’s decision to ban greyhound racing in Wales, describing the move as a “landmark moment” that will prevent the “needless suffering” of thousands of dogs.

The vote, passed on Tuesday (Mar 17), will see greyhound racing outlawed in Wales following a transition period, making it the first UK nation to take such action.

A coalition of leading charities, including Dogs Trust, Blue Cross, RSPCA Cymru, Hope Rescue, and Greyhound Rescue Wales, said the decision marked a major victory for animal welfare.

The group, known as the Cut the Chase coalition, has campaigned for years to end greyhound racing, citing concerns over injuries, deaths, and poor living conditions for dogs involved in the sport.

Owen Sharp, Chief Executive of Dogs Trust, said: “Today’s vote in Wales is a landmark moment for dog welfare and a huge step towards ending the needless suffering of greyhounds.”

“For too long, dogs have paid the price for this outdated form of entertainment, with injuries and deaths that are entirely preventable.”

Figures cited by campaigners suggest that since 2017, more than 4,000 greyhounds across the UK have died or been put to sleep due to racing, while over 35,000 injuries have been recorded.

Charities argue that racing greyhounds around oval tracks places significant strain on their bodies, often leading to serious or fatal injuries. Concerns have also been raised about conditions away from the track, including kennelling, transport, and long-term welfare.

Chris Burghes, Chief Executive of Blue Cross, said the legislation would finally bring an end to what he described as a “cruel so-called sport”.

He added: “The death of just one racing dog is one too many. We are ready to support the rehoming of retired greyhounds and ensure they receive the care they need.”

Hope Rescue, which led a public petition attracting more than 35,000 signatures, said the decision reflected strong public support for a ban.

Its Chief Executive, Vanessa Waddon, said: “We are proud that our campaign has helped secure this historic win. Wales has put animal welfare first.”

Greyhound Rescue Wales described the decision as “transformative”, with Chief Executive Claire James saying it would end a practice that had persisted despite years of campaigning for reform.

The RSPCA also welcomed the vote, with Chief Executive Jo Rowland stating that the level of injury and death linked to racing was “simply unacceptable”.

Attention will now turn to Scotland, where a similar vote is expected on Wednesday (Mar 18). Campaigners are also urging the UK Government to introduce a ban in England and Northern Ireland.

Charities say Wales’ decision could set a precedent for the rest of the UK, as pressure grows to phase out greyhound racing nationwide.

News

Senedd votes to ban Greyhound racing in Wales to protect animal welfare

Published

3 hours ago

March 17, 2026

Tom Sinclair

GREYHOUND racing will be banned in Wales after Senedd Members voted in favour of new legislation aimed at protecting the welfare of racing dogs.

The Bill introduces a phased transition period to allow the industry to wind down responsibly, strengthen rehoming arrangements for retired greyhounds, and give enforcement bodies and local authorities time to prepare for the change. The ban is expected to come into force between April 1, 2027 and April 1, 2030.

The legislation reflects a clear policy decision that the risks associated with greyhound racing – including injuries, fatalities and poor outcomes for dogs after their racing careers end – can no longer be justified. Despite efforts by parts of the industry to improve standards, harm to greyhounds has remained a persistent concern.

Huw Irranca-Davies, Deputy First Minister with responsibility for Climate Change and Rural Affairs, said: “Wales is a progressive nation, committed to ethical standards and forward-thinking legislation. This Bill strengthens our reputation as a leader on animal welfare and delivers the standards that the people of Wales rightly expect.”

The move follows significant public engagement, with thousands of people, campaigners and organisations contributing through petitions, consultations and personal testimony. Their input has played a central role in shaping the legislation.

Commenting on the news that the greyhound racing ban has been passed by the Senedd, Welsh Liberal Democrat Leader Jane Dodds MS, who has spearheaded the campaign, said “This is a massive victory for animal welfare, and I’m proud that the Welsh Liberal Democrats have helped deliver it.

“Today, Wales has made a clear statement about the kind of nation we want to be: compassionate, forward-looking, and willing to act when the evidence demands it.”

News

£15m boost for nature recovery across Wales

Published

5 hours ago

March 17, 2026

Tom Sinclair

Projects to protect wildlife, restore habitats and strengthen biodiversity

TWENTY-EIGHT projects across Wales have secured more than £15 million to protect wildlife and restore biodiversity on land and at sea.

The funding, totalling £15,186,716, has been awarded through the Nature Networks Fund, with individual grants ranging from £50,000 to £1 million. Projects include efforts to protect the brown long-eared bat, restore vital wetland habitats and safeguard threatened plant species.

The scheme is delivered by the Heritage Fund on behalf of the Welsh Government, in partnership with Natural Resources Wales (NRW). It aims to strengthen the resilience of protected sites and accelerate nature recovery across the country.

Deputy First Minister Huw Irranca-Davies, who holds responsibility for climate change, said: “This significant investment demonstrates our ongoing commitment to international targets such as 30by30, increasing the scale and pace of delivery to protect Wales’s natural heritage.

“By supporting these projects, we are not only preserving precious ecosystems but also empowering communities to become stewards of their local environments. The Nature Networks Fund is a crucial tool in our response to the nature emergency.”

The latest round of funding will focus on improving connectivity between protected sites, creating stronger ecological networks where habitats and species can thrive and adapt to environmental pressures.

Since launching in 2021, the Nature Networks Fund has supported 147 projects with a combined investment of more than £54 million.

Among the successful projects, the Bat Conservation Trust has been awarded £249,630 for a Wales-wide initiative to protect the brown long-eared bat, often known as the “whispering bat”. The project will support woodland management, tree roost surveys, improved data collection and community engagement activities.

The National Botanic Garden of Wales has secured £823,320 to safeguard vulnerable plant species. The funding will expand the National Seed Bank of Wales, which currently conserves just 11% of Welsh flora, and support improvements at the 150-hectare Waun Las National Nature Reserve.

Meanwhile, wetland charity WWT will receive £548,406 to restore habitats at WWT Llanelli and along the Tir Morfa coastline. The project aims to improve conditions for wildlife, including internationally important wintering birds, while also supporting climate resilience in the wider Burry Inlet.

Andrew White, Director of Wales at the Heritage Fund, said: “To protect Wales’ habitats and wildlife, we need long-term, sustainable action built on genuine collaboration. These awards reflect both the scale of ambition behind the Nature Networks Fund and the vital role communities play in creating a more resilient future for nature.”

Mary Lewis, Head of Natural Resources Management and Policy at NRW, added: “We are delighted to see such a strong range of high-quality projects receiving support. From marine and coastal environments to rivers, wetlands and terrestrial habitats, the breadth of ambition across Wales is inspiring.

“These initiatives use innovative approaches to tackle some of our most pressing nature and climate challenges, helping to maintain, restore and enhance protected sites while building resilient ecological networks.”

The programme forms part of the Welsh Government’s commitment to the Global Biodiversity Framework “30 by 30” target, which aims to protect and effectively manage 30% of land, freshwater and marine environments by 2030.

Below is a full list of projects being funded.

£50,000 – £250,000 grants:

Pembrokeshire Coastal Forum Community Interest Company awarded £249,584, Pembrokeshire
Merthyr Mawr Estate awarded £249,929, Bridgend
Fieldwork Studio CIC awarded £248,414, Bridgend
Carmarthenshire County Council awarded £209,950, Burry Port
Royal Society of Wildlife Trusts awarded £249,898, Bangor
British Trust for Ornithology awarded £249,968, Bangor
Denbighshire County Council awarded £247,225, Mold
The Penllergare Trust awarded £194,600, Swansea
Botanical Society of Britain and Ireland awarded £249,988, Welshpool
Cyngor Gwynedd awarded £250,000, Caernarfon
Zoological Society of London awarded £249,991, Isle of Anglesey
Friends of the Upper Wye awarded £174,633, Hay on Wye
The Bat Conservation Trust awarded £249,630, Ceredigion
Tir Natur awarded £222,030, Ceredigion
Llanymynech Golf Club awarded £249,998, Oswestry

£250,000 – £1million

Milford Haven Port Authority awarded £959,180, Pembrokeshire
The National Trust for Places of Historic Interest or Natural Beauty awarded £998,766, Bangor
The Wildfowl & Wetlands Trust awarded £548,406, Wales-wide
Black Mountains Land Use Partnership awarded £995,152, Black Mountains
The Radnorshire Wildlife Trust awarded £952,350, Powys
The Zoological Society of London awarded £997,771, Llŷn Peninsula
The National Botanic Gardens of Wales awarded £823,320, Carmarthenshire
Monmouthshire County Council awarded £999,974, Gwent
The Wildlife Trust of South and West Wales awarded £926,905, Wales-wide
Vale of Glamorgan Council awarded £574,850, South Wales
Brecon Beacons National Park Authority awarded £999,758, Brecon Beacons
Game and Wildlife Conservation Trust awarded £921,700, Powys
Welsh Dee Trust awarded £942,746, Denbighshire