Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0174, written 26 Jan 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 26 Jan 2022 |
|---|---|
| Reference | 2022-0174 |
| Deceased | Manon Jones |
| Coroner | David Regan |
| Coroner area | South Wales Central |
| Category | Mental Health related deaths · Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
ANNEX A
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)
NOTE: This form is to be used after an inquest.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
The Chief Executive of the Cwm Taf Morgannwg University Health
Board
1 CORONER
I am David Regan, Area Coroner, for the coroner area of South Wales Central
2 CORONER’S LEGAL POWERS
I make this report under paragraph 7, Schedule 5, of the Coroners and Justice
Act 2009 and regulations 28 and 29 of the Coroners (Investigations)
Regulations 2013.
3
INVESTIGATION and INQUEST
A Coronial investigation was commenced on 17th March 2018 into the death of
Manon Edie Jones. The Investigation concluded at the end of the inquest
which I conducted on 17th – 28th January 2022. The conclusion was a narrative
conclusion and the medical cause of death was 1a. Hanging. 2. Depression
4 CIRCUMSTANCES OF THE DEATH
These were recorded as :-
Manon Edie Jones, aged 16, suffered depression and emotional dysregulation.
Her behaviour was impulsive and she had a significant history of self harm. Her
mental health deteriorated from late February 2018 when she concealed an
overdose and a knife. On 5th March 2018 she used a
knife to cut herself
and required to be disarmed by the police. She was admitted for the night to the
University Hospital of Wales where she was subject to continuous observation
for her safety and transferred to the Ty Llidiard Unit with 3 escorts. Her
observation levels were reduced to 15 minute observations on the night of her
arrival at Ty Llidiard and her admission to Enfys ward. The reasons for this
were not recorded. Shortly after 21.10 on 7th March 2018 staff levels on the
ward fell as staff left it to respond to an alarm. At 21.18 Manon was found by
1
staff
She could not be revived. In light of her history of impulsive
actions it could not be determined whether she intended to end her life.
The narrative conclusion which I returned was:
Manon Jones died from ligaturing while suffering a mental health episode in
circumstances where she ought to have been subject to continuous 1:1
observation pending further assessment.
The Inquest focused upon:-
1. The provision of community care in the week leading up to the
admission
2. The adequacy of risk formulation upon and after admission
3. How that risk informed the care and treatment planning including levels
of observation and the placement of Manon in a bedroom with ligature
points
4. Staffing levels
5. The assessment and engagement of Manon while a patient at Ty Llidiard
6. The effectiveness of the resuscitation.
5 CORONER’S CONCERNS
During the course of the inquest the evidence revealed matters giving rise to
concern. In my opinion there is a risk that future deaths will occur unless
action is taken. In the circumstances it is my statutory duty to report to you.
The MATTERS OF CONCERN are as follows. –
(1) The clinicians assessing Manon on admission to Ty Llidiard did not
have available to them the records of her care made in the community
by the Crisis team, the Community Intensive Treatment team or the
University Hospital of Wales
(2) The Clinical records in the Ty Llidiard Unit were not all entered
contemporaneously in a single clinical record
(3) The absence of a single in and outpatient clinical record impaired the
ability of the clinicans at the unit on admission to be able to assess
Manon, fix a safe levels of observations, and safeguard her.
6 ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe
you and your organisation have the power to take such action.
2
7 YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this
report, namely by 18th March 2022. I, the Coroner, may extend the period.
Your response must contain details of action taken or proposed to be taken,
setting out the timetable for action. Otherwise you must explain why no action
is proposed.
8 COPIES and PUBLICATION
I have sent a copy of my report to family who may find it useful or of interest.
HeaIth Inspectorate Wales, Welsh Government, Medical Director of Cwm Taf
University Health Board. Medical Director of Cardiff and Vale University
Health Board.
I am also under a duty to send the Chief Coroner a copy of your response.
The Chief Coroner may publish either or both in a complete or redacted or
summary form. He may send a copy of this report to any person who he
believes may find it useful or of interest. You may make representations to me,
the coroner, at the time of your response, about the release or the publication
of your response by the Chief Coroner.
9
28th January 2022 SIGNED:
D Regan
Area Coroner
3
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