Manon Edie Jones · Prevention of Future Deaths report

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

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 ████████ 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.

(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 clinicians at the unit on admission to be able to assess Manon, fix a safe levels of observations, and safeguard her.