Christian Howells and Nia Gowman, instructed by Michael Imperato at Watkins and Gunn Solicitors represented the deceased’s family at an inquest at County Hall, Haverfordwest between 6 October 2025 – 13 November 2025. The Senior Coroner for Pembrokeshire and Carmarthenshire, Gareth Lewis, determined that the death of 16-year-old Kianna Patton was probably caused by failures in her mental health care.
Kianna had a history of low mood dating back to 2017. In May 2017 Kianna took a serious overdose of tramadol which subsequently led to involvement from Hywel Dda University Health Board’s Child and Adolescent Mental Health Team (‘CAMHS’). Kianna was offered talking therapy and was prescribed antidepressants. Kianna was discharged from CAMHS in June 2018 following a period of limited engagement.
During this time, Kianna’s mother repeatedly sought assistance from Pembrokeshire County Council to support her relationship with Kianna and to assist in the implementation of boundaries. Kianna’s mother was particularly concerned regarding the influence of Kianna’s friends upon her and her views toward substance misuse.
In June 2019 Kianna moved out of her mother’s home following an argument about Kianna’s substance misuse. Kianna went to reside with a friend and her family. Kianna’s mother raised concerns with professionals regarding the lack of boundaries in situ at this house, in particular, the parents’ willingness to allow Kianna to smoke cannabis. No action was taken.
In September 2019 Kianna reported to her GP that she had been hearing voices over a nine-month period and experiencing delusions and suicidal thoughts. An urgent re-referral was made to CAMHS. The working diagnosis was first episode psychosis and Kianna had contact with CAMHS throughout September and October 2019 while this was being explored. Despite Kianna’s escalating symptoms whereby it was evident she was becoming increasingly unwell, she was not provided with any treatment and a safety plan was not put in place to manage her risk.
In addition, in early September 2019, Kianna’s mother contacted her local MP raising her concerns regarding Kianna’s living arrangements, cannabis use and the effect of the same on Kianna’s mental. Kianna’s mother had not been made informed about Kianna’s decline in her mental health or her re-referral to CAMHS by professionals. The MP referred the matter to agencies, notably Pembrokeshire County Council. Pembrokeshire County Council carried out basic checks with Kianna’s schools and were informed that Kianna had re-referred to CAMHS. No further enquiries were made and no action was taken.
Kianna was reported missing on 23 October 2019 and subsequently found deceased in the disused Commodore Hotel, Pembroke Dock, on 24 October.
A post-mortem confirmed she died by hanging. Toxicology revealed presence of substances related to cannabis and an unprescribed antidepressant in her system.
Following an inquest at County Hall, Haverfordwest between 6 October 2025 – 13 November 2025 the Senior Coroner made the following particular findings:
- Adopting the evidence of the Independent Expert, the Senior Coroner concluded that Kianna “lacked necessary intent for a conclusion of suicide” and that it “was most likely” that Kianna’s thought processes had been disturbed and “falling into psychotic phenomenon, pushing her to take her own life.”
- CAMHS’ “failure to put in place a suitable safety plan probably contributed to Kianna’s death in a more than minimal way”
- “The health board made an admission in Kianna’s analysis that her assessment was not updated, and my finding is that CAMHS should have passed on to the childcare assessment team of the issues relating to Kianna’s risk, which would have caused it to perform an assessment, which may have augmented a safety plan”
- “Had anti-psychotic medication been prescribed, this would have had the effect of reducing symptoms of psychosis, and may possibly have prevented the death”.
In respect of Pembrokeshire County Council, the Senior Coroner stated:
“I cannot find any act or omission on the part of Pembrokeshire County Council probably or possibly would have altered Kianna’s outcome, even if I have found failures on their part”.
Returning a narrative conclusion, the Senior Coroner concluded as follows:
“Kianna died as a result of hanging herself on October 23, 2019, at the old Commodore Hotel, Pembroke Dock, Pembrokeshire, on the balance that her mind was disturbed by psychotic symptoms and circumstances where, during the course of her medical assessment, her risk assessment had not been updated, medication had not been provided, and no plan to safeguard her was implemented.”
The Coroner now intends to write to CYSUR, the Mid and West Wales Regional Safeguarding Children Board to invite them to complete a Child Practice Review with a view to identifying any multi-agency improvements which need to be made to safeguard and promote the welfare of children and to prevent or reduce the risk of recurrence of similar incidents.
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