Inquest resumes into suicide of 16-year-old in Pembroke Dock

Kianna’s body was found hanged from the derelict Commodore Hotel on Pembroke Dock’s Admiralty Way on the evening of Thursday, October 24, 2019.

The Commodore Hotel, Pembroke Dock (Image: Western Telegraph)

Her mother, Joanne Patton, had made repeated calls to both Pembrokeshire County Council and Hywel Dda Health Board for their intervention in safeguarding her daughter.

Ms Patton has persistently claimed that the care and support shown to her daughter were an ‘arguable breach’ of the council’s and the health board’s general duty. She further challenges the coroner’s ruling in August 2021, which concluded that Kianna’s inquest would not fully investigate the circumstances by which she met her death following the investigative duty contained in Article 2 of the European Convention on Human Rights.

Now, following her High Court Hearing in May 2022, the coroner’s decision has been quashed.

Ms Patton’s concerns stem back to 2017 when Kianna began going missing from the family home in Milford Haven; in June of that year she took her first drug overdose.

In January 2018 she started taking drugs on a more regular basis and her attendance at school began to deteriorate. She began to self-harm and was assessed by the Specialist Child and Adolescent Mental Health Services (S-CAMHS) who placed her on their waiting list.

Four months later she took a drug overdose and told medical practitioners she wanted to end her life. Another referral was made to S-CAMHS and the county council was also notified of her needs.

In July 2018, following an altercation with her mother, Kianna left home to live with a friend. She was assessed by a social worker but was found to not meet their criteria for support.

But Joanne Patton was becoming increasingly concerned at the unsuitability of the property where Kianna was living and the amount of drug misuse that was occurring there. She informed both the police and the local authority of her concerns.

The police directed her to the council with a view to them finding alternative accommodation; a police log confirms that the information Mrs Patton prepared would be shared with the council via a multi-agency referral form. But the council has no record of receiving this.

Ms Patton eventually contacted the council herself only to be told that because the drugs were recreational, it was a matter for the police. Again, there is no record of this conversation.

Joanne Patton then contacted her MP, Stephen Crabb, who asked both the council and the police to agree a co-ordinated approach in helping Kianna address her issues.

In September, Kianna visited her GP and said she was hearing voices and was having delusions that her mother had killed herself and that she, herself, had been raped. The following month she met with S-CAMHS and told them she had on-going thoughts of ending her life. Following their interview, S-CAMHS recorded a conclusion of ‘No current self-harming behaviour’.

On October 23 Kianna was reported missing. The following day her body was discovered in the hotel in Pembroke Dock.

This week Senior Coroner Mark Layton was asked to conduct an Article 2 inquest which will investigate the failures by health and council staff of recognising a suicide risk and of taking the necessary steps to prevent it. Article 2 will also consider if there is suspicion that Kianna’s death resulted from the State breaching its duty to protect her against risk.

A further ruling in respect of Article 2 will be made by the coroner in the next seven days.