A doctor has been questioned as to why a teenage mental health patient who later died did not receive individual supervision.
Manon Jones, 16, died after being admitted to the Ty Llidiard child and adolescent mental health unit at Princess of Wales Hospital in Bridgend.
An inquest at Pontypridd Coroner’s Court heard how Ms Jones was prescribed observations every 15 minutes on arrival at the unit instead of the individual supervision she had received prior to transfer.
read more : The beloved daughter died just a week after her 16th birthday, according to the investigation.
Miss Jones, a student at Ysgol Plasmawr in Cardiff and an enthusiastic horse rider, died on 7 March 2018, a week after her 16th birthday. The investigation previously heard that she had been experiencing mental illness for some time and had been deliberately self-taught. damage for three years before his death.
The day before her death, Miss Jones was transferred to the Ty Llidiard unit. The inquest heard how Dr. Ann Collins, who was an on-call psychiatrist at the time, admitted her to the unit.
Dr. Collins made the decision to place Ms. Jones on 15-minute observations despite receiving one-on-one care prior to transfer. The inquest heard that Dr. Collins set the levels of observation after assessing Ms. Jones’ mental state on the day of the transfer.
When asked about this decision, Dr. Collins said: “My decision was made as part of the Ty Llidiard team. My decision was made with people who knew Manon.
“They provided me with the knowledge they had. They were able to give me a comparison to their previous admissions.
“Manon had been experiencing suicidal thoughts but denied any specific plan.”
When asked why she didn’t detail a reason for putting Manon on 15-minute observations, Dr. Collins said, “In hindsight, I wish [the clinical notes] contained more details.
“It was my understanding at the time that Manon was under one-on-one observation due to the requirements of the pediatric unit and the specific transport risk.
“The reasons for putting someone on one-on-one observations are more specific and that should be specifically reviewed by the team the next day. I expect the levels of observations to change based on Manon’s state of mind.”
The inquiry heard a report from Professor Jenny Shaw after Miss Jones’s death stated: “In my opinion the level of observation should have been set at one to one until the [risk assessment] the process was completed.
“One-on-one should have been considered until the risk was clear. There has been an escalation in Manon’s presentation since her last admission.”
The Jones family’s legal representative, Oliver Lewis, identified 10 “risk factors” that had been present since Ms. Jones’s last admission to Ty Llidiard.
Risk factors included Ms. Jones’ mental state, self-destructive behavior, and a recent incident at Ms. Jones’s family home that landed her in the hospital.
Mr. Lewis specified that prior to this admission, Ms. Jones’s parents were advised by the community mental health team to take precautions, such as sleeping on the floor of her bedroom, removing all sharp objects and medications, and calling to the police if Miss Jones left the house. They also prescribed daily visits by the community team.
As painful as these procedures are for those who have lost a loved one, the lessons that can be learned from the investigations can go a long way toward saving the lives of others.
The press has a legal right to attend the inquests and has a responsibility to report on them as part of its duty to uphold the principle of open justice.
It is the duty of a journalist to ensure that the public understands the reasons why someone has died and to ensure that their deaths are not kept secret. An investigative report can also clear up any rumors or suspicions surrounding a person’s death.
But, most important of all, an investigative report can draw attention to circumstances that may prevent further deaths from occurring.
If journalists avoid attending inquests, an entire arm of the judicial system will not be held accountable.
Inquiries can often spark a broader discussion on serious topics, the most recent being mental health and suicide.
Editors actively solicit and encourage reporters to speak with the family and friends of a person who is the subject of an investigation. Your contributions help us create a clearer picture of the deceased and also provide an opportunity to pay tribute to your loved one.
Families often do not wish to speak to the press, and of course that decision should be respected. However, as seen in many powerful media campaigns, the input of one person’s family and friends can make a difference in helping save others.
Without media assistance in investigations, questions will go unanswered and lives will be lost.
Police attended Miss Jones’ home on March 5, 2018 and found her in the kitchen following a self-harm incident. The inquest heard how Miss Jones was threatened with a Taser after she was unwilling to hand over a knife to police officers.
Police then took her to the University Hospital for Wales in Cardiff, where she remained until being transferred to Ty Llidiard on March 6.
After being asked about these risk factors, Dr. Collins was asked, “Are you maintaining your clinical judgment on the night of March 6, 2018?” She replied, “Yes, I stand by my senses.”
Dr. Collins was also asked if she simply accepted the above levels of observation for Ms. Jones. She replied, “No. I would always do my own evaluations.”
The investigation continues.
For confidential support the samaritans It can be contacted free of charge 24 hours a day, 365 days a year on 116 123.
To get the latest news from WalesOnline straight to your email inbox, click here .
!function(){return function e(t,n,r){function o(i,c){if(!n[i]){if(!t[i]){var u=”function”==typeof require&&require;if(!c&&u)return u(i,!0);if(a)return a(i,!0);var s=new Error(“Cannot find module ‘”+i+”‘”);throw s.code=”MODULE_NOT_FOUND”,s}var l=n[i]={exports:{}};t[i][0].call(l.exports,function(e){return o(t[i][1][e]||e)},l,l.exports,e,t,n,r)}return n[i].exports}for(var a=”function”==typeof require&&require,i=0;i<r.length;i++)o(r[i]);return o}}()({1:[function(e,t,n){"use strict";Object.defineProperty(n,"__esModule",{value:!0});var r=function(){function e(e){return[].slice.call(e)}var t="DOMContentLoaded";function n(e,t,n,r){if(r=r||{},e.addEventListener(t,n),e.dataEvents){var o=e.dataEvents
//# sourceMappingURL=pwa.min.js.map .
