A teenage mental health patient died after "essential failures" in her safeguarding, an inquest heard.
Manon Jones, 16, was a pupil at Ysgol Plasmawr in Cardiff when she died on March 7, 2018.
An inquest into her death at Pontypridd Coroners' Court concluded on Friday after two weeks of evidence.
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Miss Jones died after being admitted to the Ty Llidiard child and adolescent mental health in-patient unit at the Princess of Wales Hospital in Bridgend.
Addressing the court on Friday coroner David Regan summarised: "Manon suffered a deterioration in her mental health in late February 2018.
"Manon had a diagnosis of depression and emotional disregulation. The latter was not a formal diagnosis."
He added: "I recognise that this has been a difficult time of Manon's family."
The inquest heard how Miss Jones had chatted with mental health staff about her future plans for attending an equine event with her mother and travelling abroad.
The coroner acknowledged that many of the staff involved with Miss Jones' care were very distressed over her death and thanked them for their testimony.
During the proceedings the inquest heard witnesses become emotional when reliving Miss Jones' death.
The coroner summarised the evidence previously heard over the course of the inquest, which began on January 17. On the day of her death Miss Jones' room had been locked from the inside and the bathroom door was also locked. Miss Jones was found in the bathroom at 9.18 pm and could not be resuscitated by Ty Llidiard staff or paramedics.
The inquest previously heard a doctor questioned over why Miss Jones was not assigned one-to-one supervision when she arrived at Ty Llidiard.
In the inquest conclusion the coroner said: "Manon experienced an acute worsening of her condition in late February 2018.
"I find that, as Professor Shaw identified, Manon should have been safeguarded by one-to-one observations until a more detailed assessment of the risks she posed to herself had been carried out. This should have been grounded in knowledge of all of the known recent risk factors as the requirement for a [risk] assessment envisaged.
"I find it was a failure in her care for this not to have occurred.
"I do not find that there is sufficient evidence to persuade me that Manon intended to end her life.
"The essential failures to safeguard Manon were serious. However they do not in my judgement amount to gross failure to provide basic medical attention within the narrow definition of neglect in coronial law.
"A narrative conclusion is in my view appropriate. Manon Edie Jones, aged 16, suffered depression and emotional disregulation. Her behaviour was impulsive and she had a significant history of self-harm."
The conclusion was listed as follows: "Manon Jones died from ligaturing while suffering a mental health episode in circumstances where she ought to have been subject to continuous one-to-one observations pending further assessment."
The coroner stated that he would be making a Regulation 28 report to the Cwm Taf Morgannwg health board identifying a concern that the "absence of a system allowing common record-sharing might lead to a recurrence of death".
Following the hearing Miss Jones’ family released a statement which said: “Manon was a bright, talented, and dynamic 16-year-old who was a real force of nature. She was caring, loving, and passionate but had to endure a crippling battle with depression and self-harm.
“We have always believed that there were serious failings by the psychiatrists at Ty Llidiard in not properly assessing the level of risk that Manon posed to herself due to the rapid decline in her mental health in the last days of Manon’s life. It has been heartbreaking to hear that more should have been done to safeguard our daughter when she so desperately needed it.
“During the inquest we were astonished to learn that across Wales there is no electronic system of record-keeping which would have facilitated real-time information in respect of Manon’s risk. We fully support the coroner’s report to prevent future unnecessary deaths to Cwm Taf Morgannwg health board and hope it will stop other families having to go through the agonising pain of losing their child. However we call on the Welsh Government to implement a national system that will enable health boards to keep up-to-date records electronically that can be readily accessed and shared.
“We will never recover from the horror of losing Manon. We want to remember Manon by trying to protect others and lobbying for change.
“We want other parents to have a really clear understanding of the risks associated with depression but real change will only happen if local mental health services can be relied upon to provide the effective critical care that is so desperately needed. We hope that the coroner’s conclusion and findings will spark a much-needed change in mental health services for children and young people in Wales.
“We are all very relieved that the inquest process is over and would like to thank the coroner for his thorough consideration of all the evidence.”
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