Inquest into death of Somerset teenager hears of lack of staff training

A healthcare assistant tasked with carrying out “five-minute observations” on a vulnerable teenager in a psychiatric intensive care unit has told a jury at the young woman’s inquest she had “loads” of patients to watch and had not received training on how to monitor them.

The teenager, Cariss Stone, who had been diagnosed as having emotionally unstable personality disorder and was considered at risk of self-harm, was found unresponsive in the bathroom of her room at the unit in Taunton, Somerset, and died two days later. A postmortem concluded the cause of death was hypoxic brain injury, cardiac arrest and asphyxia.

The inquest at Wells town hall was told that Stone, 19, who had been a volunteer police cadet, had been detained under the Mental Health Act and was subject to a regime of “five-minute observations” to keep her safe.

An agency healthcare assistant, Samantha Sands, said she took over observations of Stone and other patients at 2.30pm on 9 August 2019. There were gaps of up to 12 minutes in the observations between then and when Stone was found collapsed in her bathroom at 3.12pm.

In a statement, Sands said the last time she saw Stone, she seemed fine. “She was sitting on the floor on her mobile phone with her headphones on looking around the room. She did not exhibit any distress.”

When Sands looked through the window of Stone’s room at 3.09pm, she could not see her. She went away but had a “gut feeling” and returned two minutes later. Sands entered the room and found Stone critically ill in the bathroom.

Asked by the coroner’s officer, Simon Dobson, if she had been given training in how to undertake observations, she said: “Not training, just told me what to do, showed me what to do.” Asked how many other patients she was observing, she said: “Maybe 11 or 12. Loads.”

When asked why she had not done checks every five minutes, she said she had been told by care staff to do the checks “at different times” so patients did not know when they would be observed and added: “I was also checking on other people.”

She said she had not called out to Stone when she could not see her in her room because the teenager was not on “toilet observation”.

At the start of the inquest earlier this week, the assistant coroner, Nicholas Rheinberg, said there had been “lapses” in the observation regime. However, there has also been evidence from health staff that though they were called “five-minute observations”, in fact the policy was that patients on the regime should be seen five times an hour, at irregular times. He said the policy had been changed to make it clearer.

Stone’s mother, Gina Schiraldi, from Street, Somerset, has said Stone was highly intelligent and proud to be a volunteer police cadet. When she was well, she was “bright and bubbly and full of energy and ideas”.

The jury was told she had suffered anorexia, possibly caused by childhood trauma and bullying at school and been detained seven times.

At the time of her death she was under the care of staff at the Holford ward at the Wellsprings hospital site, which is run by the Somerset NHS foundation trust and provides intensive acute treatment for detained people in the most disturbed phase of their mental illness.

The inquest continues.