Police cadet, 19, who died on psychiatric ward due to lapses in her five-minute suicide watch should already have been sent home but NHS Trust was worried about its reputation, inquest hears

A police cadet who died on an NHS psychiatric ward due to 'lapses' in her five-minute suicide watch should have been sent home but bosses were more worried about their reputation, an inquest has heard. 

Cariss Stone, 19, had been detained under the Mental Health Act when she was found unresponsive in the bathroom of her room at Wellsprings Hospital in Taunton, Somerset in August 2019.

An inquest into her death heard the police cadet volunteer, who had been detained six times previously, was kept in an intensive psychiatric unit despite it being recognised that she needed to be discharged into the community.

The inquest saw documents which suggested that this was, at least in part, motivated by a desire to avoid legal or reputational risk to NHS Somerset in the event that there was a 'serious untoward incident review.'

At it's conclusion, the jury concluded that Cariss' death was 'accidental' - contributed to by 'deficiencies' in the way her observations were carried out.

The 19-year-old, who had a long history of anorexia, self-harm and suicide attempts, was being held under section at the Holford Ward at Wellsprings Hospital from June 2019.

She was meant to be observed every five-minutes, but according to a health assistant who was overseeing Cariss' care, she had 'loads' of patients to watch and no training on how to monitor them, the inquest heard.

The former police cadet was pronounced dead at Musgrove Park Hospital two days after she was found unresponsive by the healthcare assistant.

Cariss' mother, Gina Schiraldi, said her daughter was 'let down' by the services that were meant to support her and 'implored' the trust to 'reflect' on the issues raised.

Speaking at the end of the inquest, she added: 'We miss Cariss very much. There is a space where she should be - she is missing from family photos, and there is an empty chair where she should be sat at the dinner table. 

'There is only silence where there should be music and laughter, enjoying time and making plans with friends and family.

'Had Cariss' care been managed differently, we think she would still be with us and working towards her hopes and dreams for the future. 

'Despite her challenges Cariss worked so hard and she was so bright. 

'She needed help with learning how to cope with her condition, and she was let down by the services that were designed to support her.

'I also wish to express my dissatisfaction of the manner in which the coronial investigation into Cariss' death has been undertaken. Cariss died unnaturally in state detention.

'The state has a duty to investigate such deaths in a timely way. The fact that we as a family had to wait almost five years for an inquest is completely unacceptable and the passage of time hindered the quality of the investigation in numerous ways.

'It is devastating to know the Trust's decision to admit Cariss to a PICU rather than discharge her to the community was influenced by the Trust wanting to avoid future legal risk. 

'We believe that if Cariss had been discharged home at that point, she would still be with us.

'We implore the Trust to reflect on the issues raised by this inquest and the way it has conducted itself in the wake of Cariss' death, so that similar cases and additional distress to families can be avoided in the future.'

Andrew Terry, a human rights lawyer representing Cariss' family, said: 'Her records indicated that she required observations every five minutes during the day. But on the day that she fatally self-harmed she was not seen for a period of time substantially in excess of the five minutes.'

He added: 'The jury's conclusion recognises that Cariss did not intend to die. Cariss was extremely unwell, but she desperately wanted to get better.'

Between 2014 and 2018 Cariss had been admitted to hospital four times after being diagnosed with an eating disorder.

She was initially admitted to St Andrew's Ward at Priory Health Park in Wells, run by Somerset Partnership NHS Foundation Trust, on 22 March, 2019.

Cariss was transferred between various wards before being admitted to Holford Ward, a psychiatric intensive care unit (PICU), also run by the NHS Trust, in June 2019.

She remained at the unit until she was found unresponsive on the afternoon of August 9, 2019.

Jane Yeandle, service group director for mental health and learning disabilities at Somerset NHS Foundation Trust said: 'Our deepest sympathies go out to Cariss' family for their tragic loss. We apologise wholeheartedly for the shortcomings in the care we provided.

'We accept the coroner's findings and will act on those recommendations.

'In 2019 we commissioned an external review, which touched on some of the themes discussed at the inquest and made a number of improvements to our systems and processes to ensure we are working in line with best practice. We will look closely at the coroner's finding to see whether there's more we can do.

'We have improved the training for colleagues who undertake clinical observations, to ensure all details are clearly recorded and that colleagues communicate more effectively with each other. We will also undertake to improve the way we involve and communicate with families during the investigation of incidents.

'Once again our thoughts are with Cariss' family at what we realise will be a very difficult time.'

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