Mother of Somerset teenager believes her daughter would still be alive if she'd had 'correct care'

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The mother of a vulnerable teenager with a history of self-harm believes her daughter would still be alive if she'd received the 'correct care'.

Cariss Stone died aged 19 in August 2019, two days after being found on a bathroom floor at a psychiatric intensive care unit having attempted to take her own life.

At an inquest into her death, Somerset NHS Foundation Trust said the teenager, who was from Street, could "possibly" have been saved if she had been more frequently monitored.

The former Strode College student was judged a high enough risk to herself to need welfare checks several times an hour at the psychiatric intensive care unit where she spent the final two months of her life.

“Had Cariss’ care been managed differently, we think she would still be with us and working towards her hopes and dreams for the future," said her mother, Gina Schiraldi.

"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.

"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.

"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."

Dr Lucy Knight, Medical Director of Somerset NHS Foundation Trust, told the jury at Wells Town Hall that there was confusion among staff as to how often Cariss needed monitored.

She had been judged to require NHS standard Level 2 observation - which includes welfare checks five times an hour - at random intervals - and not more than 15 minutes apart.

The jury heard that a nurse in charge of Holford Ward, the facility in Taunton where Cariss was detained, had decided to implement patient checks every five minutes and had given staff record sheets with pre-printed five-minute check times.

Dr Knight said the sheets were "totally unhelpful and misleading" because they resulted in staff filling in records that weren't true.

CCTV footage from the day Cariss was found in the bathroom shows that some of her checks were up to 12 minutes apart.

Under questioning from solicitor Scarlett Milligan, on behalf of Cariss's family, Dr Knight conceded that had Cariss actually been monitored every five minutes her life might "possibly" have been saved.

She added that she believed a five-minute regime was unrealistic and could cause extra stress to psychiatric patients.

The inquest previously heard how Cariss had struggled with anorexia and self harm since she was 14.

Jane Yeandle, service group director for mental health and learning disabilities at SomersetNHS 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 themesdiscussed at the inquest and made a number of improvements to our systems andprocesses to ensure we are working in line with best practice. We will look closely at thecoroner’s finding to see whether there’s more we can do.

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

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