Inquiry into the death of a Somerset teenager hears about a 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 that she had ‘lots and lots’ of patients to look after watching and that she had received no training on how to supervise. them.
The teenager, Cariss Stone, who had been diagnosed with emotionally unstable personality disorder and was believed to be at risk of self-harm, became unresponsive in the bathroom of her room on the ward in Taunton, Somerset, and died two days later. An autopsy concluded that 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 subjected to a regime of ‘five minute observations’ to keep her safe .
Samantha Sands, a health care assistant for the agency, said she took over observations of Stone and other patients on August 9, 2019, at 2:30 p.m. There were gaps of up to 12 minutes in the observations between then and when Stone was found collapsed in her bathroom at 3.12am. p.m
In a statement, Sands said the last time she saw Stone, she seemed fine. “She was sitting on the floor with her headphones on her mobile phone looking around the room. She didn’t show any discomfort.”
When Sands looked through the window of Stone’s room at 3:09 p.m., she couldn’t see her. She left, but had a “gut feeling” and came back two minutes later. Sands entered the room and found Stone seriously ill in the bathroom.
When asked by the coroner, Simon Dobson, if she had received training in conducting observations, she said: “No training, just told me what to do, showed me what to do.” When asked how many other patients she observed, she said, “Maybe 11 or 12. A lot.”
When asked why she had not carried out checks every five minutes, she said healthcare staff had told her to carry out the checks ‘at different times’ so patients did not know when they would be observed. She added: ‘I also checked other patients. people.”
She said she didn’t call out to Stone when she couldn’t see her in her room because the teen wasn’t on “restroom observation.”
At the start of the inquest earlier this week, the assistant coroner, Nicholas Rheinberg, said there had been “errors” in the observation regime. However, there is also evidence from health staff that, although they were called “five minute observations”, in reality the policy was that patients under the regime were to be seen five times an hour and 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 was proud to be a volunteer police cadet. When she recovered, she was “bright and bubbly and full of energy and ideas.”
The jury was told she suffered from anorexia, possibly caused by childhood trauma and bullying at school, and was restrained seven times.
At the time of her death, she was under the care of hospital staff the Holford branch at the Wellsprings hospital site, which is operated by the Somerset NHS Foundation Trust and provides intensive acute treatment for incarcerated people in the most disturbed phase of their mental illness.
The investigation continues.