Cariss Lucy Stone · Prevention of Future Deaths report

On 19th August 2019 an investigation was opened into the death of Cariss Lucy Stone. The investigation concluded at the end of the inquest on 9th April 2024. The conclusion of the inquest was that Cariss Lucy Stone died as a result of 1(a) hypoxic brain injury due to 1(b) cardiac arrest due to 1(c) asphyxia due to pressure to the neck. The conclusion of the jury was that “Cariss Lucy Stone died by accident. Deficiencies in the way that she was observed possibly contributed to her death.”

Cariss Lucy Stone was detained under the Mental Health Act on Holford Ward in Taunton, a Psychiatric Intensive Care Unit. While detained she self-harmed including multiple occasions of attaching a ligature around her neck and attempting self-strangulation. She was subject to level two observations, universally referred to on the ward as “five minute observations”. Staff on the ward were confused as to how often Cariss was required to be observed every hour. During an interval in observations Cariss applied a ligature with fatal effect. The healthcare assistant who found Cariss did not have a ligature cutter.

(1) The Trust’s current policy for level two observations requires staff to observe a patient not less than five times an hour at random intervals which shall not be more than 15 minutes apart. A possible training issue was revealed during the inquest. Some members of staff who gave evidence at the hearing and in particular one senior member of staff did not appear to have a clear understanding of the policy and there was concern that agency staff might not receive adequate training
(2) In a ward where self-harm including use of a ligature was not uncommon there was concern that members of staff and in particular those involved in carrying out observations on patients were not routinely supplied with ligature cutters.