A mum has called for lessons to be learnt after her teenage daughter died on an psychiatric ward due to 'lapses' in her five minute suicide watch.

Grieving mum Gina Schiraldi said Cariss Stone, 19, "would still be with us" if she had been allowed home, after an inquest ruled her death as 'accidental'.

Cariss, who was found unresponsive with a ligature around her neck in August 2019, was kept in an intensive psychiatric unit despite it being recognised that she needed to be discharged to the community, the inquest heard.

This was motivated, at least in part, by NHS Somerset Trust's desire to avoid legal or reputational risk in the event of a "serious untoward incident review", documents seen by the inquest suggested.

After a week-long inquest, the jury concluded that Cariss' death was "accidental" - contributed to by "deficiencies" in the way her observations were carried out.

Cariss, who had a long history of anorexia, self-harm and suicide attempts, was being held under section at the Holford Ward at Wellsprings Hospital in Taunton, Somerset, 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.

Speaking after the inquest held in Wells, Somerset, Ms Schiraldi, Cariss' mum, 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.

"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."

Alexander Terry , a human rights lawyer of legal firm Irwin Mitchell 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."