Cariss Stone

4 June 2024 

Mr Nicholas Rheinberg 
c/o Taunton Coroners Court 

Trust Management Office 
Musgrove Park Hospital 

Barton House South   

Parkfield Drive 
Taunton 
TA1 5DA 

Dear Mr Rheinberg 

REGULATION 28 REPORT – PREVENTION OF FUTURE DEATHS – Cariss Lucy Stone 

I am writing in response to your correspondence dated 10 April 2024 regarding the regulation 
28 of the Coroner’s (investigations) Regulations 2013 following the inquest regarding the death 
of Cariss Lucy STONE which concluded on the 9 April 2024.  

We have set out the matters of concern as raised in the report and our response to them.  

MATTERS OF CONCERN 

(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. 

Somerset NHS Foundation Trust Response 

Since this reported incident involving Miss Stone in 2019, Somerset NHS Foundation Trust 
Policy on Observation while maintaining Safety and Engagement has undergone a number of 
revisions to reflect changes in practice and to incorporate learning from patient safety incidents. 
The most recent version was published in May 2024 and builds upon existing policy and 
practice with the aim of providing greater clarity and improved clinical governance around 
practice of observation.  

The policy maintains 4 prescribed levels of observation: 

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Level 1 – General observation. 

Level 2 – Intermittent observation. 

Level 3 – Within eyesight. 

Level 4 – Within arm’s reach. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
  
  
 To provide clarity and support better understanding on the practice of undertaking level 2 
intermittent observations, the Trust has made a number of changes to the policy, which are 
detailed below. 

For patients who are prescribed level 2 intermittent observations, the policy provides clearer 
guidance on the importance of irregular and unpredictable intervals between observations. This 
is particularly important where there is an identified risk of harm to the patient, such as those 
patients presenting with a risk of self-harm or suicide. The policy also outlines the need for a 
multidisciplinary approach to the setting of observation levels. The policy ensures it makes no 
reference to historical terms such as ‘5-minute observations’ and instead focuses on the 4 
different levels of observation and for level 2, the maximum interval for observing patients. 

There is recognition within the policy about the need to consider patients who have been 
observed at level 3 and level 4, for long periods of time, and the need to carry out irregular and 
unpredictable observations at level 2, more frequently to support the patient and as part of our 
requirement to offer more individualised care.  

Where a patient has been on level 2 observations for long periods of time it may be of benefit to 
decrease the frequency of observations, prior to stepping down to level 1 observations.  

Where there are multiple patients on level 2 observations on any one ward, a decision must be 
made by the clinical team on how many staff members are required to safely complete all 
observations. Consideration should be given to the potential risks being managed and the 
frequency of observations per hour.  

For the majority of patients admitted to mental health inpatient services and who are prescribed 
level 2 intermittent observations, the suggested maximum interval for observing the patient will 
be 15 minutes. The policy, however, emphasises that this will be the maximum duration 
between level 2 observations and places a greater emphasis on the need for irregular and 
unpredictable observations.  

Where consideration is given by the MDT to prescribe observations at level 2 at reduced 
intervals e.g. not exceeding 5 minutes, there is recognition of the high level of concentration 
and focus required. For this reason, staff carrying out level 2 observations, at intervals not 
exceeding 5 minutes, will be allocated to only 1 patient, who has been assessed as requiring 
this level of observation. The nurse in charge will need to give consideration to their shift 
staffing capacity to ensure there are sufficient staff on duty to carry out observations, whilst 
ensuring a sufficient break in between each period of observation. 

To support better understanding of level 2 intermittent observations, randomised 5-minute 
observations, the revised policy provides more detailed guidance on practice, which is as 
follows: 

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One member of staff will be allocated to only one patient as in a level 3 or level 4 constant 
observation.  

The duration of this will be hourly.  

The member of staff will remain in the clinical vicinity of the patient ensuring a sense of 
guardianship and accessibility, whilst avoiding barriers such as numerous doors being 
between themselves and the patient.  

They will not return to the clinical office after each recorded observation, unless there is 
good reason to do so, or risk assessment dictates this.  

The member of staff will always retain the observation record with them.  

 
 
 
 
 
 
 
 
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This, in some circumstances, may require retaining paper and pen on the staff members 
person if risks militate towards not carrying the usual clipboard.  

The member of staff requires a high level of focus and concentration to perform this level 
of observations effectively. They will be careful to not be distracted during intervals and 
the supporting shift team will ensure that they are protected from completing tasks whilst 
performing them.  

The number of times that a patient is seen is not limited and intervals may be very short, 
even seconds when monitoring potential high-risk behaviours. Staff should use their 
instincts and skill to determine intervals in relation to patient activity.  

As staff are singularly dedicated to this level of observation, depending on the objective 
staff should take therapeutic opportunities to engage with the patient for extended periods 
if possible and helpful. 

All staff, who undertake observations, are required to complete an assessment of competence, 
which will be assessed by a competent Registered Mental Health nurse and who has a 
minimum of 1 year post registration experience. This is the same requirement for staff who are 
employed on the Trust’s bank or via a nursing agency. 

Each nurse carrying out observations is required to be assessed shadowing two observations 
rounds, including agency staff. The same nurse will then be supervised carrying out two 
observation rounds. A formal assessment of competence will be documented covering 12 areas 
relating to the observation of patients. This assessment will then be further enhanced by the 
member of staff watching a video produced by Kings College, which focuses on routines that 
prevent patient suicide. A record of the completed assessment of competence is then uploaded 
to the Trust digital learning platform, LEAP.  

The Learning and Development Team produce quarterly reports on compliance with the 
assessment of competence, which are shared with the Head of Service and reviewed as part of 
Inpatient & Urgent Care Operational Management and Governance meetings. 

(2) 

In a ward where self-harm, including use of a ligature, was not uncommon there was 
concern that members of staff, and particularly those involved in carrying out observations 
on patients were not routinely supplied with ligature cutters. 

Somerset NHS Foundation Trust Response 

In accordance with the Trust’s Standard Operating Procedure on the safe use of ligature 
cutters, the Trust supplies 4 types of ligature cutters, which are designed to assist in the 
removal of varying types of ligatures. These include: 

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Shark Safety Knife (Sometimes known as ‘Fish’ Safety Knife)  

Barrington LC1 folding hook knife  

Utility Scissors 

Cable and Wire Cutter  

All 4 types of ligature cutters are available on all the mental health inpatient wards and for 
reasons of patient safety and potential risks to Trust staff, are held within the nursing office and 
not routinely carried on the person during a shift. An additional Shark Safety Knife is also held 
in the clinic room with the emergency resuscitation equipment. 

 
 
 
 
 
 
 
 
 
 We considered the potential risks of supplying staff on wards like Holford (PICU) and Ash ward 
(low secure inpatient rehabilitation and recovery unit for male adults with mental health 
difficulties) where there is an increased risk of violence and aggression with ligature cutters. 
This required careful consideration of both the risks to patients, who present with self-harm and 
suicide versus the risk of patients who present with high levels of violence and aggression or 
with a documented forensic history. Our conclusion from this review with the ward teams and 
senior leaders is that the balance of risk would not support staff routinely carrying ligature 
cutters. 

It is also important to recognise that the types of ligatures that patients are fashioning utilise 
clothing and linen and which cannot be removed using the Shark Safety knife or scissors and 
often require the use of the Barrington LC1 which is a more robust ligature cutter and for 
reasons of patient/staff safety this type of cutter is held in the ligature cutter box.  

Consideration and discussion is underway to consider staff holding a ligature cutter whilst 
carrying out level 2 and 3 observations for patients who present with a risk of self-harm/suicide. 
This would be alongside a further review of the types of ligature cutters that are available on the 
market, to ensure they have the safest option. Once agreed we will seek to roll this out across 
all the MH wards and update our Observation policy to provide greater detail on the process. 

The Trust has set up additional training on the Management of Ligatures which is taking place 
on 21 June 2024 and will be available across all MH Inpatients wards. This training is designed 
to offer a half day course by an external facilitator and will cover: 

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Ligature risk assessment and control measures  

Identification of different types of ligatures & ligature points  

Statistics on ligature injuries in Care Environments  

Signs and symptoms of ligature injuries  

Safe removal of ligature using a range of ligature cutters 

Individual and Team Rescue  

Safe removal from Suspension  

Safe storage of ligature cutters  

There will then be an expectation that the colleagues attending this course will act as the point 
of contact for ligature management on their wards and provide local education/training for both 
new and existing staff. 

I hope the above information meets with your approval and satisfaction and that the actions 
outlined suitably address your matters of concern.  

Please do not hesitate to contact me if you require further information. 

Your sincerely 

CHIEF EXECUTIVE 
Somerset NHS Foundation Trust