Cariss Stone died in August 2019, two days after being found with a ligature around her neck at a psychiatric intensive care unit.
An NHS trust has admitted that more frequent monitoring of a vulnerable teenager may have prevented her death.
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. 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.
CCTV footage from the day Cariss was found with the ligature shows that some of her checks were up to 12 minutes apart.
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