A teen died in a secure unit in Taunton after 'lapses' in her suicide watch, an inquest heard.
Cariss Stone, 19, died five months after being taken into a psychiatric ward after several incidents of self-harm.
The police cadet volunteer was known to mental health services since the age of 15 and had been detained six times previously.
She was staying in the Holford Ward of the Wellsprings Hospital in Taunton, Somerset, on a regime that mandated observations every five minutes.
But on August 9 2019, she was found unresponsive – dying two days later on 11 August.
Cariss, who had been diagnosed with aspergers in 2018, was put on an surveillance regiment that involved observations once every five minutes, assistant coroner Nicholas Rheinberg said.
Opening a ten-day inquest in Wells, Somerset, on Tuesday he added these hadn't always been carried out.
He told the jury: "Cariss was observed once every five minutes.
"Observation regiments range from constant observation, five minute observation, to observation at longer intervals.
"There were lapses in the five minute observation regiments."
The inquest heard Cariss’ went into her room at 2.33pm on 9 August.
At 3.12pm, the on-duty member of staff found Cariss unresponsive in her en-suite bathroom with an item of clothing around her neck.
Paramedics were called but they were unable to resuscitate her, and Cariss died two days later.
The 19-year-old was described as “exceptionally intelligent”.
She had an IQ of 156 and a “wide array of interests”, according to psychologist Dr Andreas Papadopoulos – who served as Cariss’ clinician.
Cariss was part of her school’s gifted and talented programme and did well in her GCSEs.
Mum Gina Schiraldi said Cariss was “proud” to be a volunteer police cadet when she joined up aged 16.
She “absolutely loved it”, Gina said in her witness statement.
"When well, [Cariss] was bright and bubbly and full of energy and ideas."
She arranged for her and friends to go to concerts and "loved" her cat, Bob.
Aged 16, Cariss signed up for the organ donor register.
In July 2014, Cariss was diagnosed with anorexia.
Her GP, Dr Lynn Donlevy told the inquest: "Cariss felt scared to eat as it would make her fatter and fatter. Eating made her ‘want to die’."
At one point, Cariss was so ill she needed to be fed via tubes and use a wheelchair.
The former health and social care student at Strode College, Street, also regularly self-harmed, the coroner heard.
Between 2014 and 2018 Cariss was admitted to hospital four times.
She was admitted to St Andrew's Ward at Priory Health Park in Wells, run by the Somerset Foundation Trust, on 22 March 2019 following “serious” acts of self-harm.
Cariss was transferred between various wards before being admitted to Holford Ward, a psychiatric intensive care unit (PICU), run by the same NHS Trust, in June 2019.
She remained at the unit until she was found unresponsive on the afternoon of August 9, 2019.
The Holford Ward involved patients with more “complex” needs, the inquest was told.
The inquest continues.