Due to the national shortage of mental health beds, he had already waited three weeks for a placement
Gail Rawlinson had no choice but to place her trust in medical professionals when her son was detained under the Mental Health Act.
The practice is so commonplace that providers such as The Priory and Cygnet operate a 24-hour availability system whereby NHS practitioners can request a bed. Both have pages on their websites, updated daily, to show how many beds they have available at that time. As a result, and because the Section 135 warrant had not yet been signed by a police officer, as is required by law, staff at The Harbour wrongly assumed he was being admitted as a voluntary patient.
5. The nurse who assessed Bren on arrival failed to check his medical records The nurse who oversaw Bren's admission to The Harbour on October 24, "didn't trust" the electronic medical records system. If she had done then she would, hopefully, have recognised the suicide risk. The inquest heard that senior members of staff were aware that employees were using their personal mobile phones at work despite it being against the rules. Since Bren's death all staff have been reminded that using personal mobile phones, vaping and smoking are strictly prohibited.
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