• 01616 966 229
  • Request a callback
Stephensons Solicitors LLP Banner Image

Jury confirm serious failings at mental health unit contributed to death of vulnerable young man

Do I need a solicitor at an employment tribunal?

Stephensons Solicitors LLP acted on behalf of Gail Rawlinson whose son, Brendan McFarlane (Bren as he was known to his family), died in the care of Lancashire and South Cumbria NHS Trust. 

Bren had suffered mental health difficulties since his early teens. Having undergone a number of assessments, it was determined that Bren required assessment in hospital under the Mental Health Act.

There were serious delays in obtaining a bed meaning that his admission could not occur when necessary, and continuing concerns about his mental well-being led to a warrant, known as a section 135, being issued to take him to a place of safety.

On 24 October 2022, having been seen by a mental health professional, Bren agreed to go into hospital meaning that the 135 warrant had not in fact been properly executed.   

Bren was taken to the Harbour Hospital, Blackpool and placed in the section 136 suite. This is a room which is defined as a place of safety for those suffering mental distress, who may effectively pose a risk to themselves or others due to their illness at that time. 

Given the uncertainty of Bren’s detained status on arrival at the Harbour, staff did not carry out a full search and Bren was asked to volunteer what items he had on his person. 

CCTV evidence played to the jury showed that the nursing staff who were meant to be observing Bren, spent a total of 2 minutes and 54 seconds out of a 59-minute period actually checking on whether he was ok. The footage instead showed staff plaiting each other’s hair, vaping, and checking social media on their mobile phones.

During this time, Bren had used an item that he had been left on his person to create a ligature in his room. He then attached this to a fixed point in the ensuite bathroom, which should have come away from the wall if weight was applied if fitted correctly.

Bren was taken to Blackpool Victoria hospital where he was found to have suffered irreversible brain damage as a result of hanging and he suffered brain stem death, with life support being withdrawn on 29 October 2022.

Bren had however courageously agreed to organ donation before his death and went onto make life changing contributions to at least three others despite his death.

The jury made conclusions that Bren died as a result of misadventure, contributed to by neglect. 

They found that, on the balance of probabilities, the care and delivery issues more than minimally, trivially or negligibly contributed to the death of Bren. 

They returned a number findings that had been accepted by the Trust to have been below expected standards.

Gail Rawlinson, Bren’s mother said……

As a family, as you can imagine, we are beyond words and utterly devastated at the findings and at the loss of our precious, beautiful, kind, bold hero of a boy. 

The findings of the jury and the admissions of the trust that, on admission to the unit, there was no proper review of Bren meaning he was not properly observed, along with the actions of the staff and general environment did not protect my son like it should have been done.    This amounted to a gross failure to provide basic medical attention and care to my son who was in a dependent position. 

As a family, we feel it is important to highlight the issues so that no family should go through anything like this ever again. 

Bren will live on in our hearts forever more and is now in the arms of Jesus."

Natalie Tolley, an associate at Stephensons in the inquest team added “the circumstances of this case reflect that the lack of basic care afforded to Bren on his admittance to the Harbour contributed to his tragic death. The Trust accepted that Bren’s risk to himself was not properly assessed on his arrival at the unit, this included his historical risk factors. The lack of policy in place when someone arrived at the Harbour without an Approved Mental Health Professional (AMHP) or police officer with them meant that Bren was not properly searched or observed and ultimately was able to ligature which resulted in his death. It is comforting for Bren’s family that the jury’s findings reflect the failings of the Trust and the evidence heard throughout the week”. 

Ms Rawlinson and her family were represented by  Laura Nash  from St Johns Buildings Manchester instructed by Natalie Tolley from Stephensons' inquest team.