a faithful record of the assessment and care of an individual. - but if something then happens, i of course, they re also the record that gets looked at and examined l if an investigation is required. l so, yeah, they re really, really important. - at bluestone, the 15 minute patient checks became part of the investigation into sean s death. the investigators said they could not be confident sean was observed as prescribed within every 15 minute period, as written on the observation sheets. this is because a member of nursing staff said in a written statement and an interview they had seen sean walking into his room at 3.40pm, less than 15 minutes before he was found asphyxiated. this sighting counted as a check on sean s welfare, but the ward cctv camera told a different story. when questioned by the police, the staff member said they had made a mistake.
much as a last resort. when he was admitted, sean refused to take a covid test. he was uneasy interacting with staff who were wearing full ppe. for infection control reasons, he was confined to a four bedroom corridor away from most other patients. covid restrictions were applied across mental health servicesl in northern ireland. unfortunately for people with a mental illness, i this could add to the distress, - you know, and you have that concern about transmission of covid. at the same time, it was a terrible situation for everybody. but for people with mental illness, we know that i their illnesses got worse. watched by the wards cctv camera, sean spent hours on his own with almost nothing to do. he didn t sleep and refused food. his paranoia led him to believe it could have been tampered with. at some point during the night, a member of the nursing staff took