David Morgan, a 35 year-old man, told staff he’d taken an overdose. A nurse decided the man seemed drunk and needed to ‘sober up’. No proper medical assessment was conducted, and staff locked him in a holding cell. Over the next two and a half hours David became ‘increasingly distressed and unwell’, ‘incapable of coherent speech’ and ‘was unable to prevent himself from repeatedly falling on the floor’.
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