A number of failings have been admitted by Greater Manchester Mental Health (GMMH) following the death of a 24-year-old man.
Alex Turner, 24, went missing from the Eagleton Ward at Salford Royal Hospital's Meadowbrook Unit on the evening of December 5, 2019
The first day of a two-week inquest into Alex's death at Bolton Coroner's Court heard that he was found dead on the railway line, near Eccles station, the next morning.
Just a week before his death, the court heard that Alex had been discharged from the Swift Assessment for the Immediate Resolution of Emergencies (SAFIRE) Unit at North Manchester General Hospital - despite repeatedly warning staff that he would take his life if released.

Later the same day, November 29, he was admitted to the Eagleton Ward at Salford Royal Hospital's mental health inpatient unit Meadowbrook.
Dr Muhammed Kazmi worked as a psychiatrist at the SAFIRE unit and was involved in the decision to discharge Alex.
He admitted that the decision had been a "failure".
Alex's dad Matthew Turner described his son as a "loyal, loving and sensitive person."
Mr Turner told the court that Alex was born in Bolton but that the family moved to New Zealand when he finished primary school.
After Alex finished secondary school, they returned to England and settled in Whittle-le-Woods, in the borough of Chorley.
Alex studied Computing at Bolton College and eventually got a job as an IT technician. Mr Turner said that Alex struggled and eventually found work with FedEx.
He took on a range of jobs at the company, including as a delivery driver, warehouse operative and transport co-ordinator.
Mr Turner told the court that Alex resigned from the company in early 2019 as he "thought he was being stitched up" by a colleague and wanted to leave before he was sacked.
In March of that year, Alex got a flat in Little Hulton with his friend Nathan, despite being out of work at the time.
Alex got a number of temporary jobs but Mr Turner said that he struggled to come by full-time work and had difficulty paying his bills, which also led to tensions with Nathan, Mr Turner said.
The court heard that Alex also regularly used cannabis and cocaine and would borrow money from people to help pay for the drugs.
Mr Turner referenced Alex's debts spiralling to around £15,000.
In June 2019, a party at the flat was gatecrashed and Alex witnessed Nathan get injured. Mr Turner said that Alex was very distressed by the incident.
Alex told his mum Andrea of a plan to take his life on September 9, Mr Turner told the court. He was taken back to his home in Whittle-le-Woods and prescribed anti-depressant fluoxetine.
After a few days, Alex decided to return to Little Hulton as he 'felt bad' for Nathan.

Mr Turner also told the court that Andrea is a foster carer for vulnerable adults and at the time, the family were being asked if they could look after someone.
" Me and Andrea wanted to know for certain that he was okay with us taking in this person," he said.
"If he wanted to come home he could just tell us. He didn’t want to get in the way of mum’s career."
The following month, Alex was given a repeat prescription for fluoxetine.
Alex's girlfriend Demi-Kay Wynne told the court that throughout November, Alex tried to take his life several times.
However, on November 19, he secured work as a delivery driver, which Mr Turner said Alex was 'very happy' about.
After five days, he was let go from the job and told Miss Wynne told the court it was because of lateness.

The following day, November 25, Alex was taken to the SAFIRE unit and diagnosed with borderline personality disorder and kept at the unit for assessment.
On November 27, Alex was told that it could take up to 10 years to control his condition, to which Mr Turner told the court he responded: “What’s the f***ing point then. I may as well just end it now."
Alex also made references to taking his own life if he was discharged, Mr Turner said.
Two days later, on November 29, Alex was discharged.
Mr Turner told the court that Alex had rang him in the morning and was very upset about being discharged.
Mr Turner then rang SAFIRE and told them that he did not agree with the decision but he was told that Alex was being put into a taxi with his belongings to Chorley Town Hall - where he would then present to the council's housing services.
Asked whether Alex would have been allowed to stay at their family home, if they had been asked by medical staff, Mr Turner said: "Of course."
Explaining the decision, Dr Kazmi said: "The overall impression was that he wouldn’t benefit from further time and that the ward environment was distressing him."
Later that day, he ended up at Eagleton Ward.

In the following days, there were a number of discussions between Alex and medical staff, Mr Turner said.
Mr Turner said that Alex heard voices that told him to harm himself and that there were occasions of self-harm.
Miss Wynne also told the court that during walks with Alex, when she visited him, he spoke about the railway tracks and made reference to having found a way down to them.
She also spoke about a conversation Alex had with a receptionist at the ward when he was asking her questions about the railway tracks. Miss Wynne also claimed that she never saw staff asking inpatients to sign in and out.
On December 3, after raising concerns about plans to discharge Alex again, Mr Turner said that he received a call from the ward, in which he was told that Alex was being detained for 72 hours under Section 5(2) of the Mental Health Act.
The next day, Mr Turner said he was told that Alex had not been detained.
"I felt as if I’d been told something to pacify me," he said.
"Nothing they said had been acted on. They weren’t aware of the section, it was quite shocking."

On December 5, the court heard that Alex and Miss Wynne exchanged a number of messages, after their parents had a discussion about whether it was best for them to split up.
Miss Wynne told the court that she never told Alex the relationship was over but admitted: "At that stage I felt the relationship couldn’t go on any further.
"I felt I was being blamed for everything.
"I said I wanted him to come out happy and healthy."
The court heard that Alex said that he was 'going' and that he loved her, before telling her about some notes he had left in his bedroom.
Miss Wynne told the court that she rang Alex at around 7.30pm and told him 'not to do anything stupid'. She added that after speaking with her mum, she decided that Alex would have just gone for a walk to clear his head.
The last message she sent to Alex was around 9pm, speaking about the potential of a fresh start when he got out of hospital.
At around 2am on December 6, police attended at Miss Wynne's house to tell her that Alex was missing from Eagleton Ward.
Miss Wynne claims she told them to look at the railway lines near Eccles station but a legal representative for Greater Manchester Police (GMP) claimed that she made no specific mention of areas and just told officers: “He might have gone to bridges or tram stops”.
PC Kathryn Heaton, from Lancashire Police, also told the court that she knocked and rang the doorbell at Alex's family home but said there was no response. She then left a calling card.
Mr Turner said he did not hear anyone at the door and said that his dogs did not bark at any point but admitted he had missed calls from Salford Royal Hospital and GMP.
He told the court that if he had been woken up, he would have gone to Salford to look for Alex.
Alex's body was found on the railway line near to Eccles train station at 5.16am on December 6, by British Transport Police.
Trust failings
GMMH admitted two failings in failings in regards to the discharge from SAFIRE and a further failing in relation to the care Alex received on the Eagleton Ward.
The admitted failings are:
- The Trust accepts that there was a failure to formulate a comprehensive discharge care plan for [Alex's] discharge from SAFIRE Unit.
- Whilst there was engagement with [Alex's] father around discharge planning the Trust accepts that there was a failure to fully involve and engage [Alex's] father in the discharge from SAFIRE Unit on Friday 29 November 2019.
- Following admission to Eagleton Ward the Trust accepts there was a failure to:
- Involve and engage [Alex's] father in risk formulation and risk management planning;
- Fully record information which was significant to risk assessment and management;
- Ensure that risk information gathered was disseminated to staff on duty;
- Fully assess the escalating risk of [Alex] harming himself on 5 and 6 December 2019;
- Formulate a robust risk management plan to address the escalating risk on 5 and 6.
The inquest continues.