for no reason?
Geoffrey Hodgkins died in a psychiatric ward after being restrained
by staff for 25 minutes. Are
measures introduced to prevent such deaths going to make a difference?
Adam James investigates
over two years ago Geoffrey Hodgkins died after being restrained
in the ‘family room’ of the Cheriton psychiatric ward
in St James’s Hospital in Portsmouth.
105 page independent report, commissioned by Hampshire and Isle
of Wight Strategic Health Authority, into the death of the 37-year-old
schizophrenia patient frequently reports “concern” about
Hodgkin’s standard of care. To Joanna Bennett, sister of David
Bennett who also died while being restrained, in 1999 in a Norwich
clinic, this is a gross understatement. She describes Hodgkins’
care as “unbelievably bad”.
starters, Hodgkins was not violent, aggressive or threatening anyone
immediately prior to being restrained, the report details. Secondly,
staff made no efforts to talk to Hodgkins before restraining him.
Thirdly, four security guards without basic life support training
were primarily involved in restraining Hodgkins. Fourthly, tranquillisation
drugs were injected into Hodgkins despite staff knowing he did not
respond to them. Fifthly, Hodgkins had been restrained many times
before his death on the evening of November 19, 2004. On occasions
he was restrained for up to six hours. Moreover, he died after being
held face down (the ‘prone’ position) for 25 minutes.
This was despite hospital guidelines stating patients should not
be held in the prone position for more than three minutes. Plus,
despite being obese and a heavy smoker (making prone restraint additionally
risky) no assessment of Hodgkin’s physical health was ever
made. As a final wretched humiliation, staff restraining Hodgkins
were reported to have passed round a communal cigarette to each
a cruel twist of irony, Hodgkin’s “template” care
plan actually had a “brief mention” of the widely-publicised
inquiry 11 months previously into the death of Bennett, also diagnosed
with schizophrenia. Like Hodgkins, Bennett had died after being
restrained face down for just short of half an hour.
City Teaching Primary Care Trust has admitted the treatment of Hodgkins
was “inexcusable". It said it is examining the raft of
recommendations included in the report.
while there are no central national figures on the number of deaths
of psychiatric patients held under restraint in mental health units,
the report into Hodgkins’ death has stepped up pressure for
measures to both ensure restraint is carried out safely and that
the need for it is decreased.
year Nice issued wards with guidelines on the short-term management
of violent behaviour in psychiatric in-patient settings. One key
recommendation is that rapid tranquillisation of patients only be
used if de-escalation and other non-physical strategies have failed
to calm a patient. This was not applied in Hodgkins’ case.
is the NHS Security Management Service (NHS SMS) which has responsibility
for encouraging wards to take up the Nice guidelines. Training representatives,
usually nurses, from NHS trusts and private employers are participating
in seminars to recognise, understand, de-escalate and safely manage
violent incidents on mental health and learning disability settings.
The training, entitled Promoting Safer and Therapeutic Services,
is said to be the first time such a course has been developed to
a national standard. To date more than 500 trainers have participated.
Their job is to return to their employers and, in turn, deliver
the training to their colleagues. NHS SMS pledges that, by March
2008, the training will be delivered to all frontline mental health
[as well as learning disability] NHS staff.
report on Geoffrey Hodgkin’s death makes grim reading, and
is dispiriting” admits Rick Tucker, NHS SMS’s head of
security management in mental health services. “But actions
have been since taken,” he says. Significantly, he claims
the training is obligatory. “It is a legal requirement –
in terms of a trust’s health and safety and healthcare commitments,”
discussing restraint, the debate around how long someone should
be held in a prone position is perhaps the most highly-charged.
The Bennett inquiry recommended patients not be held longer than
three minutes. But, in February last year the government rejected
Tucker, a nurse, believes a time limit is not all-important. “The
three minute recommendation is impractical,” he says. “The
main issue is to always be checking the physical well being of the
patient. When involved in high risk physical intervention, as a
clinician you have to be constantly assessing the physical well
being of a person. Plus, you should not lie across the back of the
legs, you should allow breathing to take place, and you should put
a patient being restrained into another position as soon as possible.
It’s a distraction to have a time limit.”
it is the bigger and bleaker picture of ward environments that is
the main focus for people working to de-escalate violent incidents
and physical restraint.
Nice’s guidelines were on the heels of a 2005 Healthcare Commission
audit exposing a violent ward culture which service user groups
have long complained about. Such a culture leads to confrontations,
so precipitating restraint. The audit found 78% of nurses, 41% of
clinical staff and 36% of service users have either been personally
attacked, threatened or made to feel unsafe. And 35% of service
users said staff ‘winded them up’. This year’s
Mental Health Act Commission biannual report stated more than half
of mental health wards were understaffed and untherapeutic. “On
some wards you could cut the atmosphere of danger with a knife,”
is how Tucker, whose work takes into him into different wards around
the country, puts it.
Psychiatrists are, it seems, equally concerned. And the Royal College
of Psychiatrists (RCP) has identified key factors necessary to build
therapeutic psychiatric ward environments. These include that wards
are clean, well-furnished and well lit, patients have privacy and
therapy if required, and the trust is not reliant on agency staff.
Plus there is strong leadership.
a bid to promote therapeutic wards, the RCP has launched an accreditation
scheme for acute inpatient psychiatric wards. Trusts are being asked
to check themselves against more than 100 measures, covering everything
from staff support and training, to patient advocacy provision,
to making sure that on the day a patient is admitted and well enough
they are notified who their primary nurse is, and how to arrange
to meet with them. A three-tiered accreditation scheme means wards
will be, at best, “excellent” and, at worse, “a
significant threat to patient safety, rights or dignity and/or would
breach the law.”
to now around 20 wards have participated in a pilot of the scheme,
which is run in partnership with the British Psychological Society,
the College of Occupational Therapists and the Royal College of
"Staff on the wards are being very explicit [about what they
are experiencing],” says Paul Lelliott, director of the college’s
research and training unit. “Yes, there is a point at which
you feel despondent. But the challenge is to do something about
that. There are excellent staff in these wards. But too often they
do not feel they can improve their wards. The responsibility lies
with managers to back them.”
Lelliott adds: “Nice guidelines are necessary but they are
questions remain as to whether the RCP ward accreditation scheme
– which is voluntary - like the Nice anti-violence guidelines
and Healthcare Commission ratings system - have the teeth to bring
Bennett, a senior research fellow at the Sainsbury Centre for Mental
Health, says: “A ward can get a particular accreditation one
week, but the situation can quickly change, like the staffing levels.
Having policies alone is quite useless. There is a lot of paperwork
saying what people should do. But when it comes to applying it,
it does not seem to happen.”
her brother’s case, no one was prosecuted in connection with
his death. Although Hodgkins’ family lawyers are examining
the report, it is likely the same will apply. The report into his
death stated no individuals were responsible.
some in mental health wish the services for which they work were
- in cases of violence management and restraint - accountable to
law. Lelliot, for example, questions why trade unions have not been
proactive in pursuing cases under health and safety laws when poorly
trained, under-resourced staff are caught up in violent incidents.
“I am surprised there have not been more prosecutions,”
he says. “Trusts do have employees at risk, and trusts should
take this more seriously.”
Bennett believes that unless something akin to corporate manslaughter
in brought to the statue books, mental health services have no obligation
to change. She says: “There’s never been anybody legally
held responsible for these deaths. Therefore, things will never
of November 19, 2004, around 8pm at Cheriton Ward, St James’s
Geoffrey Hodgkins threw glass cup at another patient. Carrying fork
and glass cup he went into ward’s family room.
Decision made to restrain Hodgkins. Discussion between four security
guards, three nurses, and two healthcare support workers about which
restraint process to follow, who should enter family room first
and which positions individuals should take.
Staff enter the room with Geoffrey Hodgkins standing with back to
Security guard brings Hodgkins to floor. Hodgkins held in prone
position on his front. Three security guards, two nurses and two
healthcare support workers restrain Hodgkins.
Nurse injects Hodgkins with Haloperidol and Lorazepam. Hodgkins
kicking, swearing and struggling.
After about 25 minutes, Hodgkins stops breathing. Mouth to
mouth given. Hodgkins starts breathing and is placed into recovery
position. Hodgkins stops breathing again, mouth to mouth resuscitation
Hodgkins taken by ambulance at 8.58pm to Queen Alexandra Hospital,
accident and emergency department. Arrives at 9.23pm. Hodgkins’
life support turned off on 20th November, at 8.25am.
says mental health wards should implement for short-term management
of violent behaviour
Staff training to include anticipating, de-escalating or coping
with disturbed/violent behaviour.
All staff involved in administering or prescribing rapid tranquillisation,
should receive ongoing competency training to a minimum of Immediate
Life Support issued by the Resuscitation Council UK
Staff employing restraint be trained to Basic Life Support (BLS),
issue by Resuscitation Council UK.
Patients have access to information about what may happen if they
Patients at risk of violent behaviour should have opportunity to
have wishes recorded in advance directive.
Rapid tranquillisation, physical intervention and seclusion should
only be considered once de-escalation and other strategies have
During restraint one team member is responsible for protecting and
supporting head and neck.
Level of force applied justifiable, appropriate, reasonable and
proportionate to situation. Applied for minimum amount of time.
* A shortened
version of this article appeared in Mental
Health Today magazine
into death of Geoffrey Hodgkins
Oct 30, 2006: Patient who died after
being restrained not threatening anyone, report reveals - staff
also made no efforts to engage with schizophrenia patient before
3, 2006: Man with schizophrenia need not have died during restraint
by police, jury decided - Andrew Jordan, 28, died when pinned
down on stomach
17, 2005: Detained psychiatric patients have no protection under
national mental health code of practice, campaigners warn -
following a House of Lords ruling over patient seclusion case
28, 2005: Mental health staff should understand how their behaviour
can increase or decrease risks of violence, guidelines urge -
but campaigners '"dismayed" that National Institute for
Clinical Excellence does not recommend three-minute time limit for
face-down restraint of patients
do you think? Email your comments on the above
article to the editor using the form below. Selected comments will
© 2001-7 Psychminded Limited. All
about this article