died after being restrained not threatening anyone, report reveals
psychiatric patient who died after being held face down for 25 minutes
had not been threatening anyone before he was restrained, a report
Geoffrey Hodgkins, a 37-year-old schizophrenia patient on the Cheriton
ward at St James’s Hospital in Portsmouth, died after being
restrained by seven staff on November 19, 2004.
A report, commissioned by the Hampshire and Isle of Wight Strategic
Health Authority, highlighted a series of failings in Mr Hodgkins'
care leading up to his death.
The report reveals Mr Hodgkins was restrained despite not posing
an immediate threat to staff or patients on the ward, and having
gone into a 'family room' by himself after he had thrown a cup at
The report also showed staff made no efforts to engage with Hodgkins
before restraining him.
Four security guards without basic life support training were also
primarily involved in restraining Hodgkins, and tranquillisation
drugs were injected into Hodgkins despite staff knowing he did not
respond to them.
had been restrained many times before, sometimes for up to six hours.
died after being held face down (the ‘prone’ position)
for 25 minutes. Despite being obese and a heavy smoker (making prone
restraint additionally risky) no assessment of Hodgkin’s physical
health was made.
restraining Hodgkins on the day he died, staff were reported to
have passed a communal cigarette to each other.
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 on his death.
An inquiry into the death of psychiatric patient David Bennett in
1999 after he was being restrained in a Norwich clinic for 28 minutes
recommended that patients not be held in the prone position for
longer than three minutes.
But in February last year when the National Institute for Clinical
Excellence released guidelines on managing violence by patients
on psychiatric wards, it did not include a time limit on prone restraint
into death of Geoffrey Hodgkins
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
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