restraint caused death of psychiatric patient
death of a psychiatric patient who died at a Swansea hospital six
years ago was caused by excessive physical restraint, an inquest
jury has ruled.
The inquest into Kurt Howard's death
in June 2002 at Cefn Coed Hospital ended last month with a detailed
The jury's findings also drew attention
to failings in staffing, training and facilities at the hospital.
Abertawe Bro Morgannwg University
NHS Trust said many changes in procedure had been made since Mr
The five-week inquest had heard
Mr Howard, 32, from Swansea, and diagnosed with schizophrenia, tried
to attack a nurse on ward five at the hospital.
He was restrained twice on the day
of his death, for up to 55 minutes in total.
The jury, after four days of deliberation,
issued a 1,800 word narrative verdict.
up the jury said Mr Howard’s sudden death “was caused
by an excessive, prolonged physical restraint, face down on the
floor in a confined environment, suffering acute behavioural disturbance
in a background of chronic psychosis brought on by a history of
illicit drug taking”.
also set out eight separate conclusions which all draw attention
to shortcomings which contributed to Mr Howard's death.
them are the fact that some of the staff involved in the restraint
did not have the right level of training to carry it out.
spokeswoman for Abertawe Bro Morgannwg University NHS Trust said
a series of actions had been put in place by the former Swansea
NHS Trust following an internal review in 2002 after Mr Howard's
concentrated on more robust
violence and aggression management training, and tighter procedures,
"A clear system of checks
was set up to ensure regular staff training and awareness-raising
were undertaken," said the spokeswoman.
"When restraint is used now,
the circumstances are reviewed in all cases to ensure best practice
is shared with staff and lessons learned."
She said the trust also acknowledged
that procedures around reporting unexpected deaths to police were
not robust enough six years ago and there are now firm and clear
rules in place.
"ABM University NHS Trust will
now be reviewing the original 2002 Action Plan to see if any additional
work can be done to improve the service still further," she
the inquest a senior mental health nurse had denied accusations
that she got rid of vital evidence and covered up the circumstances
of Mr Howard's death.
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