The 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 narrative verdict.
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 Howard’s death.
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.
Summing 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”.
It also set out eight separate conclusions which all draw attention to shortcomings which contributed to Mr Howard’s death.
Among 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.
A 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 death.
They concentrated on more robust violence and aggression management training, and tighter procedures, she said.
“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 added.
During 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