A psychiatric patient who died after being held face down for 25 minutes had not been threatening anyone before he was restrained, a report reveals.
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 another patient.
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.
Hodgkins had been restrained many times before, sometimes for up to six hours.
Hodgkins 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.
While restraining Hodgkins on the day he died, staff were reported to have passed a communal cigarette to each other.
Portsmouth 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