NHS Criticised Over Mental Health Patient’s Death Under Restraint

The NHS was blamed yesterday for the death of a mental health patient who was held face down on the floor of a Portsmouth hospital for 25 minutes until he turned blue and stopped breathing.

An independent inquiry found Geoffrey Hodgkins, 37, was not threatening anyone when seven nurses, security guards and support workers overpowered him in the Cheriton ward of St James’s hospital. It noted allegations that they passed cigarettes to each other as they squeezed the life out of him.

Mr Hodgkins had thrown a cup at another patient who was behaving inappropriately and staff became concerned when he locked himself alone in a darkened side room. They decided to restrain him because he had a record of becoming violent during periods when his medication changed.

The inquiry said Mr Hodgkins first showed psychiatric symptoms at the age of 10 and was detained under the Mental Health Act at 19, due to aggression and symptoms of paranoid schizophrenia.

But he was not violent all the time. His brother Bruce saw him a few hours before the fatal incident in November 2004. “He was relaxed and friendly. We talked about his love of music and where we would go for a pre-Christmas dinner,” the brother said yesterday.

The inquiry was commissioned by Hampshire and Isle of Wight strategic health authority. It found Mr Hodgkins was held face down in arm and leg locks by three poorly-trained security guards, two nurses and two other members of staff. For 25 minutes he struggled, spitting and biting. Staff were at a loss to understand why sedatives did not appear to be working. Then he stopped breathing. They turned him over and saw that “his eyes were flicking and he was turning blue”. They started mouth-to-mouth resuscitation, but due to a communications mix-up did not get an ambulance to the scene for 15 minutes.

Mr Hodgkins was taken to Queen Alexandra hospital, but his condition was irrecoverable. The life support machine was switched off the following morning.

The case bore an uncanny resemblance to the death of David “Rocky” Bennett at the Norvic secure unit in Norwich in 1998. An inquiry into that incident found in February 2004 that Mr Bennett had been killed by being held face down on the floor for 28 minutes by at least four mental health nurses.

Eight months before Mr Hodgkins’s death, the Bennett inquiry recommended that patients should never be restrained face down on the floor for more than three minutes. But the government rejected this advice.

The inquiry found no individual was to blame for Mr Hodgkins’s death, but it criticised Portsmouth City Teaching primary care trust, which was responsible for his care. It said the trust allowed untrained staff, including security guards, to be involved in the restraint. It failed to provide basic care for Mr Hodgkins, such as addressing his obesity and heavy smoking. It did not keep his family informed and failed to implement the results of an internal inquiry.

Zenna Atkins, chairwoman of the PCT, said the treatment of Mr Hodgkins was “inexcusable”. She added: “The care he received fell below the standards we aim to offer the local community and for that we are deeply sorry. Since his tragic death, we have closed the ward he was living on and introduced new ways of working for all our staff.”

Previous deaths

1999 Roger Sylvester, 30, who had manic depression and drug problems, was held down for 20 minutes when he became violent at a psychiatric hospital. He had a heart attack, went into a coma and died a week later.

2003 Andrew Jordan, 28, who had schizophrenia, died after being subdued on a sofa for 10 minutes and suffering positional asphyxia, triggering cardio-respiratory arrest.