Adam Farrer from No5 Chambers has acted for the Health and Safety Executive (HSE) at the inquest into the death of a female patient who was being detained in a secure hospital in Lincoln. The six-day inquest was before HM coroner Mr Fisher and a jury.
In 1997, the deceased was convicted of the manslaughter of her husband. She had been a patient in the secure hospital since 2002. The inquest heard that the deceased’s mental health had deteriorated over the weeks leading up to her death, resulting in the need for her to be physically restrained on a regular basis.
On 30 June 2012, the deceased became aggressive, resulting in staff having to restrain her. In total, eight support workers restrained her in a kneeling position against a bed while they waited for nurses to obtain a sedative injection. Staff did not end the restraint when she shouted that she could not breathe. Shortly thereafter, staff noticed that she had turned blue and ceased the restraint. By this time she was unconscious and was declared dead. The cause of death was cardiac arrhythmia in an obese individual in an agitated state while being restrained.
The inquest heard from Eric Baskind, a leading expert on restraint techniques. He gave evidence of the risks of positional asphyxia, especially in an obese person.
The jury returned a narrative conclusion, recording that the restraint was not performed in accordance with training as no member of staff took control or monitored the safety of the restraint. Staff did not recognise the risk to the deceased from the position of the restraint. Finally, the risk of positional asphyxia was increased by the deceased’s obesity.