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Coroner raises concerns over how a 'vulnerable' man was restrained

PUBLISHED: 15:39 14 May 2019 | UPDATED: 12:43 15 May 2019

Norfolk Coroners Court. Photo: ANTONY KELLY

Norfolk Coroners Court. Photo: ANTONY KELLY

Archant Norfolk 2016

A coroner has expressed concerns over how a man with learning disabilities and mental health problems was physically restrained and cared for in the days leading up to his death.

Gary Smyth had been under the care of Jeesal Cawston Park but was discharged into the community on April 26, 2017,

He died at the Norfolk and Norwich University Hospital on May 22, 2017.

Three weeks prior to his death, the 52-year-old, who had epilepsy, learning disabilities and mental health problems, had been admitted to the NNUH from the Little Plumstead Hospital after injuring his bottom lip.

At an inquest into Mr Smyth's death held at Norfolk Coroner's Court on Tuesday, the court heard details of the events surrounding Mr Smyth's initial admission to and discharge from the NNUH, which included instances of heavy restraint by police officers and the use of a spit hood.

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On returning to the LPH, Mr Smyth became dehydrated and suffered a cardiac arrest, an event he never recovered from.

Linda Page, a matron on the ward Mr Smyth was treated at while at the NNUH, said seeing Mr Smyth restrained was 'inhumane' and said it was one of the 'most disturbing' things she had witnessed during her 36-year career.

The inquest also heard evidence from Mr Smyth's GP and other medical professionals involved in his care both at the NNUH and at LPH.

Following the evidence, Yvonne Blake, area coroner for Norfolk, said she had concerns around a number of areas relating to how Mr Smyth was medicated, and how his levels of hydration and physical health were monitored.

She also said she had concerns over "the level of resuscitation used on a vulnerable 52-year-old man with learning disabilities who had physical and mental health issues."

Drawing a narrative conclusion, Ms Blake said Mr Smyth's death was "very sad" and added: "Mr Smyth was discharged from the acute hospital back to residential care. His physical and mental condition appeared to be deteriorating, he did not pass urine and was clinical dehydrated."

Adding that his refusal to allow physical examination prevented the true extent of his condition to be understood by nurses, she said: "Mr Smyth suffered cardiac arrest the cause of which is unknown and a diffuse global hypoxic brain injury."

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