30 SECOND RESTRAINT RESULTED IN A MAN’S DEATH
A Coroner recently write to a care home in a bid to prevent another tragedy following an inquest into a mental health patient who died after being restrained.
The jury returned an open verdict into the death of Derek Lovegrove, after the Deputy Coroner Martin Gotheridge advised that it could be the only option because there was no definite cause of death.
RESTRAINT COULD NOT BE RULED OUT AS A CAUSE OF DEATH
However, during the hearing a Pathologist told an inquest that restraint cannot be ruled out as contributing to the death of a mental health patient. Dr Ralph BouHaidar, a consultant forensic pathologist told the inquest a post-mortem examination could not prove the death had been caused by restraining him, but it could not be completely ruled out. He said: “The restraint has played some role in some way that you can’t completely exclude that.”
A jury at an inquest at Nottingham Coroner’s Court heard that Derek Lovegrove, 38, died after being restrained at Cedar Vale, a 16-bed unit in East Bridgford for people with learning difficulties and mental health problems, on July 10, 2006.
The inquest has previously heard that Mr Lovegrove was a very challenging patient, with mental health and communication problems. He was prone to destructive outbursts and would grab at staff, pull hair and tear off clothes.
LONE WORKING
On the day of his death he had been alone in his room with support worker Abrahal Kariam, despite regulations stating that he should be looked after by two workers at all times.
SUPINE RESTRAINT
Mr Kariam told the inquest Mr Lovegrove grabbed him and pulled them both to the ground. He said he initially couldn’t get free of his grip and then he managed to get to the side and he and support worker Stephen Bloxham restrained Mr Lovegrove by holding one arm each while Mr Lovegrove was on his back.
Shortly afterwards they noticed he wasn’t responding and had stopped breathing. They called for help but efforts to resuscitate him failed.
30 SECONDS IS ALL IT TOOK
The court was told the restraint is not believed to have lasted more than 30 seconds.
The inquest also heard a post mortem examination report said that Mr Lovegrove’s death was a “sudden unexpected death during restraint”.
Dr BouHaidar added: “Thirty seconds is not a long enough time for someone to die suddenly from a restraint.” Dr BouHaidar said there was some food in Mr Lovegrove’s airways, but this could have occurred before or after death. He said the possibility of Mr Lovegrove suffering a heart attack could not be excluded either.
THE EFFECT OF THE INCIDENT ON THE MEMBER OF STAFF
Since the incident Abrahal Kariam has suffered a number of breakdowns. Mr. Kariam told the Court that he wished that he had passed away that day rather than Derek Lovegrove. Mr. Kariam said: “I’ve suffered multiple breakdowns since the incident, my health has suffered. I live every day with what’s happened and I suffer through it. Sitting here is the hardest thing in the world for me. I feel suicidal everyday. I wish it was me that passed away that day, not Derek.”
POSSIBLY PLACED IN THE WRONG ENVIRONMENT?
Prior to going to Cedar Vale Mr. Lovegrove had spent more than ten years at Rampton secure hospital before being moved to Cedar Vale as part of a drive to reserve Rampton for people convicted of a crime. However, Mr. Lovegrove’s mother, Linda Daley, had earlier told the jury that she didn’t think Cedar Vale was the right place for her son. During the eleven months Mr. Lovegrove was at Cedar Vale he had been restrained 28 times.
WAS THE CORRECT TRAINING GIVEN AND WERE ADEQUATE RESOURCES AVAILABLE?
Staff at Cedar Vale were trained to use the Maybo technique to deal with patients. Maybo teaches staff who work with patients how to avoid being struck or grabbed and how to calm a patient by moving away if possible.
Workers at Cedar Vale had completed a three-day training course in Maybo, as well as a one-day refresher course, before Mr Lovegrove’s death, the inquest heard.
WERE THE FORESEEABLE RISKS COMPETENTLY AND PROPERLY MANAGED?
Mr Frame told the inquest they had not trained staff in how to move patients to the floor safely in 2005 because they couldn’t find a safe enough method. He added: “Where you have to take control of an individual, that’s a last resort where there’s no other option.”
The Deputy Coroner Martin Gotheridge said:
but no one seemed to check that it was followed.”
He has said that he would write a letter under Rule 43 of the Coroner’s Rules, which means it will also be seen by the Minister of Justice.
The fact is if it was foreseeable that Mr. Lovegrove would have ended up in a restraint on the floor, what control measures were put in place to either prevent that happening or to control it and minimise the risks associated with it to a competent level?
THE LESSONS LEARNED
This tragic case once again highlights the risk of restraining vulnerable people. However, it also highlights, once again, the risk of restraining someone on the ground.
SUPINE RESTRAINT
It also highlights the risks associated with supine restraint positions – a position in which a person is restrained on their back as opposed to on their front.
One of the things that has to be considered here is that due to the very well documented risk of the prone (face down) position and the risk of death, some organisations are advocating that the supine position (face up on the floor) is a safer position.
INADEQUATE TRAINING
Another seemingly glaring omission is the fact that the training did not adequately deal with the risks associated with how Mr. Lovegrove would be restrained and the possibility of having to control the risks associated with the fact that he would have very likely have ended up on the ground.
LACK OF SUPERVISION
The case also seeming highlights a growing lack of management supervision, monitoring and review (as required by Section 2[2][1] of the Health and Safety at Work Act 1974) on behalf of the management of Cedar Vale.
THE HUMAN COST
The case also reflects the huge underlying costs in terms of how such incidents can affect the quality of life for those involved. Not only will the family of Mr. Lovegrove now have to live with the fact that he has died, but Mr. Kariam, the member of staff involved, is also now carrying a life sentence.
SAFE SYSTEMS OF WORK IN LINE WITH PROPER ASSESSMENTS OF RISK
Our BTEC Level 3 Advanced Restraint & Breakaway Instructors Course gives instruction on safe ways to control someone on the floor which have been constructed in line with a proper assessment of risk by suitably qualified and competent persons.
The course also covers all of the facts and risks associated with the risk of a restraint related death and provides safe systems of work and safe working practices to help eliminate or reduce such risks occurring.
To view our next course go to: https://nfps.info/physical-intervention-trainer-course.