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| Geoffrey Hodgkins was a long stay in- patient who suffered from schizophrenia, whilst he was in the care of the Portsmouth Teaching Primary Care Trust He died during a restraint process Cp Bennett Inquiry and the comment The Panel would like to use this opportunity to make the family aware that it was evident that the staff, who were familiar with Geoffrey Hodgkins, were very fond of him. They spoke warmly of him as an individual who, for most of his time as an in-patient, was a very gentle and friendly person, and who was always apologetic to staff after the occurrence of incidents over which he had no control. The Panel was not able to draw any conclusion as to whether any different actions by individuals would have resulted in a different outcome. However, it is the view of the Panel that had those critical issues been appropriately considered and addressed the risks posed to Geoffrey Hodgkins would have been substantially reduced. That's all they can say ! The PCT is [ was ] currently a 2-star trust. The Adult Mental Health (AMH) Service provided by the PCT was, in 2003, awarded three stars in the NHS rating by the Healthcare Commission and a 'highly recommended' scoring by the Social Services Joint Review , which the PCT considered was a reflection of the excellent partnership working across organisations (voluntary and statutory), staff, service users and carers. However, the Adult Mental Health Service moved to 2 stars in 2004 and to 1 star in 2005. Geoffrey Hodgkins was born on 16 September 1967 and first presented with psychiatric symptoms at the age of 10. He was admitted to St James's Hospital in Portsmouth in 1986 under Section 2, Mental Health Act 1983 and re-graded to Section 3 Mental Health Act due to his aggressive behaviour towards others and marked symptoms of paranoid schizophrenia. Since 1986 he had been an in-patient at St James' Hospital with limited periods of time living in the community with his parents. 2.1.2 In early 1998 episodes of complex partial seizures started to emerge and the evolution of these seemed to follow a predictable pattern. The seizures would usually start after 8.30 – 9.00pm and Geoffrey Hodgkins would become agitated and begin to pace and stare at his own reflection in the windows and giggle and laugh to himself. 2.1.3 At the beginning of 2000 this pattern changed when Geoffrey Hodgkins At the beginning of 2000 this pattern changed when Geoffrey Hodgkins began to assault staff, kicking, biting and spitting to a degree that would require restraint for very prolonged periods of time. These restraints could include 3 – 4 staff for up to 7 hours. During these times one of his symptoms was hyperventilation. To treat the complex partial seizures he was, in the beginning of 2001, prescribed Paraldehyde PRN to which he responded positively. 2.1.4 Following a brain SPECT scan at the end of 2000 Geoffrey Hodgkins was referred to a Consultant Neurologist which resulted in some changes to his medication leading to him having less frequent epileptic episodes. In March 2002, Geoffrey Hodgkins was transferred to Cheriton ward and in June 2002 he became an informal patient. From June 2002 to August 2003 there does not seem to have been any episodes of aggression or violence and he seemed fully compliant with medication and treatment plans. It was noted in March 2004 that, following a change in the medication dose of Clonazepam to reduce drowsiness during the day and the increase in the dose of Lamotrigine to prevent relapse of seizures, his psychotic symptoms were more obvious. It was also noted that it was difficult with Geoffrey Hodgkins to maintain a treatment balance of his psychosis and his epilepsy. Why the change ? Geoffrey Hodgkins was engaged in Occupational Therapy activities up to April 2004, his level of motivation was described as poor and, due to his medication regime, he was feeling drowsy most of the day, sleeping and having difficulties in engaging in any purposeful activity, requiring prompting from staff to do the daily living tasks including self care. Amongst the things which he enjoyed was visiting his parents and going out with his brother. Geoffrey Hodgkins was received by Uplands Hospital on 14th April 2004 th but, due to his aggression, he was, on 20 July 2004, admitted to Solent Intensive Care Unit then re-admitted to Cheriton ward on 26 July 2004. In response to an inquiry from the PCT about placing Geoffrey Hodgkins in a private nursing facility, Kitnocks House wrote to the PCT at the beginning of August 2004 confirming that it would be able to provide the necessary level of care for Geoffrey Hodgkins. On 3 October 2004 Geoffrey Hodgkins set fire to a flip-chart and attacked a member of staff after which he was restrained by 6 persons using the C&R technique. Lorazepam and Haloperidol were administered. During this restraint staff noticed that Geoffrey Hodgkins' breathing became compromised and he was slightly cyanosed and hyperventilating. He was moved onto his back and a Senior House Officer attended who checked blood pressure and respiratory rate and advised staff to monitor his respiratory rate if further Lorazepam was administered and to call 999 if his breathing became inhibited. A one-to-one observation was carried out. The Risk Event Form states that an urgent review of his status was needed. At the ward round on 13 Geoffrey Hodgkins' recent behaviour appeared to relate to psychomotor epileptic phenomenon and concern was expressed that he might have missed a couple of doses of medication, which must be taken regularly. Staff were asked to monitor his compliance. 2.1.16 Ward rounds on 20 and 27 October 2004 noted that Geoffrey Hodgkins th had been sleeping excessively and also during day time. On 27 October 2004 his medication dose was changed again. November 2004 when it was 2.1.17 A medical review was carried out on 3 decided that Geoffrey Hodgkins' mental health status was to be reviewed if his mental health state continued to deteriorate. It also noted that Paraldehyde was to be used once but only if Haloperidol and Lorazepam did not work. 2.1.18 On the 12 November 2004 Geoffrey Hodgkins entered the staff office saying that he did not feel well. He threw his cup at a member of staff and was restrained for approximately 2 ½ hours using C&R. The Risk Event 24 Form stated that Geoffrey Hodgkins' case should be discussed concerning his Mental Health Act status. In the medical notes was an informal patient were noted and a Section 3 Medical Recommendation form was filled out by one of the consultant psychiatrists. The Tragedy. The Panel was informed that it had been a really busy afternoon shift on the Cheriton ward with a total of 4 restraints between 4pm and 8pm and assistance had already been required from both security guards and other wards. The evening shift consisted of Nurse 1, a staff nurse, and HCSW 1, a health care support worker (HCSW). Due to the previous activities they both agreed to go into the office to get some of the paper work done around 8pm. Geoffrey Hodgkins was, at that time, in the dining room eating a take away meal and staff did not observe any signs that he was getting upset nor had they done so earlier in the day. Whilst in the office, Nurse 1 and HCSW 1 heard the sound of smashing 28 29 which was also heard by Nurse 2 and HCSW 2 , who were talking together whilst Nurse 2 was doing a one-to one observation on another service user further down the corridor. When HCSW 1 and Nurse 1 came out of the office they saw Geoffrey Hodgkins at one end of the corridor with a glass cup in his hand which he threw at another service user who was at the other end of the corridor. Geoffrey Hodgkins then walked past Nurse 2 and into the family room. Geoffrey Hodgkins was noted to be carrying a fork and a glass in his hands when he went into the room. The light was on in the room. Nurse 2 and HCSW 2 were holding on to the door to keep it closed due to concerns about Geoffrey Hodgkins. editor:- at this point the duty doctor should have been requested. Restraint is anticipated and the doctor should be present or handy. HCSW 2 suggested that Nurse 1 ring for help and Nurse 1 pulled the pin to get assistance from the Front Hall and other wards. HCSW 2 also suggested that the door to the family room be locked until help arrived and HCSW 2 locked it. Security guards and staff from other wards then arrived. Once inside the family room Geoffrey Hodgkins had turned the light off. The door to the family room had a see-through glass panel. HCSW 1 started clearing the glass from the floor in the corridor and Nurse 30 31 3 , the (1701) bleep-holder , arrived from Fair Oak and took control of the situation. Nurse 1 went back to the office to draw up medication for Geoffrey Hodgkins...... the editor believes restraint plus medication should never proceed without hte presence of the duty doctor. .... Nurse 3 suggested that the staff get a quilt to put over Geoffrey Hodgkins for the safety of all involved. HCSW 1 went to get some towels as HCSW 1 knew from past experience that Geoffrey Hodgkins would spit when he was being restrained. There seems to have been some discussion between the clinical staff and some separate discussion Nurse 3 suggested that the staff get a quilt to put over Geoffrey Hodgkins for the safety of all involved. HCSW 1 went to get some towels as HCSW 1 knew from past experience that Geoffrey Hodgkins would spit when he was being restrained. There seems to have been some discussion between the clinical staff and some separate discussion between the security guards about which process to follow, about who should enter first and about which positions individuals should take.
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, Security
2.2.7 Outside the door to the family room were Security Guard 1
33 34 35
Guard 2 , Security Guard 3 , Nurse 2, Nurse 3, Nurse 1, HCSW 3 and
HCSW 2. HCSW 2 was given the quilt to throw over Geoffrey Hodgkins. at this stage the editor believes mechanical restraint with velcro strapping to the confine the legs was advisable - and later if necessary to the arms also, Nurse 3 took the quilt to throw over Geoffrey Hodgkins as HCSW 2 had ended up against a wall when HCSW 2 had attempted to do so. The quilt ended up under Geoffrey Hodgkins' waist. Geoffrey Hodgkins was on the floor lying on his front. Security Guard 1 took Geoffrey Hodgkins' left arm, Nurse 3 took his right arm; Security Guard 2 took Geoffrey Hodgkins' legs from underneath him and held them. Nurse 2 was on his legs and HCSW 2 took his thighs whilst HCSW 3 also held a leg. Security Guard 3 was laying on Geoffrey Hodgkins' legs and his head was put to one side. HCSW 1 came back with the towels and was asked by Nurse 3 to go to Geoffrey Hodgkins' head. HCSW 1 placed one towel around each hand and a towel around each of Geoffrey Hodgkins' hands and a towel under his head to protect it from the rough carpet. The towels around HCSW 1's hands were because he was spitting and biting. HCSW 1 was kneeling at the top of his Geoffrey Hodgkins' head facing him. Some blood was noticed coming from his face and this was, according to staff, because he had cut himself shaving earlier in the week or had a cold score and the scab had fallen off during the restraint. Where was the duty doctor Nurse 1 came in and gave Geoffrey Hodgkins an injection of Haloperidol and Lorazepam. During this period, Geoffrey Hodgkins was kicking, swearing and struggling a lot. Nurse 2 took over from Nurse 3 on Geoffrey Hodgkins' right arm so that Nurse 3 and Nurse 1 could reassess the situation. They agreed that Nurse 3 should return to Fair Oak and send over a member of staff to assist with the one-to one observation which Nurse 2 had left. 36 Agency Nurse 1 arrived and took over Geoffrey Hodgkins' right arm from Nurse 2. Security Guard 2 took Security Guard 1's position on Geoffrey Hodgkins' left arm as Security Guard 1 had to leave to attend to another patient. HCSW 3 and HCSW 2 were each holding a leg whilst the security guards were clearing away the furniture. After about 25 minutes, Nurse 1 decided that the medication was not working as expected. According to Geoffrey Hodgkins' notes, Paraldehyde could be prescribed but, if needed within 2 hours of a restraint it had to be agreed with the duty doctor, otherwise nurses could administer it. Nurse 1 contacted Nurse 3 and informed that the medication was not having an effect. Nurse 3 contacted the duty doctor who was off-site and discussed this. Nurse 3 contacted Nurse 1 and passed on the information that the duty doctor had agreed that Paraldehyde could be given if the nurses considered this to be the best option. where was the duty doctor ? During this period, Geoffrey Hodgkins was still moving about and he was biting into the towel under his head. HCSW 1 was pulling at it to try to get it out of his mouth. 2.2.14 Suddenly, Geoffrey Hodgkins stopped breathing. Both HCSW 1 and Security Guard 2 became aware of this at the same time. Geoffrey Hodgkins' eyes were flicking and he was turning blue. HCSW 1 turned him over to his back and he was released. Nurse 2 was, at that time, leaving the family room having been relieved by Agency Nurse 1. Nurse 2 heard that Geoffrey Hodgkins had gone blue and ran to the office to inform Nurse 1 and asked that a medical emergency call be made. Nurse 2 also asked where the Laerdal masks were and, as they were in the office, took one back and gave it to HCSW 2 who had started performing mouth to mouth resuscitation on Geoffrey Hodgkins. HCSW 1 had, by then, got up and also run to the office to Nurse 1, who was there drawing up Paraldehyde. HCSW 1 then returned to the family room and started doing chest compression. Nurse 1 put out a 9-999 call, called Nurse 3 and went back into the family room. This emergency call was likely to be the first call Hampshire Ambulance Services received at 20.43.40 hours. Geoffrey Hodgkins stopped breathing once more and was turning grey so resuscitation was started again. Nurse 3 took over the mouth to mouth resuscitation and asked for an Ambi bag from Fair Oak to be brought over but, when it arrived, did not feel this was as effective as performing mouth to mouth, which had been continuing in the interim. Nurse 1 tried to take a blood pressure but could not get a reading.
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