Inquest rules carer’s assault on mental patient was not direct cause of death

A PATIENT at the Central Mental Hospital died from injuries incurred while he was being restrained by staff during his transfer from one part of the facility to another, an inquest has heard.

Gary Connell, 35, of the Morning Star hostel died from restraint asphyxia and inhalation of gastric contents which occurred during a restraint and control procedure on September 12, 2001 at the facility.

The jury recommended that an external and independent audit on all hospital policies and procedures be regularly carried out to ensure that best international practice is met. In particular, the jury highlighted the area of patient risk assessment, control and restraint procedures, and training and facilities available for control and restraint.

Last night, the Central Mental Hospital sympathised with the family and said all staff and management of the hospital have been extremely distressed by the circumstances surrounding his death.

Since the incident, a number of new protocols and practices have been introduced in the hospital.

The inquest at Dublin City Coroner’s Court heard that Mr Connell had assaulted a member of staff with a piece of broken glass at approximately 10.15 on September 12 and was being transferred to a seclusion room in another unit.

Up to eight staff members were involved in the transfer and they employed a range of different restraint and control techniques over the course of the 30 minutes it took for the transfer, including wrist locks, to control Mr Connell.

The state pathologist, Professor Marie Cassidy, who carried out the postmortem told the court that the restraint asphyxia which caused Mr Connell’s death could have been caused by “any action which would affect breathing,” during the course of his restraint.

The court heard that in the course of the transfer Mr Connell was placed lying on the floor, face down on numerous occasions and handcuffs were used to tie his hands behind his back both of which could have impeded his breathing.

“Death wasn’t caused by any one action. It seems to be a sequence of actions. It’s a very complicated incident.”

The patient was more susceptible to his form of asphyxia because he was suffering from coronary artery disease, the inquest heard.

While he was being transferred, Mr Connell was viciously assaulted by a care officer at the facility, Mr Brendan Cullen who kicked him in the head among other injuries meted out.

A postmortem also revealed extensive bruising and other abrasive injuries to Mr Connell’s head, face, neck and body, some of which were consistent with kicks while others were probably due to being struck with the handcuffs.

Professor Cassidy told the court that while these injuries, incurred by Mr Connell, during the assault by Mr Cullen, would not have directly caused his death, they were a contributory factor.

Mr Cullen, who pleaded guilty to assault causing harm to Mr Connell in 2006 and later had his sentence reduced to a two years suspended sentence, cuffed Mr Connell’s hands behind his back.

By the time Dr Emily McCabe arrived on the scene at 10.45am, Mr Connell showed no signs of life.

He was subsequently pronounced dead at St Vincent’s hospital.

Brendan Cullen yesterday told the court that when he came upon the staff members who were bringing Mr Connell to Unit 1(b) they were just 60% in control.

John Thompson was among five staff members who gave evidence when the full inquest opened on Tuesday, of the aggressive attack perpetrated by Mr Cullen which included details of how Mr Cullen had stood or stamped on Mr Connell’s back and kicked him with a full foot into the face, as well as dropping on him on his knees.

Counsel for the Central Mental Hospital, Barry O’Donnell told the court that at the time of the incident, that the policy was that, “under no circumstances should handcuffs be used in the management of aggressive behaviour”.

He told the court that since the incident, there have been a number of changes including the availability of widely distributed seclusion rooms to avoid the need to transport patients long distances, (as had happened with Mr Connell).

Speaking outside the court for Mr Connell’s mother, Christine Heath, solicitor David Quinn said: “It’s been a very stressful time for us over the last six years since Gary’s death in 2001.We are happy that all the facts have come to light over this two-day inquest. We are relieved the inquest has finally come to a close.”