A coroner has called for a review of practices at the region's mental health trust after a man who ran out of schizophrenia medication died at Ipswich Hospital after suffering fatal injuries.

Neil Jewell, 42, of Philadelphia Lane, Norwich, died on January 17, 2014, while sectioned under the care of the Norfolk and Suffolk Foundation Trust (NSFT). The NSFT apologised after a jury inquest, which concluded yesterday, identified failings.

A 'pale' Mr Jewell arrived at Norwich's Hellesdon Hospital clinic on January 6, 2014. He had run out of Clozapine, his schizophrenia treatment drug which had kept him stable for three years. He had previously been sent away without enough supply, the inquest heard.

He was admitted to Hamilton House in Norwich after his mental health deteriorated. When he was transferred from West Suffolk Hospital to Ipswich Hospital with police aid, he was laid face down on an ambulance stretcher with his arms and legs restrained.

He was placed in a seclusion room under constant observation at Ipswich Hospital's Woodlands Unit. The next day, January 12, he was found unresponsive after suffering a cardiac arrest. He never regained consciousness.

The inquest jury in Ipswich concluded he died from complications following a cardiac arrest caused by postural asphyxia, with the asphyxia caused by the position in which he was lying, and the adverse effects of sedative drugs used in his rapid tranquillisation to which neglect contributed. A post mortem revealed the cause of death was bronchopneumonia and hypoxic brain damage.

Dr Peter Dean, coroner for Greater Suffolk, said he will he will write to the NSFT asking for a review of protocols when dispensing medication, training with regards to observing patients who have undergone rapid tranquilisation, and ensuring patients' needs remain central during restructures.

He said Mr Jewell's family acted with 'tremendous dignity'.

A family statement said: 'Neil was a gentle person, quiet and unassuming, but extremely naive and vulnerable and who became increasingly isolated because of the deterioration in his mental health. The evidence during this inquest clearly points to a catalogue of missed opportunities, poor decision making, inadequate record keeping and routine disregard for policies.'

Background

Neil Jewell's death at the age of 42 came during a troubled time for the region's mental health services.

The Norfolk and Suffolk Foundation Trust (NSFT) was in the middle of a 'radical redesign' of services which saw cuts to beds, staff and services.

Its chief executive, Aidan Thomas, stepped down during the redesign and a month after Mr Jewell's death inspectors found failings at the NSFT's Hellesdon Hospital in Norwich.

Improvements have now been made - the NSFT is no longer rated as 'inadequate' by inspectors. But Mr Jewell's death exposed a lack of mental health beds in the region which is still a problem now.

Patients are still sent away, sometimes to facilities rated 'inadequate' by the Care Quality Commission.

Mr Jewell was sent to Hamilton House care home at Catfield, which has now closed, because the NSFT did not have any beds itself. It was there that his condition deteriorated.

Inspectors warned in 2011 that improvements were needed at Hamilton House and in 2015 it was rated as 'inadequate'. After his death, the Norfolk and Suffolk Safeguarding Adults Board carried out an investigation.

The review named Mr Jewell as AA. It described him as a 'quiet and gentleman who lived with paranoid schizophrenia' which he managed thanks to community support workers.

But in 2011 this all changed when the NSFT made Mr Jewell's care coordinator redundant. 'The level of care support that he received reduced dramatically', the review found.

The report found a series of events then led to his death – he ran out of medication, there was no suitable mental health hospital bed for him so he was admitted to the care home which seemed unsure about how to deal with his challenging behaviour.

The police were asked to intervene in a situation which required mental health professionals.

Rather than getting help, he was handcuffed, sedated, strapped to a stretcher and put in confinement in Suffolk because there were no beds in Norfolk.

Mr Jewell's death has rightly served as a warning about how we treat people with mental health conditions.