What happened
Kurt Howard, 32, from Swansea, was a detained patient at Cefn Coed Hospital. He had had mental health problems since 1991 and had been treated there before. He also had a drug habit and criminal convictions.
On 29 June 2002 he tried to attack a nurse. He was restrained twice that day, for around 55 minutes. In the first, after he punched a nurse, four staff held him on his back on the bed while he struggled and spat at them. When they loosened their hold he struggled again. After about 30 minutes there was what the nurse supporting his head described as a surge of energy. They could not hold him, and all of them ended on the floor, where he flipped over and lay face down. They restrained him again, one of the four supporting his head, for about 20 minutes. He was turned over and given mouth-to-mouth and chest compressions within seconds, but he had gone lifeless.
The outcome
A five-week inquest at Swansea ended on 27 June 2008 with a detailed narrative verdict. The jury ruled that his death was caused by excessive physical restraint, and their findings drew attention to failings in staffing, training and facilities. They found acute behavioural disturbance against a background of chronic psychosis and illicit drug taking.
The trust said an internal review in 2002 led to stronger training, tighter procedures and firm rules on reporting unexpected deaths to the police.
What went wrong
The nurse supporting his head told the inquest that he was worried about Howard’s breathing because he was on his front, and that he had never been trained to manage a patient in that position: “We are taught to restrain a compliant patient, but we come across all sorts of funny positions.” Staff kept checking his pulse while he went on shouting.
The team discussed turning him onto his back but could not while he was struggling. They judged that releasing him was not an option because of other patients on the ward. They had already given two injections, so no further medication was available.
The ward manager could not show a record of a key worker or a care plan.
What it teaches
Duration and position are the two variables a trainer can control. Fifty-five minutes of restraint, ending face down with no trained technique for the position, repeats a pattern already set down in the Bennett case four years earlier.
A pulse taken through a struggle is not a check on breathing, and breathing was the risk the nurse had named. The team needed a third option, and the ward offered none.
Questions for the room
- A pulse was being checked every few minutes. What was not being checked, and why does that distinction matter?
- The team could not turn him and would not release him because of other patients. What third option should have existed on that ward?
- The ward manager could not produce a record of a key worker or a care plan. What does that absence say about the restraint decision that day?
Evidence and limits
Confidence: confirmed. The verdict is reported by BBC News, and the restraint sequence, positions and duration separately by WalesOnline from the same inquest evidence. The inquest ended on 27 June 2008.
The accounts give around 30 minutes, and 30 to 35, on the bed; the record’s total of around 55 minutes is used here. The nurse’s account is his evidence to the inquest, not a finding against him, and he is not named. No prosecution is recorded in the sources held.
Sources
Our vulnerable and volatile persons training covers what a ward team does when a hold is running long.
Reviewed 20 October 2026.