Coroner of Inquests Jayne Hughes has recommended several changes to practice at Manannan Court mental health facility following an inquest into the death of an inpatient.

But she said staff could not have done more to prevent the death of Kevin Frank Broadhead, who died at Noble’s Hospital on August 28 2018 aged 38.

Mrs Hughes recorded a narrative verdict into the Peel man’s death, saying it was ’as a result of hypoxic brain injury which was due to or as a consequence of aspiration pneumonia and cardiac arrest while an inpatient at Manannan Court’.

She added: ’I find that the aspiration pneumonia was due to Kevin sleeping on his back while in a sedated state as a consequence of the medication properly prescribed and dispensed to him which compromised the protective reflexes guarding his lungs and which could not have been avoided by any reasonable measures above those in place.’

Mrs Hughes said she had ’heard nothing during the evidence in this inquest which would or should cause any individual to feel that they failed Kevin or could have done more’.

Recommendations

During his time in Manannan Court, Mr Broadhead was observed overnight including from August 22 to 23 2018 when he was taken to Noble’s Hospital. During this time, he was physically unwell.

Mrs Hughes said she would not be making any recommendations in respect of the observation policy that was carried out by Manannan Court.

She did, however, recommend a number of changes in practice such as all staff using the same clock to record the time of their observations and ceasing the practice of record sheets having preprinted hours of the day on them.

She said that staff should be encouraged to carry out checks randomly within the required hourly rate rather than on the hour itself.

And Mrs Hughes also said that she would be writing to the Department of Health and Social Care to recommend that any samples taken from patients admitted to Noble’s Hospital in similar circumstances to Mr Broadhead should be retained.

In closing, Mrs Hughes gave her condolences to Mr Broadhead’s family.

And she praised their dignified manner throughout the inquest, which she added ’must have been incredibly painful’.