Health chiefs in North Staffordshire announced a series of disciplinary measures after making public the findings of the inquiry into the death of Freda Ann Latham, 42, in May this year at Stallington Hospital at Blythe Bridge.
A police investigation into her death has been completed and the Crown Prosecution Service is deciding whether to recommend criminal proceedings.
The inquiry committee heard that the unofficial form of restraint had developed and become common practice at the hospital without senior management knowing anything about it.
The committee condemned the 'hooking on' procedure as 'totally unacceptable' and criticised the 'complacency' of the hospital's management.
Miss Latham, who had been a resident at Stallington Hospital since the age of four and had 'considerable and profound disabilities', was left in a lavatory in Erica Ward. Tapes from a bib around her neck were tied to the inlet pipe of a cistern while her nurses went for lunch. Her body was found by a cleaner 45 minutes later. A Home Office pathologist said she died due to 'inhalation of vomit and suspension'.
The inquiry heard that other female patients had been 'hooked on' to hospital lavatories by their bra straps and left alone.
The report said: 'Two different reasons were given for 'tieing on' on 13 May, 1992. Firstly, it was suggested that it was to prevent Miss Latham from eating regurgitated food on the floor. Secondly, because her underwear was new, it was suggested that hooking it to the cistern would have damaged it.'
The report made 38 recommendations to North Staffordshire Health Authority, which commissioned the inquiry. It said: 'The recommendations made by the committee are intended to further the quality of life of the residents on Erica Ward or are aimed at ensuring that the adoption of unacceptable or unauthorised practices does not again go unrecognised.'
Richard Priestley, the health authority's chief executive, said yesterday that of the four ward staff on duty on Erica Ward on the day of the death, two had been dismissed and two had been given formal warnings. Two sector managers at the hospital had been suspended on full pay pending further investigations.
He said Charles Aked, the unit general manager for learning disablities, had been moved out of Stallington Hospital to another post where he will not be responsible for patient care.
'Members of the public and relatives and friends of residents at Stallington Hospital can be assured that the health authority is treating the recommendations of the inquiry committee with the
utmost seriousness and will be taking action swiftly and cleanly.'
Michael Fabricant, the Conservative MP whose Mid-Staffordshire constituency includes Stallington Hospital, called on Virginia Bottomley, Secretary of State for Health, to launch an urgent inquiry into the 'hooking on' practice. He added that there needed to be a total review of management procedures.Reuse content