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 last night apologised after a jury inquest, which concluded yesterday, identified failings.

A “pale” Mr Jewell arrived at Norwich’s Hellesdon Hospital clinic on January 6, 2016. 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 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 examination 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 tranquillisation, and ensuring patients’ needs remain central during restructures.

He said Mr Jewell’s family, who had a framed photograph of Mr Jewell and flowers in court, 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.”

Mr Jewell’s death came during a troubled time for the region’s mental health services. The Norfolk and Suffolk Foundation Trust (NSFT), no longer rated ‘inadequate’, was in the middle of a “radical redesign”; cuts to beds, staff and services.

A Norfolk and Suffolk Safeguarding Adults Board investigation in 2015 found the NSFT made redundant Mr Jewell’s care coordinator in 2011. He then ran out of medication, a new care home seemed unsure how to deal with his behaviour, and he was handcuffed, sedated, strapped to a stretcher and put in confinement due to a lack of mental health beds.

Dr Jane Sayer, director of quality at the NSFT, said: “We fully take on board the findings and unreservedly apologise for what has been deemed as our Trust’s part in the contribution to this patient’s death. The care provided was not acceptable.

“Our Trust is a different organisation with different leadership today. We have put things right to avoid this happening again.”

She said patients will always have a named mental health professional or duty worker coordinating their care and their rapid tranquillisation policy and training for staff has improved.