Kurt Howard died after being restrained
An inquest jury has ruled the death of a psychiatric patient who died at a Swansea hospital six years ago was caused by excessive physical restraint.
The inquest into Kurt Howard's death in June 2002 at Cefn Coed Hospital ended with a detailed narrative verdict.
The jury's findings also drew attention to failings in staffing, training and facilities at the hospital.
Abertawe Bro Morgannwg University NHS Trust said many changes in procedure had been made since Mr Howard's death.
The five-week inquest had heard Mr Howard, 32, from Swansea, tried to attack a nurse at the hospital.
He was restrained twice on the day of his death.
Steven Parsons, one of the nurses involved in his restraint told the inquest Mr Howard "went lifeless" after almost an hour of holding him.
He also told the jury he was concerned about the patient's breathing because he was on his front and he said he had not had the training to deal with a patient in that position.
In the weeks before his death Mr Howard had claimed he was in the SAS, that he was a barrister and a gynaecologist, the jury heard.
He had began to suffer mental heath problems in 1991 and was treated on a number of occasions at Cefn Coed Hospital and elsewhere.
Mr Howard also had a drug habit and a number of criminal convictions for which he was imprisoned.
Earlier in the inquest, it was put to ward manager Martin Arber that the hospital had failed Mr Howard.
He said there was no record of a key worker being assigned to Mr Howard and he could not remember what care plans, if any, were made after an incident in which Mr Howard had become violent.
Mr Arber denied failing in his duty of care.
In its verdict, the jury said Mr Howard suffered acute behavioural disturbance in a background of chronic psychosis brought on by a history of illicit drug taking.
A spokeswoman for Abertawe Bro Morgannwg University NHS Trust said it would need some time to consider the verdict in detail and as such it would be inappropriate to comment on it yet.
But the spokeswoman said a series of actions had been put in place by the former Swansea NHS Trust following an internal review in 2002 after Mr Howard's death.
They concentrated on more robust violence and aggression management training, and tighter procedures, she said.
"A clear system of checks was set up to ensure regular staff training and awareness-raising were undertaken," said the spokeswoman.
"When restraint is used now, the circumstances are reviewed in all cases to ensure best practice is shared with staff and lessons learned."
She said the trust also acknowledged that procedures around reporting unexpected deaths to police were not robust enough six years ago and there are now firm and clear rules in place.
"ABM University NHS Trust will now be reviewing the original 2002 Action Plan to see if any additional work can be done to improve the service still further," she added.