The jury concluded that a number of failings in his care caused or contributed to his death, including inadequate management and risk assessment and missed opportunities for improved care.
They found the communication with Jason’s supportive living provider was ineffective, and his care was not discussed at multi-disciplinary meetings as it should have been.
The 37-year-old had suffered a brain injury in September 2022 and was later treated for a schizophrenic illness, which required inpatient care five times in the five years before his death.
His mother, Vevine, said: “Jason was a loving and thoughtful son. Everyone who knew him described him as smiling, gentle and kind.
“The mental health teams should have done better and we are heartbroken to have lost Jason in such a violent and shocking way as a result – we pray this doesn’t happen to anyone else. His daughter Dejeanne and I miss Jason terribly.”
Lucy Mckay, spokesperson for the charity INQUEST which supported the family, said: “Security guards clearly have a role in initially responding to incidents like this.
“They must be adequately equipped and able to do so safely and effectively, without putting lives at risk.”
There have been four inquests in the past year in which restraint by security staff has been criticised and found to contribute to a death, she said.
