The jury in the inquest of Gary Connell, a patient at the Central Mental Hospital who died after a violent assault by a staff member, has recommended that the hospital regularly carry out an external and independent audit of all its policies and procedures, to ensure "international best practice in all areas".
It also recommended regular reviews of patient risk assessment, control and restraints procedures, including training, and facilities for control and restraint.
The inquest came to a close yesterday and the jury of four men and two women returned a narrative verdict in accordance with the evidence.
The inquest heard harrowing evidence about how Mr Connell died from injuries incurred while he was being restrained by staff during his transfer from one part of the facility to another.
Mr Connell (35), of the Morning Star hostel, died from restraint asphyxia and inhalation of gastric contents on September 12th, 2001.
The inquest at Dublin City Coroner's Court heard that Mr Connell had assaulted a member of staff with a piece of broken glass and later was being transferred to a seclusion room in another unit.
Up to eight staff members were involved in the transfer and they employed a range of different restraint and control techniques over the course of the 30 minutes it took for the transfer, including wrist locks, to control Mr Connell's aggressive behaviour.
State Pathologist Prof Marie Cassidy, who carried out a postmortem on Mr Connell, told the court that the restraint asphyxia which caused Mr Connell's death could have been caused by "any action which would affect breathing" during his restraint.
While he was being transferred to Unit 1(b), Mr Connell was assaulted by a care officer at the facility, Brendan Cullen, who kicked him in the head among other injuries meted out.
Prof Cassidy told the court that while the injuries incurred during the assault by Cullen would not have directly caused Mr Connell's death, they were a contributory factor.
Cullen pleaded guilty to assault causing harm to Mr Connell in 2006 and later had his sentence reduced to a two-year suspended sentence.
In a statement last night the HSE reiterated its "sincere sympathies" to the family of Mr Connell for their bereavement and expressed its appreciation to the family for their co-operation during this difficult period.
Since the event, a number of new protocols and practices had been introduced in the hospital, the statement indicated.
These includes revised practices for handling aggressive patients, an increase in the number of consultant psychiatrists and the closure of the ward in which the incident occurred and its replacement with a modernised facility.