A man died after tearing up a tissue and forcing it down his throat when he was in seclusion on a mental health ward.
Farooq Hussain, 49, of Ray Park Avenue, Maidenhead, was diagnosed as bi-polar and had previously spent time at specialist mental health unit Prospect Park Hospital in Reading.
An inquest at Windsor Guildhall on Tuesday, Wednesday and Thursday heard that Mr Hussain had a history of overdoses dating back to 2003 and had suicidal thoughts in early 2010.
On November 4, 2010 he was admitted to a mental health ward at Heatherwood Hospital, in Ascot, after he described hearing voices telling him to hurt himself and others.
Two days later he said he felt like stabbing himself with a knife and he was secluded after he put his hands around the neck of a fellow patient and threw a cup of tea.
He asked to be moved to Prospect Park Hospital and had been placed under observation when the incident happened on November 8, 2010.
Care support worker Adaobi Orji was responsible for watching Mr Hussain through the room's window and making notes every 10 minutes.
She recorded him pacing and banging his head and he requested again to be moved to another ward. At one point he walked towards a window with his back to her, entering a blind spot.
The inquest heard Mrs Orji saw Mr Hussain dab his forehead with one of two pieces of paper tissue in the room, before he tore it up. But when he came back from near the window she saw his breath was a 'bit laboured'.
Berkshire coroner Peter Bedford commended Mrs Orji for her speed in alerting other members of staff. He said: "She had no knowledge of Mr Hussain's medical history and whether this was commonplace but she took no chance and immediately sounded the alarm."
Staff were on the scene quickly and entered the room just before he collapsed. He died two days later on November 10 after having been placed on life support. A post mortem revealed that he died from a cardiac respiratory arrest due to choking.
The jury of five men and four women reached a narrative verdict and concluded his death was a result of misadventure.
Shortcomings have been acknowledged, a spokesman for Berkshire Healthcare NHS Foundation Trust told the inquest.
Stuart Grey said the window to the seclusion room has been made bigger and a fish eye mirror installed to eliminate any blind spot.
He added that patients have had access to paper towels in the seclusion room for 22 years without any problems. The trust has discussed the policy but decided to keep it the same.
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