On April 30, a 27-year-old English teacher from New Zealand was admitted to a psychiatric hospital in the city of Yamato, Kanagawa Prefecture, after a manic episode linked to bipolar disorder.

Ten days later, his heart stopped.

Kelly Savage was rushed to another hospital in the city, where he was resuscitated but was left with severe brain damage. He died seven days later.

The Savage family alleges that the death was caused by the use of physical restraints, pervasive across psychiatric hospitals in the country and a practice long criticized internationally as inhumane and cruel.

Kelly’s older brother Pat, who lives in Yokohama, was with him when he was hospitalized at the privately run Yamato Hospital. He suspects the death resulted from the use of restraints, saying his brother remained strapped to his bed at the waist, wrists and legs nearly continuously for 10 days.

Savage said the lack of mobility during this period likely led to the formation of deep vein thrombosis (DVT) in his brother’s leg, which traveled up the bloodstream, blocked the flow of blood in the lungs and caused a heart attack.

“I don’t have problems with the doctors who treated him,” Savage told The Japan Times last week. “The only one that sticks out is the restraints.”

He said they “should never have been used in the first place” and especially not for 10 days.

Kelly Savage, a dual U.S.-New Zealand citizen who was born in Nevada and grew up in Wellington, came to Japan in August 2015 under the government-sponsored JET program to teach English in the city of Shibushi, Kagoshima Prefecture.

Back in New Zealand, he had mental health issues, and in 2012 was hospitalized for five weeks for depression. But he had recovered and graduated from a university.

In Kagoshima, he was loved by his students and fellow teachers for his friendly character, a former colleague said.

“He was a motivated and great teacher, always trying hard to make English lessons fun and interesting for the children,” said Takeshi Fukudome of the Shibushi Board of Education, who knew him well. “He even played with the children during the breaks. He had many friends in the community.”

But he didn’t like the side effects of his medication and began to take it irregularly, his older brother said, adding that, in March or April, he stopped taking medication completely and symptoms of mental health problems reemerged.

In late April, while staying at his brother’s apartment in Yokohama, he had a couple of manic episodes. On April 30, Pat Savage called the police and an official from Yokohama arranged for an examination by psychiatrists, who decided he should be admitted to Yamato Hospital through the compulsory hospitalization process authorized by law.

Savage, who was with his brother throughout the process, said he was surprised to see restraints being used right away. By then, he said, his brother had calmed down and was complying with orders.

“I was shocked that they suddenly put restraints on him,” Savage said. “And I told them I don’t think he needed that, but they said he will remain restrained for a while.”

During the Golden Week holidays, family members were not allowed to visit the hospital, but Savage called every day to ask that his brother’s restraints be removed. The request was not because of the risks of DVT — which he did not know of at the time and which was never explained by hospital staff — but simply because he was worried about his brother’s comfort, he said.

But his brother remained strapped down, Savage said, quoting a doctor who briefed the family after his death. The doctor explained that, during the 10 days, the wrist restraints were sometimes removed but the leg and waist restraints were not, he said.

On the night of May 10, Kelly Savage was found in a state of cardiac arrest and was taken to Yamato Municipal Hospital. He died on May 17 from brain damage caused by a lack of oxygen, but an autopsy failed to pinpoint the cause of his cardiac arrest, his brother said.

But according to hospital records dated May 14, a cardiologist at Yamato Municipal Hospital wrote: “To speculate, given that he was restrained for 10 days, it is possible that DVT was formed at some point and that this led to pulmonary embolism and cardiac arrest.”

Asked by the family why a blood clot wasn’t found, the cardiologist explained that when a blood clot is new, it’s hard to distinguish from regular blood that hardens after death, the family said.

It has long been accepted that physical restraints on psychiatric patients increase the risk of developing DVT.

In a study published in the medical journal Psychosomatics in 2014, Dr. Takuto Ishida examined the conditions of 181 restrained patients at Sakuragaoka Memorial Hospital, a psychiatric hospital in Tama, western Tokyo. The study found that, while all restrained patients wore compression stockings and received anticoagulant shots to prevent DVT, the condition was detected in 21 patients, or 11.6 percent, much higher than the incidence of DVT in the general population — 1 in 1,000.

Meanwhile, in a letter addressed to the family dated June 26 and seen by The Japan Times, Yamato Hospital Director Dr. Kazuhiko Ishii defended the decision to not report the case to a third-party medical accidents investigation center — created by the government in 2015 to probe “unexpected” hospital deaths — despite the family’s request to do so.

Ishii wrote that the hospital’s treatment was “appropriate,” and that the death “cannot be considered to have resulted from treatment” at Yamato Hospital. Ishii also suggested that the municipal hospital should report the death to the investigation center as it “has more expertise” about what caused the death.

In addition, Ishii wrote in another letter dated June 27 that the cardiac arrest was “beyond (the hospital staff’s) control” and that Kelly Savage had been restrained “only when it was necessary.”

Yamato Hospital, when contacted by The Japan Times, requested that inquiries be directed to its lawyer, Kimihiro Itaya.

Itaya declined to answer questions about the case, saying that since the Savage family has given notice of plans to sue, the hospital will make its case in court.

Norio Sato, head of the general affairs department at Yamato Municipal Hospital, declined to comment, citing privacy concerns and saying the case mainly concerns Yamato Hospital.

The death and the family’s quest for an investigation have bigger implications for mental health care in Japan, where the use of physical restraints has surged over the last decade.

The use of restraints at mental hospitals is permitted by law only when designated doctors determine that patients can harm themselves or others.

According to the latest health ministry statistics, the number of patients strapped down was 10,682 in fiscal 2014, compared with 5,109 in 2003, when the government started taking statistics.

Toshio Hasegawa, professor of health sciences at Kyorin University in Tokyo, said the use of restraints is increasing, adding that the duration of their use is inhumanely long. His study of 11 psychiatric hospitals across the nation in 2015 found that 245 patients were restrained for 96.2 days on average, with some being restrained for more than six months or even a year. While statistics are hard to find, that’s much longer than in countries where data are available, where the use of restraints typically lasts less than 50 hours at the longest, he wrote in his 2013 book on the issue.

Hasegawa attributed the soaring ranks of restrained patients to a recent increase in the number of psychiatric emergency rooms, where the standard practice is to use restraints first.

“Routine restraining is increasing,” he said.

He added that many psychiatric hospitals embrace the idea that restraints are an acceptable and meaningful way to “offer abundant care,” even though, he said, it deeply traumatizes patients, not to mention violates their dignity and human rights.

The United Nations Committee against Torture, in its report on Japan in 2013, said that in the area of psychiatric health care, it remains concerned “at the frequent use of solitary confinement, restraints and forced medication, actions which may amount to inhumane and degrading treatment.”

Hasegawa said Kelly Savage’s case is only the tip of the iceberg.

“We need to make the process more visible,” Hasegawa said. “We need to videotape the clinical environment, so we can examine if the use of restraints is appropriate.”

Pat Savage is also asking that the policy of tying down patients be reviewed — at Yamato Hospital and beyond.

“The problem is that it’s legal, that it’s been done all throughout Japan,” he said. “I don’t think it’s a case we can win in courts; the problem is bigger than that. The laws need to be changed to bring (the situation) in line with the international community.

“We just want all the hospitals in Japan to change their practices.”