The NHS, and especially its mental health services, have been branded institutionally racist by an inquiry team set up to examine the care and treatment that 38-year-old Rocky Bennett received at the Norvic secure psychiatric clinic in Norwich before he died, in October 1998, after being restrained by up to five nurses.

The report, Independent Inquiry into the death of David Bennett published on 12 February, found that ‘at present people from the black and minority ethnic communities, who are involved in the mental health services, are not getting the service they are entitled to. Putting it bluntly, this is a disgrace.’ It goes on to call on the Department of Health to ‘cure this festering abscess [racism], which is at present a blot upon the good name of the NHS’.

Before the report was launched, Rocky’s family met (in private) with the minister for health Rosie Winterton who was said to have totally accepted the inquiry’s recommendations. The report had asked for a ‘ministerial acknowledgement of institutional racism in the mental health service’, but the response from John Reid secretary of state for health in a statement to the Commons avoided an acceptance of institutional racism. Hedging his bets he merely said, ‘I accept that there is discrimination in the NHS, both direct and indirect.’ More crucially, he failed to concur with a key recommendation in the report – that a three minute time limit be set for restraining people in a prone position. On this, his response was, ‘The National Institute for Clinical Excellence (NICE) will shortly publish guidance in this area.’

Reaction to the report

Richard Stone, a member of the Bennett Inquiry panel who also served on the Stephen Lawrence Inquiry, told IRR News: ‘If the government does not respond to our recommendation that they acknowledge institutional racism in the mental health service they will get away without doing anything. Furthermore, my concern is that there will be more deaths resulting from restraint in the prone position unless recommendation nine – the three minute time limit for such restraint – is implemented as a matter of urgency. We can’t wait for more research. I am also very wary of cultural awareness training – millions have been spent on that in the police service [after the Stephen Lawrence Inquiry]. It is not racial awareness training that has resulted in changes, it’s the behaviour of people who work in the institutions. In policing, random stops of black people are now eight times more likely than of white people compared with a few years ago when it was just five times more likely.’

“If the government does not respond to our recommendation that they acknowledge institutional racism in the mental health service they will get away without doing anything.” – Richard Stone

Errol Francis, a long-time campaigner on Black mental health, now at the Sainsbury Centre for Mental Health, who gave evidence to the Inquiry, cynically asked at the report launch: ‘How much cultural awareness training does a nurse require before they realise that too much force will kill?’

Helen Shaw of Inquest, a group that has campaigned against deaths in custody since 1981, told IRR News: ‘The failure to implement a three minute time limit on the use of prone restraint is dismissive of the panel and its witnesses, dangerous and knocks a hole in the heart of the recommendations. Why is it so difficult for the Department of Health to accept a time limit, such as that issued by the Prison Service over ten years ago? Unless the dangers of prone restraint are acknowledged and acted upon by the Department of Health, other measures arising from the report will be undermined and more patients will die.’

Inquest says that it will carry on working with families, mental health and anti-racist campaigners and organisations to ensure that the issues remain on the agenda. ‘The findings of the report are not the property of the NHS and the Department of Health but belong to us all in our ongoing work to prevent so many young Black men dying in violent and brutal circumstances while in the care of the state.’

The inquiry

The government agreed to hold an extended inquiry after the inquest on Rocky Bennett’s death in May 2001 recorded a verdict of accidental death aggravated by neglect. The inquiry was not a judicial inquiry like the Macpherson Inquiry into the death of Stephen Lawrence that had the power to summon witnesses, but an extended Health Authority Inquiry (usually carried out after deaths in psychiatric care). It was chaired by Sir John Blofeld QC and had on the panel professionals with relevant experiences of the mental health system. The six recommendations to the health secretary made by the coroner at the inquest were incorporated into the terms of reference of the Bennett Inquiry. The first part of the inquiry was held in private and examined the circumstances of Rocky’s death; the second, which examined wider mental health and race issues, was held in public. Sadly, these sessions were attended by a total of five members of the public.

What happened to Rocky

On the night of his death, Rocky was involved in an altercation with another patient who racially abused him. As a result, Rocky was removed from the ward for the night and he became upset and assaulted a nurse. This led to ‘control and restraint’ measures being used. He was restrained face down, at first by five nurses and then by four nurses for over 25 minutes. They restrained him across his upper body and by holding his arms and ankles. It was only after some time that the nurses, realising that Rocky was no longer struggling and unresponsive, attempted resuscitation and called an ambulance. The doctor ‘on call’ took over an hour-and -a-half to arrive because of problems with transport. An ambulance arrived and Rocky was taken to hospital where he was pronounced dead. The report found that ‘evidence is conclusive that he died whilst still at the Norvic Clinic’. Rocky’s family were not informed of his death until the following morning, and then they were misleadingly told he had died from ‘breathing difficulties’.

The CPS decided not to prosecute anyone for Rocky’s death in November 2000. Of the five nurses involved in the fatal restraint, most have returned to work and have been retrained though one has been reported to the Nursing and Midwifery Council.

Key recommendations from the report

The report made twenty-two recommendations that included:

• Under no circumstances should any patient be restrained in a prone position for a longer period than three minutes.
• The setting up of a national system of training in control and restraint.
• Ministerial acknowledgement of institutional racism in the mental health service and a commitment to eliminate it.
• A post of National Director of Mental Health and Ethnicity should be created to oversee the improvement of mental health services to minority communities.
• The promotion of an ethnically diverse workforce.
• The Department of Health should collate all deaths in psychiatric custody including information on ethnicity.
• All medical staff should have first-aid and Cardio-Pulmonary Resuscitation (CPR) training.
• Training to tackle overt, covert and institutional racism.
• Cultural awareness and sensitivity training.
• Treatment and detention of patients in secure units should be reconsidered and kept constantly under review.
• Patients should be allowed a second opinion from a doctor of their choice/ family’s choice.
• An informed debate on the care and treatment of people suffering from schizophrenia.

Key findings on the Rocky Bennett case

The report found many institutional failures in the treatment and care of Rocky Bennett in the mental health system, including:

• No ‘real attempt to engage his family in the treatment and management of his illness during this period of 17 years from 1980 to 1998.’
• He ‘was not treated by the nurses as if he were capable of being talked to like a rational human being, but was treated as if he was a ”lesser being” [the phrase is Dr Joanna Bennett’s, his sister], who should be ordered about and not be given a chance to put his own views’.
• No indication that his racial, cultural or social needs were adequately attended to.
• A highly insidious form of racist abuse which inevitably has an effect upon its victim. For, ‘the victim is bound to feel acutely sensitive’ and may have the ‘desire to retaliate, particularly if their perception is that no action may be taken to prevent racist abuse. Where the victims are mentally ill and subjected to racist abuse they will have greater difficulty dealing with it.’
• He was receiving three anti-psychotic drugs daily when only two anti-psychotic drugs were authorised by the Second Opinion Approved Doctors. A doctor said that the medication prescribed to Rocky was ‘higher than almost any other patients she had known.’
• The restraint was mishandled by the nursing staff, who were ‘pressing onto’ his body ‘when they should not have done so. His capacity to breathe adequately was restricted so that he was unable to inhale sufficient oxygen… restraint continued for substantially longer than was safe.’ It is a ‘serious failure of training’ that no time limits were given for the restraint of a person in a prone position. At no time did the senior nurse involved in the restraint give any instructions to the other nurses, as they had been trained to do.
• That members of the family were allowed to go away without a ‘reasonably full disclosure of the relevant facts was not only inhumane but also bound to lead the family to suspect that there was some cover up going on… We regard the behaviour of both the Trust and the police with dismay.’
• ‘There was no central training [on control and restraint – now known as prevention and management of aggression], no central accreditation of trainers, no clear definition of the content of the training or of the people who should go for training or on the time they should spend being trained… this is a subject that badly needs central control.’

Lessons not learnt?

‘The clear message we received on almost every subject in our terms of reference was that no, or insufficient, action was presently being taken to deal with problems in the mental health services that have been recognised for years.’ A damning indictment. One of the most serious allegations in the Rocky Bennett report is that lessons have not been learnt from previous deaths. Referring to previous recommendations in an inquiry following the death of three Black men at Broadmoor psychiatric hospital: ‘we express our grave concern at the apparent lack of reaction by anybody in authority to attempt to implement … recommendations made in that report.’ Key recommendations now being made in the Bennett inquiry also appeared in Big, Black and Dangerous: Report of the Committee of inquiry into the death of Orville Blackwood and a review of the deaths of two other Afro-Caribbean patients which was published eleven years ago.

Big, Black and Dangerous examined the deaths of Michael Martin, Joseph Watts and Orville Blackwood, who all died at Broadmoor psychiatric hospital after being placed in seclusion cells. Although concerned specifically with Broadmoor, it did recognise many issues which affect all black users of the mental health service. Big, Black and Dangerous included the following recommendations:

• to introduce training in the control of violent incidents without resorting in the first instance to physical restraint;
• to monitor patterns of diagnosis among minority ethnic groups;
• further research into the diagnosis of schizophrenia in Afro-Caribbeans;
• all staff be given adequate training in all forms of resuscitation techniques appropriate to their discipline and such training should be regularly updated;
• one [black] appointee should be given particular responsibility for tackling the problem of racism in the special hospitals – to advise on the development of a programme of race awareness training and to devise an effective equal opportunities policy;
• that the hospitals develop clear procedures for advising relatives of the death of a patient and to ensure minimum distress is caused to relatives.

Richard Stone told IRR News, ‘It’s a scandal what is happening. The report Big, Black and Dangerous still holds. Very few of the recommendations of that report have been implemented. All the institutions in this country need to become anti-racist; racism has to be acknowledged.’

“Very few of the recommendations of the Orville Blackwood report have been implemented.” – Richard Stone

Other deaths in psychiatric custody

The Institute of Race Relations, which has been monitoring deaths in suspicious circumstances involving Black and Minority Ethnic people in psychiatric custody since 1970, has on its files 18 cases which give cause for concern. We list below twelve that have taken place since the death of Orville Blackwood in 1991.*

• 28/8/91 Orville Blackwood (31) Orville was found dead in a secure unit of Broadmoor top security hospital after being given a tranquilliser injection. He had been detained under Section 37 of the Mental Health Act 1983 after suffering from paranoid delusions. The inquest in October 1991 recorded a verdict of accidental death. Orville’s mother appealed to the High Court for a judicial review of the inquest verdict. The inquest verdict was quashed and a new inquest held in April 1993 which again recorded a verdict of accidental death.
• 8/1/92 Mark Fletcher (21) Mark was detained by police and then sectioned under the Mental Health Act and transferred to All Saints Psychiatric hospital, Birmingham. At the hospital he collapsed after being restrained and given an injection into his spine. The inquest, which should have been, but was not, before a jury found that he had died from a cardiac arrest.
• 6/92 Munir Yusef Mojothi (26) Munir was a psychiatric patient at Bootham Park psychiatric hospital, he was given an injection of droperidol and then transferred to Clifton hospital, where he was given another injection of the same drug to calm him down. As this did not work, an intravenous dose of the drug was given by a doctor. This injection had the desired effect, but within 15 minutes he had stopped breathing. The inquest found that Munir had died from droperidol intoxication and ‘furring of the arteries’ and recorded a lack of care verdict.
• 23/6/92 Jerome Scott (27) Jerome collapsed and died on his way to hospital in a police van. He was suffering from depression and his mother called his GP, who could not help him. The emergency social work team called the police and two psychiatrists, who decided to administer an intravenous injection. Jerome was held down by police and then injected with two different anti-psychotic drugs – haloperidol and diazepam – put into a police van and died minutes later on the way to hospital. The inquest recorded a verdict of therapeutic misadventure.
• 30/1/94 Rupert Marshall (29) Rupert died in Horton psychiatric hospital, Epsom after being restrained and injected with an anti-psychotic drug. Inquest verdict not known.
• 10/8/94 Jonathan Weekes Jonathan died in Chase Farm hospital, north London after being sent there by social workers who claimed his depression was becoming worse. On the night prior to his death, nursing staff were unable to calm Jonathan so a doctor was called – but did not attend. The inquest recorded a verdict of ‘death by natural causes’, (pneumonia). However, it was later revealed that Jonathan was receiving eight different drugs, this information was not available to the inquest.
• 5/6/95 Dajin George (26) Dajin, a schizophrenic, died after falling from the fifteenth floor of a block of flats in Leyton, east London. He was a patient at Hackney hospital and should have been escorted throughout all outside visits. (He was also considered a suicide risk after making two previous attempts on his life.) He fell from a friends balcony without his escort being with him. Inquest verdict not known.
• 1/96 Newton White (33) Newton a mental patient in the Denis Hill Unit of the Maudesely hospital, south London died after being found drowned and scalded in a bath in the hospital. Newton was left unattended for over 90 minutes despite being on a 15-minute observation regime, as he had been assessed as ‘at risk’ days before his death. The post mortem found no evidence of a heart attack, stroke or head injury. Newton had no history of heart problems, epilepsy or high blood pressure. The inquest in March 1997 recorded an open verdict.
• 11/96 Veron Cowan (32) Veron died in Blackberry Hill hospital, Bristol from a blood clot on her lungs. She was admitted to the psychiatric secure unit at Blackberry Hill in October 1996 and died three weeks later. Her mother claims that she was fit and healthy before entering the unit but her physical condition began to deteriorate after she began taking the drugs prescribed by the hospital. At the inquest in April 1997 the coroner directed the jury to record a verdict of death by natural causes. However, the family wanted the inquest adjourned so that they could get independent medical advice, after MIND had submitted a critical report to the coroner about the care Veron received. However, the coroner preferred the evidence from those people connected with the trust which ran the hospital. A verdict of death by natural causes was recorded.
• 3/01 Eugene Edigin (19) Eugene attended the psychiatric unit at the Whittington hospital, north London and was detained the day before his death under the Mental Health Act because of ‘erratic behaviour’. The following day he was found unconscious in his bed. The inquest in February 2003 recorded an open verdict. His family were critical of staff who, they allege, failed to monitor his diabetes.
• 21/6/03 Ertal Hussein (32) Ertal was found collapsed at Bethlem Royal hospital, south London he was taken to Princes Royal University hospital where he was pronounced dead on arrival. Since 1990, Ertal had been sectioned several times. A police investigation is ongoing and the hospital has launched an internal inquiry.
• 4/9/03 Tema Kombe (aka Emmanuel Silva/ Gladwell Moseki Keenao) (32) Tema, a Ugandan asylum seeker was found hanged in the toilet of a psychiatric ward at Heatherwood hospital, Ascot. In January 2004, an inquest returned a verdict of misadventure after hearing that he had made three previous attempts on his life.

Related links

Full text of the Independent Inquiry into the death of David Bennett (pdf file, 807kb)

Inquest

Black deaths in custody – IRR factfile

United Families and Friends Campaign

Injustice – a film by Migrant Media