The public part of the inquiry into the death of David ‘Rocky’ Bennett began this week. Rocky Bennett, a 38-year-old Black man, was certified dead in the early hours of Saturday 31 October 1998. He had been a detained patient in the Norvic Clinic, an NHS medium secure unit in Norwich, for three years.
His death followed an incident involving the use of restraint. The inquest opened on 3 May 2001 and returned a verdict of ‘Accidental Death aggravated by Neglect’ on 17 May 2001. Following the inquest, HM Coroner for Norfolk made six searching recommendations with an emphasis on the need for national standards on restraint in psychiatric hospitals, and for staff to be pro-active in dealing with incidents of racist behaviour by and against patients.
Following the inquest, the family of Mr. Bennett, their lawyers and the campaigning group ‘Inquest’ called on the government to consider holding a public inquiry into Mr. Bennett’s death. Instead, the Minister agreed to an extended form of the usual inquiry that follows a death in psychiatric detention, with a public element looking at the national lessons to be learnt.
Helen Shaw, co-director of Inquest, said: ‘We have welcomed this inquiry although it falls short of a full public inquiry. This is a case that raises significant questions about the treatment of black people in psychiatric custody, institutional racism within the NHS and the dangers of restraint. We are pleased that members of the panel conducting the inquiry include Dr Richard Stone, advisor to the Lawrence Inquiry and Professor Sashidharan, a consultant psychiatrist and leading expert in mental health issues and the black and minority ethnic communities. We hope that this inquiry will result in significant and lasting change.’
The issues which Inquest will be raising, when it presents evidence to the inquiry on 1 April, will be:
- ‘institutional racism’ within the NHS;
- the failure of the NHS to learn from previous deaths following the use of control and restraint and the failure of government to ensure cross communication across different custodial settings;
- the lack of central collection of information on deaths of detained patients and monitoring of the issues arising from inquests;
- over-diagnosis of severe mental illness in Black people with mental health problems;
- the poor treatment of bereaved families following a death.
Inquest has drawn national and international attention to the disproportionate number of deaths of black people in custody following the use of force or gross medical neglect. There have been detailed coroners’ recommendations on the use of restraint and the dangers of positional asphyxia following deaths in police and prison custody. Despite urging from ourselves and the MPs concerned in Mr Bennett’s case soon after his death, no formal mechanism has been established to ensure that the dangers of restraint are being learnt in all relevant forums and government departments. There is a complex and controversial scientific debate about deaths following restraint and yet it continues to be routinely used in many settings (psychiatric, social services and educational) without due regard to the potential dangers.
One of the ways in which bereaved families can find comfort and move on from such a tragedy is if they believe, despite the horrific nature of the particular circumstances of the death, that some positive changes will be made for the future. The death of David Bennett could provide an opportunity to precipitate root and branch change in the treatment of all people with mental health problems and in particular address the specific needs of Black patients.