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Died in mental health careOrville Blackwood stopped breathing in a seclusion cell at Broadmoor special hospital after being forcibly restrained and given three times the recommended dose of a tranquilizer in 1991.
Roger Sylvester collapsed in St Ann's hospital, a psychiatric unit in north London, after being restrained by police officers. An inquest this year ruled that Sylvester had been ‘unlawfully killed’.
Munir Majothi , a psychiatric patient in Clifton hospital, York, died because of a "lack of care" according to an inquest. It was noted that the 26-year-old caterer had been given sedative injections in "unusual quantities"
Dubbed the ‘Stephen Lawrence Inquiry of the mental health world’ the inquiry report, released next month, is expected to brand the NHS as institutionally racist.
Blink can exclusively reveal that the Bennett inquiry will condemn the NHS for failing to learn lessons from previous deaths, and in hard-hitting recommendations demand a radical shake-up of the mental health system.
38 year-old black psychiatric patient Rocky Bennett died in October 1998 at a Norwich secure unit after being restrained. An inquest returned a verdict of 'Accidental Death aggravated by Neglect' in May 2001.
Since then the bereaved man’s family have mounted a long-running campaign to bring to light the circumstances surrounding Rocky’s death, leading to this semi public inquiry chaired by retired high court judge Sir John Blofeld.
restraint
Recommendations are expected to include calls for a new unit in the department of health to deal specifically with black and minority issues within the mental health field.
The inquiry may also demand new standards on the use of force when restraining patients, resuscitation procedures, and dealing with racist behavior.
Rocky Bennett, a father-of-two from Peterborough, was about to be released from Norvic secure unit in Norwich after three years in the institution, but died of positional asphyxia on 31 October 1998.
He was subjected to racial abuse from another patient and later became angry that he and not the other white patient were moved off the ward. The inquiry into his death heard that Rocky hit out at nurse Sharon Hadley. He was immediately restrained face down on the floor.
He was then held face down for 25 minutes by as many was five nurses. His family were not informed of his death until two days later.
hope
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| David ‘Rocky’ Bennett: died of restraint in ‘racist’ mental health system |
Rocky’s sister, Dr Joanna Bennett, a lecturer in mental health nursing at South Bank University, told Blink of her hope that the inquiry would bring about much needed changes to the care of mental health patients.
She said: "His life won’t have been lost in vain if this campaign and semi public inquiry lead to positive changes in mental health services.
"The imminent recommendations are a start, but they are only a start. I continue to see that black service users are not getting the level of service that they deserve or require."
As a mental health professional Dr Bennett said that Rocky’s experience was not unique.
"There needs to be national policies in place to ensure that other black men are not subjected to this kind of treatment."
hearings
The inquiry into Rocky’s death has held its’ hearings in Birmingham and includes top medical professionals including Professor David Sallah, Professor Sashi Sashidaran, Joyce Struthers and Dr Richard Stone who previously sat on the Stephen Lawrence Inquiry.
Inquiry chairman Sir John Blofeld said: "Our research through the inquiry has shown black mental health patients are over-medicated and spend too much time in secure wards."
The recommendations will be submitted to health minister Rosie Winterton, and she will decide whether the report is made public.
A source told Blink: "The report promises some hard hitting changes and will be banging on the door of the NHS with some tough recommendations."
The inquiry is expected to look at the problems of disproportionate diagnoses of severe mental illness in black people, and the over-zealous use of seclusion and detention of black patients.
They found that the NHS do not even centrally collect information on deaths of mental health patients.
Mental health services are blamed for a failure to manage frustration and anger and the poor treatment of bereaved families following a death. The NHS will also be blamed for failing to learn from previous deaths caused by restraint.
sectioned
The inquiry heard evidence that Rocky often expressed fears that he would be killed in the mental health institution run by Norwich Mental Health Care NHS Trust.
Dr Ian Gibson, MP for Norwich North, has criticised Norfolk Mental Health Care Trust accusing it of being "blasé" over criticisms arising from Rocky’s death.
A spokesman for the mental health trust was recently quoted as saying: "It has been a long time since Mr Bennett's death and the changes have already been implemented."
Some black health campaigners believed a culture of racism and neglect has infected the mental health system. Department of Health figures show black people are over five times more likely to be detained in high security units.
Even though black communities constitute less than 3% of the national population, official figures show they make up 16% of high security detention, and 30% of medium risk patients. Black people are also six times more likely to be sectioned than white people.
Errol Francis, a consultant at the Sainsbury Centre for Mental Health, told Blink: "This is an under explored area that needs to be looked at."
Lawyer for the Bennett family Sadiq Khan said the inquiry into Rocky’s death has been "the best kept secret there is" receiving little press coverage.
Helen Shaw, from campaign group Inquest, has been supporting the Bennett family in their quest for justice.
She said: "Some positive changes can be made for the future. This Inquiry can provide an opportunity to precipitate change in the treatment of all people with mental heath problems and in particular address the specific needs of black patients."
chaotic
Coroner at Rocky’s inquest William Armstrong told reporters after the neglect verdict: "The horror of listening to what happened that night is going to live with me forever. I am gravely disturbed by the chaotic way in which the situation was managed showing that the mental health service continues to fail to respond to what should have been learned from similar previous incidents."
Dr Joanna Bennett said she hoped the report would bring changes to the system so that "Rocky’s life is not to have been lost in vain." She warned that the report must not sit on shelves gathering dust.
Expected recomendations
- Details on all deaths within mental healthcare institutions including ethnicity, age, location and mode of death. There is currently no information available about the number of deaths there have been in mental health units in hospitals.
- A national standard for training and use of force, short term guidance should be issued by the Department of Health suspending the use of the prone position in control and restraint.
- Proper records of all use of control and restraint on patients, serve as a useful tool in identifying training needs and abuse.
- A fully equipped resuscitation trolley with proper equipment available, with members of staff trained to use it – recommended for all NHS clinics where there are a significant number of patients.
- Greater attention to therapeutic engagement with individual patients.
- A new unit needs to be established to deal specifically with black and minority issues within the mental health world.
- The disproportionate number of black patients to black professionals in NHS settings in the mental health departments needs to be looked at and commented.
- Information about care or support workers for relatives of the bereaved should be readily available.
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