UK: Call for public inquiry after neglect verdict
01 May 2001
On 18 May the jury at the inquest into the death of David "Rocky" Bennett, a 38-year old black patient at the Norvic clinic in Norwich, returned a verdict of accidental death aggravated by neglect. David had been a detained patient at the National Health Service (NHS) secure unit for three years when he died in October 1998 while being restrained by up to five staff for 25 minutes. Following the verdict Norwich coroner William Armstrong made a number of recommendations emphasising the need for national standards on the use of restraint in psychiatric hospitals and for the need for staff to be pro-active in dealing with incidents of racist behaviour by and against patients. The Norfolk Health Authority have stated their intention of holding an inquiry, but the campaigning group INQUEST are calling on the government to consider holding a public inquiry to consider the wider issues.
The inquest decided that David had died of "positional asphyxia" after being restrained by three - and possibly five - members of staff, reaching a verdict of accidental death aggravated by neglect. The events had been sparked by a fight after David was racially abused by a white patient. David was angered when that it was he who was moved off the ward, and a brief struggle led to him being restrained in a manner that prompted the coroner to remark, "The horror of listening to what happened that night is going to live with me forever". He added:
I came away quite disturbed by the fact that there are no proper safeguards for the prevention and management of aggression and violence that apply nationally [in the NHS], and gravely disturbed by the chaotic way the whole situation was managed, with tragic and fatal consequences.
Armstrong also criticised NHS trusts, accusing them of failing to take the issue of racism seriously. Pointing towards institutional racism within the NHS he noted the lack of a system for dealing with complaints of racism and a casual racism among staff who stereotyped David as "big, black and dangerous". Armstrong believes that the Trusts should have a written policy on racist abuse, a recommendation that Norwich has since taken up. He also called for national standards on restraint techniques and for more medical staff to be available as well as for better trained staff and resources. Scrutiny of procedures and internal reviews following the death of a patient are also called for.
However INQUEST, while welcoming both the coroners "searching recommendations" and the promised Norfolk Health Authority investigation, would like to see "a more wide-ranging and authoritative inquiry that can address the many systematic issues that arise...". These include institutional racism within the NHS, specifically, the over-diagnosis of severe mental illness in Black people with mental health problems; the over use of seclusion and detention of Black patients; the failure of the psychiatric services to implement appropriate strategies to manage frustration and anger; the failure of mental health services to provide appropriate support and care at an early stage; the poor treatment of a bereaved family following a death and the apparent failure of the NHS to learn from previous deaths following the use of control and restraint.
INQUEST press release 2.5.01; Catherine Jackson "Dangerous neglect" Guardian Society 18.7.01, pp2-3