CALL FOR INDEPENDENT PUBLIC INQUIRY FOLLOWING DEATH OF DAVID 'ROCKY' BENNETT

By INQUEST campaign group

inquest@inquest.org.uk
www.inquest.org.uk

Today the jury at the inquest into the death of David 'Rocky' Bennett returned a verdict of "Accidental Death aggravated by Neglect". Mr. 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, a 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.

HM Coroner for Norfolk, sitting at the County Court, King's Lynn, made six searching recommendations following the verdict. INQUEST particularly welcomes his 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.

The family of Mr. Bennett, their lawyers and INQUEST are calling on the Government to consider holding a public inquiry into Mr. Bennett's death. We welcome the Norfolk Health Authority intention to hold an inquiry at the conclusion of the inquest as required by current legislation but this case warrants a more wide ranging and authoritative inquiry that can address the many systemic issues that arise including:

* 'institutional racism' within the NHS;
* 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;
* over use of seclusion and detention and over medication of Black patients; * the over representation of Black people as psychiatric patients and their under representation as staff;
* the apparent failure of the psychiatric services to implement appropriate strategies to manage frustration and anger;
* the apparent failure of mental health services to provide appropriate support and care at an early stage;
* the poor treatment of bereaved families following a death;
* the failure of the NHS to learn from previous deaths following the use of control and restraint and failure of Government to ensure cross communication across different custodial settings.

With its narrow remit, the inquest could never provide an adequate forum to examine the policy and practice issues that arise from this tragic death. The Health Authority inquiry will not have the resources to address the complexity of issues arising here and neither will its findings have the authority to require action to be taken across the NHS. 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 the dangers of prone restraint are being learnt in all relevant forums and government departments. There is complex and controversial scientific debate about deaths following prone 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.

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