The Metropolitan Police and the South London and Maudsley NHS Foundation Trust were subject to a damning verdict in the south London Coroner’s court earlier today – each of them facing criticism for contributing to the death of a vulnerable man. The death of Olaseni Lewis in September 2010 is one the most sensitive, controversial and difficult of all the death in police custody cases I’ve known connected to mental health issues. I had the opportunity to hear Mrs Lewis speaking in Brixton last year about her family’s ongoing ordeal: it was nothing short of absolutely heartbreaking to listen to the experience of someone who’d already waited six years to learn how her son died, and to hear first hand how the post-incident system had exacerbated the distress of what must have already been a devastating incident.
Various resources relevant to this post –
- The Record of Inquest – a narrative verdict, which explains what occured and how Seni Lewis died.
- Press release from Inquest, the charity who have supported the Lewis family since 2010.
- Press release from the Metropolitan Police.
- Press release from the South London and Maudsley NHS Foundation Trust.
- Channel Four coverage of the case, including a 5 minute video with interviews.
- The Guardian’s coverage.
- The Independent’s coverage.
Seni, as he was known, was detained by the Metropolitan Police under s136 of the MHA and removed to a Place of Safety for assessment. After absconding from the unit, he was located and returned before being admitted on a voluntary basis to the Bethlam Hospital in south London, part of the South London and Maudsley trust. Following a disturbance on the ward which involved him trying to leave and damaging a door in the unit, the police were called. As officers were seeking a briefing about what was going on and what they were being asked to do, a nurse beckoned them on the ward itself because things were becoming very difficult. Seni was restrained in handcuffs by the police and staff asked the officers to remove him to a seclusion room within the same hospital. The officers engaged in a 10 minute restraint as they placed him in to the room. After failing to close the door properly, it was thought necessary to re-take control of him using restraint and attempt against to place him within the seclusion facility, this time involving a 20 minute restraint which involved officers striking him using a police baton and other mechanical restraints. He collapsed under the strain of all of this and a DR examined him, finding a very slow heart rate. Little was done at that stage and when Seni fully collapsed, there was an inadequate response with failures in first-aid and CPR.
This is all reflected in the narrative verdict published today.
The jury stated that five things had a cumulative effect in creating conditions in which police restraint of a patient on a mental health ward would be thought necessary:
- The admission process was substandard: lacking a full Doctor’s assessment, adequate risk assessment and the influence of family members to help.
- Ineffective use of medication to treat escalating agitation.
- The NHS trust failed to meet their own target for trained mental health staff to adequately ensure care.
- A lack of communication throughout between the police and the medical staff contributed to inadequate responses to Seni’s medical needs.
- A lack of trained and physically able staff to move Seni from the ward to a seclusion room, which led to them asking the police to do this, having already used hancuffs.
“These five cumulative factors led directly to the police restraints within the seclusion room.”
Five issues: all of them omissions, conscious or otherwise, on the part of an NHS Trust, indirectly creating conditions within which calls for police support / restraint become more likely than they would otherwise have been. This is exactly what the 2017 Memorandum of Understanding (MoU) on police restraint in mental heatlh settings was designed to address. If you are an operational police officer, please read this document from cover to cover, twice.
The narrative verdict lists three things which, on the balance of probabilities, contributed to Seni’s death at the hospital.
- The two periods of restraint were each described as ‘prolonged’, the first being ‘unnecessary and unreasonable due to the length of time Mr Lewis was in a prone position. The second restraint involved ‘excessive force, pain compliance techniques and multiple mechanical restraints’ which were ‘disproportionate and unreasonable’.
- During the second period of restraint, a doctor examined Seni after he became unresponsive and recorded a pulse of 45-50 beats per minute but failed to respond to this medical emergency.
- The police failed to follow their training, which requires them to place an unresponsive person into the recovery position and, if necessary, administered basic life support.
WHAT DOES THIS ALL MEAN?
This means, that police officers can be drawn in to situations in NHS trusts where factors way beyond the officers’ control, influenced by decisions taken hours and even days before by healthcare managers, may create conditions in which nursing and / or medical staff want the police to do things they should be extremely careful about doing, if they agree at all. I’m afraid to say this, but in the real world I police and given what we know about the accountability mechanisms and how they work, officers need to realise they are NOT there just to do as they’re told or to agree to everything that’s asked of them. It could be OK – in fact, it could be critically necessary – to say ‘No!’ and do something else, whilst escalating to the duty inspector to take control of the wider issues. I also accept this can create conflict with mental health staff on wards and I regret that, but only to a degree: conflict is not always a bad thing – it forces greater consideration of intuitive ideas and a counter-intuitive truth is a truth nonetheless.
The verdict tells us, in this case as in others, a failure to communicate throughout the incident created the problems which contributed to a death. The 2017 MoU tells us, the police should remain as uninvolved as possible until we’re clear what’s being asked or attempted. In Seni’s case, agitated behaviour led to him damage a door on the unit. We can all agree, I’m sure: that’s nothing worth risking his life over because we can always repair or replace a door. What prevents officers containing a situation, preventing a patient from approaching others or damaging things further but leaving them more-or-less untouched? This could involve something like a small, moving cordon on the ward whilst we think about how best to achieve the objective. Of course, professionals make the point that no-one thought life was being placed at risk: but no period of high-intensity or proloned restraint is inherently safe.
Any period of prone restraint is inherently unsafe – and it’s less safe the longer it goes on. This is all the more precarious when we refer to those of us with mental health issues.
This is more than hypothetical – but I want to stress ahead of the example that follows: all situations turn on their individual circumstances and involve subjective judgements. What follows doesn’t imply it could have ‘worked’ in any other situation. It’s offered only in the hope that nurses and police officers may take just a second or two, if at all possible, to think whether it offers ideas that may help.
Some years ago I attended a medium secure mental health unit to a similar report of a disturbance. We also met a large, physically strong man at 5am who had, apparently, “smashed up the ward” when they were understaffed. We were being asked to move him to a seclusion room … does this sound familiar? Of course, all circumstances are different and officers vary in their judgement of what’s needed but more than once in such cases, we’ve been able to put a few officers between the patient and the other people present and then just allow time in which he can see the officers are not going to use a high-intensity restraint. We tried to strike up a conversation, in fairness to a bloody cheeky PC on my response team, they somehow managed to get jokes going at my expense about how the boss is bald(!) … the patient laughed for the first time. He then joked at my expense and we laughed again. We spent about 20 minutes moving in a small area of the ward corridor and didn’t touch him during that period whilst nurses made various arrangements, moving other patients and so on. In fairness, I did touch the mental health nurse who entered the ‘cordon’, walking in to the patients personal space and shouting at him(!), because that really wasn’t helping.
At the end of building a some degree rapport based on giving him time and space to be safely in distress and for the situation to defuse, he moved to a seclusion room without being touched or even ‘ordered’ to do so. Ultimately, some patient discussion by officers caused him to agree to receive medication and no-one was restrained. The only adverse outcome was for the cheeky PC had to get himself back to the nick sharpish to have coffee on my desk by the time we’d returned – but he’s one of those cops who can influence others, he knows how to influence with words. He did his job well. For the record: this doesn’t always work despite best efforts and my telling this tale is about suggesting there are other ways which are far less controversial to contain, not restrain. Worst case scenario, it doesn’t work – but by that time, the bosses should be involved.
WHAT HAPPENS NOW?
It seems highly likely the Coroner in this case will issue a Regulation 28, Preventing Future Deaths notice which normally comes out a short while after the announcement of a verdict and is normally uploaded to the website of the Chief Coroner. We will have to wait to see what that says, but it seems it will have implications beyond London, because other forces have experience of being called in to mental health units in similar circumstances. Of course, both South London and Maudsley NHS Trust and the Metropolitan Police made referenence in their press responses to the Memorandum of Understanding between five major national bodies, which I was involved in drawing together over the last two years. It’s fair to say some officers on social media, want to know what they are expected to do if called in similar circumstances.Some officers are still of the view that there should never be a role for the police on mental health wards and that NHS organisations need to ensure staffing, training and so on which ensure the capacity, capability and training to handle incidents.
There will be more to say on this case in due course, once we see the PFD report but in the meanwhile, I encourage all operational police officers to read the MoU mentioned above, twice. Your role on mental health wards is finite and limited – and it does NOT extend to doing everything you’re asked to do by others, just because they are struggling. Doing ‘something’ might be the worst thing you could do; doing ‘nothing’ can often be best, containing a situation from getting worse, whilst pausing to escalate to some very senior people, getting them out of bed, if we need to do so. And if operational police officers do have concerns about the background conditions in any healthcare facilities creating conditions around this sort of thing, the MoU makes it absolutely explicit that things should be escalated and reviewed.
The worst news for Mrs Lewis and her family, is that this is far from over. They have called for the CPS to review the decision not to bring criminal charges against the officers involved, the IPCC have directed Gross Misconduct and Misconduct hearings against the officers involved, there is an outstanding Health and Safety Executive investigation in to the South London and Maudsley NHS Trust and the potential for civil or human rights challenges to be brought, if thought necessary. Based on history, it could be several years yet before those processes conclude and when you remember that we’re almost seven years beyond Seni’s death, you can’t help but wonder why things have to take this long.
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