This report examines the treatment, care and tragic death of an African Caribbean patient while at the Norvic Clinic, in Norwich. (Norfolk, Suffolk and Cambridgeshire Strategic Health Authority 2004)

The David Bennett Inquiry report  looks into the treatment and care of, David Bennett, an African Caribbean patient, who died after he was forcibly restrained by those tasked with his care.

His death followed an incident involving the use of restraint. The jury at the inquest returned a verdict of accidental death aggravated by Neglect on 17 May 2001 and said that the cause of death was due to prolonged restraint and long-term anti-psychotic drug therapy.

On the night of Bennett’s death, he was racially abused by a fellow patient during a dispute over the hospital phone. Nurses told Bennett  that he would be moved from where he was staying to a more punitive ward to diffuse the situation. When he resisted the situation deteriorated and led to a team of up to five nurses forcibly restraining him face down for almost half an hour.

The nurses only released him once they realised he had stopped breathing.  No attempt was made to resuscitate him.

Bennetts pathology report showed that he had three and a half times the BNF formulary limits of medication in his blood stream.

Retired high court judge, sir John Blofeld, chair of the Bennett Inquiry condemened the racism within mental health services as a blot on the good name of the NHS.

22 recommendations were made within the Inquiry report to address the systemic racism and inequity in treatment and outcomes of black patients.

2008 marks exactly 10 years since David Bennetts death.

To date not one recommendation within this report has been fully implemented.

The 2007 Deaths In Custody report rather shows that that has been a 40% increase in the death rate of patients detained under the Mental Health Act in the last 12 months. 

Read the David Rocky Bennett Inquiry Report in full.

Read the Forum for Deaths in Custody Report in full.