Restraint and seclusion: two names

Twenty-five minutes face-down on the floor

David "Rocky" Bennett was held face-down on the floor by nursing staff for about 25 minutes, from 22:58 to 23:25 on 30 October 1998, and was pronounced dead at 00:20 the following morning. Five staff held him for the first two or three minutes, then never more than four — nobody at his head.

The independent inquiry chaired by Sir John Blofeld concluded that institutional racism was present in the NHS, and recommended, at recommendation 9 of 22: "Under no circumstances should any patient be restrained in a prone position for a longer period than three minutes."

Neither was adopted. The Secretary of State for Health declined to make the acknowledgement of institutional racism the inquiry called for. And NICE's 2015 guideline NG10 set a ten-minute benchmark for manual restraint — not Blofeld's three-minute limit on prone restraint.

The inquiry sat under HSG(94)27, with no power to compel evidence, and was not the first: a 1993 inquiry into three deaths at Broadmoor had already made findings the Blofeld panel called "disturbing".

[7] Independent Inquiry into the death of David Bennett, HSG(94)27, Norfolk, Suffolk and Cambridgeshire SHA, December 2003, recommendation 9 · [8] NICE NG10 (2015)

Seven years to the conclusion, eight to the Act

Olaseni "Seni" Lewis, 23, was restrained at the Bethlem Royal Hospital by Metropolitan Police officers — not by nursing staff, with hospital staff present. He collapsed, was transferred to another hospital, and died days later.

On 9 May 2017, seven years after the investigation opened, the inquest concluded that he "died from hypoxic brain injury caused by restraint in association with acute behavioural disturbance". The jury returned a narrative conclusion: the restraint was prolonged, disproportionate and unreasonable, the Trust had failed to meet training targets, and police had failed to follow their training.

The Mental Health Units (Use of Force) Act 2018, known as Seni's Law, followed. It prohibits no restraint technique and imposes no time limit. It requires policies, training, recording and reporting. Twenty years after Bennett, the three-minute limit is still not a rule.

[9] Regulation 28 Report to Prevent Future Deaths, South London Coroner's Court, Senior Coroner Selena Lynch, 28.06.2017, ref 2017-0205 · [10] Mental Health Units (Use of Force) Act 2018 c.27

The number "142" circulates as a statistic. It is not.

The figure of 142 restraint- and seclusion-related deaths over ten years circulates everywhere as data. It is a newspaper's own tally, compiled by the Hartford Courant for its "Deadly Restraint" series of 11–15 October 1998. It was never an official statistic and has never been independently audited.

When the General Accounting Office examined the question the following year, it did not attempt to verify the count. It reported instead that no comprehensive federal reporting system then existed, and that from the fragmentary information available it could identify at least 24 such deaths in fiscal year 1998 — a floor, not a total, with the note that "many more deaths related to restraint or seclusion may occur".

That gap has since been closed. Federal rules made in 1999, now at 42 CFR 482.13(g), require hospitals to report restraint-related deaths. Presenting 1998 as the present state would be inaccurate.

[11] US General Accounting Office, "Mental Health: Improper Restraint or Seclusion Use Places People at Risk", GAO/HEHS-99-176, September 1999, p.1 and footnote 2 · [12] 42 CFR 482.13(g)