Recommendations following death at Norfolk secure unit still not implemented, says charity

Schizophrenic David Bennett, 38, from Peterborough who died in controversial circumstances while det

Schizophrenic David Bennett, 38, from Peterborough who died in controversial circumstances while detained at a psychiatric clinic in Norwich. - Credit: PA

Concerns were raised today that recommendations made following the death of a man at a secure mental health unit in Norwich 15 years ago have still not been implemented across the country.

An inquiry into the death of David 'Rocky' Bennett at the Norvic Clinic in Thorpe St Andrew called for new measures to be put in place regarding the physical restraint of mental health patients. However, NHS trusts were accused of failing to implement the recommendations of retired High Court judge Sir John Blofeld - published nine years ago - to stop health workers using unacceptable force when restraining patients.

The 38-year-old Mr Bennett, who had been treated for schizophrenia for 18 years, died after five members of staff restrained him face down for almost 25 minutes at the Drayton Ward of the Norvic Clinic in October 1998 after he punched a female nurse. An inquiry discovered institutionalised racism throughout the NHS.

In his findings, Sir John said that 'under no circumstances should any patient be restrained in a prone position for a longer period than three minutes'.

However, the mental health charity Mind said that the specific recommendations about the use of physical restraint, especially face-down or prone position restraint, have still not been implemented.


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There have been at least 13 restraint-related deaths of people detained under the Mental Health Act in England since 2000, eight of which occurred in 2011.

The Norfolk and Suffolk NHS Foundation Trust, which runs the Norvic Clinic, declined to reveal how many times face down restraint were used in 2011/12.

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However, the figures, released under the Freedom of Information (FoI) act, revealed that Norfolk and Suffolk NHS Foundation Trust physically restrained people in their care on 1,118 occasions in 2011/12 - more than twice the national average.

Michelle Allott, deputy director of nursing, quality and patient safety for Norfolk and Suffolk NHS Foundation Trust said the trust had a higher number of restraint cases because of the size of the organisation and a policy of reporting all safety incidents. She said that staff undergo training every year on how to use physical restraint techniques, including face-down restraint, in the safest possible way.

She added: 'As a trust we always encourage staff to be proactive in regards to reporting any incidents; it is one of the ways we safeguard our patients and monitor safety and any emerging trends. All reported incidents are monitored very closely and we work with clinical teams to understand where we can improve.

'In addition, when we talk about reporting the use of restraint this will include any physical contact even if it is, for example, escorting a patient from one room to another by guiding their arm. Full restraint of a patient is only used as an absolute last resort where all other interventions have been exhausted,

'Our training, policies and reporting processes are continually updated to reflect national best practice and standards,' she said.

Norfolk and Suffolk's NHS trust used physical restraint 1,118 times in 2011/12, compared with the 455 England average.

Thirty-three of those incidents resulted in the police being called, compared with the national average of eight, and eight of those incidents resulted in a physical injury to a patient, according to the results of the FoI gathered by Mind.

Charity bosses called on the Department of Health to end the use of life-threatening face down restraint in healthcare settings after the figures revealed huge differences in the way NHS trusts use such restraints.

Officials from Mind and INQUEST added that further deaths in secure units in England could have been avoided if the recommendations from the inquiry into the death of Mr Bennett had been fully put in place.

Deborah Coles, co-director of INQUEST, which fights on behalf of families seeking justice for loved ones who have died in custody, said: 'Despite the plethora of restraint-related recommendations from inquests and inquiries into deaths it is shocking that restraint is still relied upon at such disturbing levels. Had recommendations been enacted, in particular those following the inquest and inquiry into the death of David Bennett then further deaths and injuries may have been averted.'

'National standards and accredited training must be introduced urgently hand in hand with more rigorous and transparent oversight of the use of force and restraint to ensure that restraint is only used as a last resort and is proportionate and lawful. Without this there is the ever present risk of more deaths and injuries of some of society's most vulnerable people.'

Mind said that at least 3,439 patients in England were restrained in a face down position in that period.

In a single year, one trust reported 38 physical restraint incidents, while another reported 3,000.

Cambridgeshire and Peterborough NHS Foundation Trust only used physical restraint on 63 occasions, according to the results of the FoI request.

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