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Inquest for Olaseni Lewis - Chronology and Transcript Quotes

9 May 2017

Collated by the Lewis Family

The Inquest

The inquest into the death of Olaseni Lewis (‘Seni’) has sat for 37 days and heard evidence from 125 witnesses.
An inquest is not a trial, it is an inquiry, a fact-finding exercise intended to establish the truth of the events leading up to Seni’s death following a police restraint at Bethlam Royal Hospital in 2010.  Because of the involvement of the police, the inquest jury is required to decide who the deceased was, where the deceased died, when the deceased died, and how the deceased came by his death, i.e. by what means and in what circumstances he came by his death.  In doing so, the jury is required to address relevant issues that have contributed to or caused his death.  The jury can address failures of action or inaction, draw inferences, but cannot attribute blame.  They are asked to find facts, and to address what did happen rather than what should have happened.  In this case, the jury was instructed to return a narrative conclusion, using succinct, neutral, and factual language.

 

Chronology Of The Events Leading to the Death of Olaseni Lewis

Olaseni Lewis died at Croydon University Hospital on 3rd September 2010.  He was 23 years old, and had recently completed his Masters postgraduate degree in IT.  He had no history of violence or any mental disorder and lived at home with his mum Aji Lewis.

Over the August Bank Holiday weekend of 2010 Seni began to display signs of mental disorder, he couldn’t sleep, he became suspicious of others, he was agitated and fearful.  Things escalated and in the early hours of Tuesday, 31 August, Aji contacted the Croydon Police.  She explained she had meant to call a doctor, but the police were concerned and dispatched two police officers, and when they arrived Aji reassured them that she was able to look after her son.

After their departure Seni’s mother and father (Conrad Lewis) took him to what was then the Mayday Hospital, arriving there at about 4 am, accompanied by one of his best friends Omari.  At the Mayday Seni continued to behave in an agitated and erratic manner and the police were called.  Officers from Croydon attended and a decision was made to detain Seni under section 136 of the Mental Heath Act and take him in a police van to the Maudsley Hospital in Denmark Hill for assessment by mental healthcare professionals.  

After Seni arrived at the Maudsley Hospital, he was left in the care of hospital staff.  Unfortunately, despite receiving medication, he didn’t want to stay, and at 9.20am he managed to leave the Maudsley Hospital via an unlocked emergency fire exit.

Seni made his way bare foot to Denmark Hill railway station intending to get on a train to visit friends.  Hospital staff followed him, and called the Southwark Police to assist them.  Seni was persuaded to return to the hospital by hospital staff, his friend Omari, and plain clothes police officers who came down to the platform to talk to him.  Seni walked with this group towards the platform exit, but when he saw uniformed officers on the stairs he tried to turn around, and was placed in an arm restraint by Officers.

On his return to the Maudsley, Seni received more medication and was assessed by doctors and an approved mental health professional.  At 4.15 pm Seni was discharged from the Maudsley.  He was then taken by cab, accompanied by a nurse and his mother, to the Bethlem Royal Hospital in Beckenham, where he was admitted as an ‘informal’ or ‘voluntary patient’ to Gresham Ward 2.  

Aji and Conrad Lewis stayed with Seni after his admission to help him settle in until they were required to leave because of the end of visiting hours.  Soon afterwards, Seni became agitated.  He asked to leave, but was prevented from doing so by hospital staff. He tried to force his way out of the hospital ward, and in doing so he kicked and damaged a door frame and took a set of keys from a member of the staff.  At this point he was restrained by an emergency team comprising of medical staff, and he was formally detained under section 5 of the Mental Health Act, so that medication could be administered.

Bromley Police were called for assistance by two members of the medical staff, apparently because of the damage to the door, but also to help with Seni.  Five Bromley police officers arrived at around 9.40pm and put Seni in handcuffs whilst still on the Gresham 2 Ward.  He was then taken down by the Police to the seclusion room on the ground floor of Bethlem Hospital, a room with an separate observation room alongside it. 

Seni became very agitated when he reached the door of the seclusion room and tried to prevent the police officers from taking him in.  They pushed him inside onto a mattress where they restrained him face down for roughly ten minutes while still in handcuffs.  The four police officers then attempted to leave the room using a procedure known as a ‘cell extraction’.  However, Seni managed to get back to his feet and reached the door before it could be shut on him.

Seni was then pushed back into the room while he struggled to get out, and in the process one of his legs struck a police officer in the nose.   After this point Seni was restrained for roughly twenty more minutes until he lost consciousness.  During this second restraint, four more Bromley police officers arrived at around 10.20pm, and joined three minutes later by two more Bromley police officers, so that there were eleven of them altogether.  They continued restraining Seni on the floor whilst his arms were tied together in two sets of handcuffs, and his legs were bound in two sets of leg strap restraints.  At one point, the end of a baton was used to strike blows to Seni’s upper arm, and at another a ‘pain compliance’ pressure point technique was applied to his jaw. In the meantime, further medication was administered to him.

The officers did not release Seni from the restraint until he stopped moving, and they then left him on his own in the room instead of tending to him, apparently in the belief that he was ‘feigning’ unconsciousness.  After the door locked behind them, Seni was still lying unresponsive on the floor.  Several vital minutes passed before medical staff and police officers re-entered the room and attempted CPR on Seni.

Seni was eventually taken by the London Ambulance Service to the Mayday Hospital, arriving there at about 11.25 pm. Sadly he never regained consciousness,  and he was pronounced dead four days later, on 3rdSeptember 2010.  Upon a post-mortem examination of his body, the pathologist found that the restraint, taken with Seni’s psychiatric condition, caused a cardiorespiratory arrest, meaning that his heart stopped.

 


Evidence from the Court Transcripts from the Croydon Coroners Court Inquest into Olaseni Lewis’s Death

Maudsley Hospital 136 Suite

"He said he was hearing voices in his head.  I can't remember what he told me the voices were saying, but he was clearly having this little battle in his head between wanting to come with us but also not wanting to, wanting to make an appointment."
Southwark Police Officer PC Wayne Golden

Seni’s Voice;  "My head is in two places, I don't know what's going on with me.  I think I've been drugged.”
SHO Maudsley Dr Sulagana Chakrabarti

"Taking someone off the street and depriving them of their liberty is a really big deal.  People are vulnerable, scared, and they must understand what their rights are and what the duties and obligations of the staff are.  Ideally two doctors are summoned, one who hopefully knows the patient, like a GP."
Expert Consultant Psychiatrist Professor Bob Peckitt

" I kept my head level so as not to be intimidating, kept my head below his.  He seemed to understand, but then would start questioning again, full of anxiety and fear."
Clinical Team Leader Dave Day

"I told him to take his medication and then he had a sleep.  Omari went to get some food.  He came back, we all ate something.  All calming, all looking good for the future."
Mother Aji Lewis

"My impression was of a person with mental and behavioural disorder.  I concluded there was no active psychopathy."
SHO Maudsley Dr Sulagana Chakrabarti

"There was a wealth of evidence to suggest that poor Mr Lewis had agitation and a psychotic illness of some sort, so sooner or later he's going to need anti-psychotic medication and something to reduce his agitation.  The two things work together.  It's synergy.  In my book he would have had an anti-psychotic and lorazepam.  Anti-psychotic medication has a number of effects.  The sooner you start using them, the sooner you get an effect.  Yes, it would be stupid to give somebody whose never had anti-psychotics a big dose, but if you've got somebody who is very unwell, paranoid and agitated, the sooner you start medication to relieve that suffering the better and the more likely it is that your efforts to deescalate will meet with success.  I have very little faith in promethazine as a method of sedation.  I understand some practitioners do like it. It wouldn't be my first choice."
Expert Consultant Psychiatrist Professor Bob Peckitt

"I wouldn't have told him he wouldn't be able to leave.  The whole idea of the informal admission was that he would be able to leave."
AMHP Maudsley Mr Simon Abbott

"A doctor would be under a clinical duty to explain to a patient, 'If you accept the bed in hospital as an informal patient you need to understand that if you attempt to leave the hospital and we think you're a risk to yourself or others because of your mental health we can make you stay'.  A lot of people might promise anything to get out without meaning it, and it's a matter of judgment and skill and tact to make sure you do have an understanding with the patient.  If someone had already escaped that would heighten my concern they might do something similar in the future.  The risk that a patient might change their mind is at the top of the list of things to be considered, and the role of the family is something that staff should consider in every case."”
Expert Consultant Psychiatrist Professor Bob Peckitt

"I reassured him they didn't use straitjackets anymore.  I reassured him that he might be offered medication and it might be in his best interests to accept it.  He never said he didn't want to take it.  I did not tell him he may be subject to forced medication if he did not agree to taking medication because I didn't think he could be subject to forced medication as an informal patient.  It never came up what would happen if he was going to change his mind about being an informal patient."
Nurse Maudsley Hospital Julia Drysdale-Brown

 

On Gresham 2 Ward at the Bethlem Royal Hospital Beckenham

"About half past 8 we were told that visiting was over.  I said did they have my number.  They said yes, but they took it again and I saw it in red on a file on a piece of paper, and then we said goodbye."
Mother Aji Lewis

Seni’s Voice;  "The more I was talking to him, he was getting more and more anxious.  My belief was to give him some space to calm down.  He was scared.  He didn't know where he was.  He said he would be better at home."
Charge Nurse Ram Doolaree

"I saw Mr Lewis running along the corridor.  Nurse Rogers told me he had damaged several doors and tried to take her keys.  I told staff to give him intra muscular medication because he was apparently refusing oral medication, and because of his level of violent aggression it was decided during this handover that Mr Lewis would be sectioned, and that would be so that intramuscular medication could be given against his wishes.  You couldn't medicate him against his wishes unless he was sectioned."
Night Site Manager Hilda Abban

“The briefing was quite clear; that if he refused the medication again, he will have to be restrained, whether he was being violent or not.  And that's exactly what happened.”
Healthcare Assistant Charles Okech

"I was in handover, that is coming on duty, when I was alerted to a disturbance.  I saw Mr Lewis.  He was very disturbed, going up and down, not directly violent to anyone, saying he wanted to leave.  I think one of the doors got damaged and Darren Hanoomansing warned him if he didn't stop, he'd call the police for criminal damage.  The emergency alarm had already been activated and some of the emergency team were already there."
Nursing Assistant Peter Peprah

"There were often shifts where the staff were not only not trained in PSTS, they were not capable of carrying it out.  It was not a safe situation in an all-male acute environment.  So the ward staff would get fearful of an escalating situation and would call the emergency team.  None of them, the emergency team, would be PSTS trained either."
Susan Smith Director of Nursing SLAM

"I believe the staff at the time could not handle him.  He was physically violent and would put me and my colleagues in danger.  I thought it more appropriate for the police to handle it."
"We've got criminal damage on the ward and violence.  We need police at speed please."
Nursing Assistant Darren Hanoomansing

"I saw Morgenne Carponen who told me to back off, so I went to the porter, who told me to call the police."
Staff Nurse Patricia Smith

“We don't advise staff to call the police for restraints.  We call the police to ask for situations that can't be managed, situations of high risk, situations of major difficulty on the ward.  It would     depend on what the restraint was.  If the restraint is to -- it could be for a whole range of reasons, but we wouldn't call the police automatically, no.”
Mr Steve Davidson Service Director SLAM

“I asked her what had happened and she stated that he'd asked to leave but the door had been locked on the ward.  He'd then became extremely violent and in an effort to get out he'd damaged one of the doors to the ward.  She stated because of this, they were now going to place the patient under a section of the Mental Health Act.”
Bromley Police Officer P.C Michael Aldridge

Seni’s Voice; “He said he is from Nigeria.  He wants to go back to his parents, he wants to go to his sister.  That was when I knelt beside him and I said "I am from your country, mate.  Is there anybody that we can get in touch with for you? Is there anybody that we can phone for you, so that you are able to speak to them?"  All that he said was "Sis, I want to go home."
HCA Ms Florence Bamigbade

"I came on to the ward and saw Mr Lewis sweating profusely.  His clothing was soaked.  On sighting us he moved at speed to our position, crouched forward, shouting he wanted to get out, it was nearly all over, repeating it again and again."
“Mr Lewis presented a possible risk to others in the corridor and he damaged the door, so I took my handcuffs out and placed a hand in cuffs.  He was really strong.  Even with PC Smith, who was pulling the other arm, we couldn't get the cuffs on, so I asked PC Curran to help.  We got him hand cuffed in a rear stack position, still struggling.”
Bromley Police Officer P.C Michael Aldridge


“He wasn't trying to hit anybody, ma'am.  He was just trying to -- you know, he was trying not for them to handcuff him, ma'am.”
HCA Ms Florence Bamigbade

"I wouldn't worry.  I've no intention of nicking this fella.  He obviously needs a bit of help, and even if he's caused any form of damage he's in the correct place.  At the moment I don't intend to arrest him for anything, regardless of what staff say."
Bromley Police Officer PC Stephen Boyle

"I was told he had been given a sedative but it had had little effect.  He [Dr Naqvi] wanted me to transfer him to the intensive care unit.  I asked if he had a team on standby to effect that transfer.  Normally we'd leave the staff at the hospital to carry out that transfer unless absolutely necessary.  He told me he didn't have the team, the staff.  I asked if he could get some from elsewhere within the ward or hospital.  Again he told me no.  I was engaged in conversation for a few minutes and could hear Mr Lewis's level of aggression in his voice was increasing.  Once I had carried out the risk assessment and decided it would be appropriate to assist my power to assist was under the common law.  In my mind I was using section 3."
Bromley Police Officer Sergeant Smith

"I was surprised to see the police, although I had been told they had been cancelled.  I thought it was to do with the door.  They needed to cancel the alarm.  I took the sergeant to the side to explain what the problem was.  Nurse Compton had by now made it clear she didn't want to nurse Mr Lewis on the ward and the decision to seclude had already been made.  Although the police were there to deal with the door and turn the alarm off, we might as well make use of them.  I didn't consider the fact that their techniques are different from ours because at that stage he wasn't being restrained.  They were just being asked to apply handcuffs and take him downstairs.  We just asked them to help us take him down."
Doctor Syed Naqvi

"Regarding the use of police, I would expect locally agreed protocols and guidelines to assist police and health staff, but if there are pieces of paper in a big file and they're not understood and operationalised by staff on the ground, then it may be difficult to get the response you want when the emergency arises."
Expert Consultant Psychiatrist Professor Bob Peckitt


The Seclusion Room Bethlem Royal Hospital
The First Police Restraint

"At this point he resisted quite heavily, put all his weight, like he really dug his heels into the ground and didn't want to go in.  We pushed, shoved him in.  It was, though, controlled."
Bromley Police Officer PC James Smith

"We all fell forward, stumbled off balance on to the mattress.  Mr Lewis began thrashing from side to side.  I took verbal control and instructed PC Boyle to go round to pin Mr Lewis's legs."
Bromley Police Officer P.C Michael Aldridge


"They put him on the mattress, two holding each side.  One of them, a bald officer, was searching his pockets if there's anything that will harm him or any weapon."
Staff Nurse Patricia Smith

"I leant forward and took hold of his arms and at this point Mr Lewis stopped resisting against us and stopped struggling, so we took the opportunity to carry out the extraction."
Bromley Police Officer PC Stephen Boyle

"There was a staff member that was supposed to shut the door.  As we were travelling backwards out of the room, I heard somebody shout 'the door the door'.   I hadn't heard anyone giving instructions to the staff member, but in my mind it was he who failed to shut the door."
Bromley Police Officer PC Stephen Boyle

"The officers tried to leave the seclusion room but Mr Lewis followed them.  Me and PC Glover stepped between them.  They backed out of the room.  We blocked Mr Lewis from going further.  We started to back out.  I got caught between the door and the frame.  Mr Lewis began to push against the door.  I got wedged between the door and was trying to push it back.  The door flew open.  So to prevent him getting out I pushed him back with all my force.”
Bromley Police Officer PC Howard

"At the door it was a bit of a mêlée.  The initial stages of any restraint that is being resisted do tend to descend into a semi-controlled form of chaos until control can be established."
Bromley Police Officer Sergeant Simon Smith

“You just do what you can.  It's like fight or flight.  All I remember is we end up back in the room.  He's kind of face down near the edge of the mattress.  You're kind of fighting to get back control, not necessarily aware of where everyone else is.  He's prone but this time his left hand is kind of trapped under the front of his body.  He's twisting and kicking his body.
Bromley Police Officer P.C Michael Aldridge


SENI’S VOICE: “But he -- he was quite upset and he said, "Can you tell them to get off me?"  Saying things along the line of "I'm not mad, why are they treating me like a criminal?"  Things like that.”
Doctor Syed Naqvi

"Well, overall it would be me in charge.  I wanted to make sure somebody was controlling the head and monitoring the breathing.  Other officers would try to get control of the arms.  The safety officer was PC Aldridge.  He was at the head.  I was laying across the legs.  Mr Lewis managed to pull one free from under my arm and kicked out, kicking me in the face, causing bleeding.  It wasn't deliberate."
Bromley Police Officer Sergeant Simon Smith

"I used my ASP and struck him three times in a closed mode strike to the upper muscly part of his upper left arm.  My intention was as a distraction strike to deaden his arm.  It had no effect."
Bromley Police Officer PC Stephen Boyle

"They were trying to get his hand round.  They weren't successful.  A stocky bald officer used a stick and struck Mr Lewis around the elbow two or three times in an effort to try and get his arm round and managed to and he was back in cuffs.  Mr Lewis was still struggling, resisting.  I felt I could help.  I went in They were trying to decide between them what to do next, talking to each other, some giving instructions to Mr Lewis.  I felt it might make it difficult for Mr Lewis and I said 'Seni, you need to relax, calm down'.  He said 'Tell them to get off me'.  I said 'They will relax if you stop fighting back'.  I was pleading with him.  It wasn't working.  An officer said 'Would you step aside?' In some ways I understand.  The position was difficult.  My talking to him wasn't having a lot of effect or difference and I came out."

“I went in again, and again pleaded with him to calm down.  I was in the way and an officer asked me to step aside.  At one stage an officer almost sat on him as you would sit on the edge of a chair, with one thigh on, almost on the edge of him, towards the right side of Mr Lewis opposite where I was in the observation room.  Not very long, this was about 15 to 20 seconds."
Doctor Syed Naqvi

"I saw the baton strike, one or two.  Police fell off the mattress on to the floor and at that point I pressed my emergency button."
Bromley Police Officer PC James Smith

"Can we have some more units please?  We've got some leg restraints.  We're in awful trouble here."
Bromley Police Officer PC Stephen Boyle

"There was one set of leg restraints by his ankles and then PC Aldridge thought we would put another set on as it's how we're trained, ankles and knees.  I helped put a second set on.  That's when the other units turned up."
Bromley Police Officer PC James Smith


“…officers are taught the safest place generally to restrain someone is on the floor.  Now, the reason for that is twofold.  One, clearly when people lose their balance you often end up on the floor.  But more importantly, perhaps, when a person is on the floor they are less able to kick you, they are less able to punch you, they are less able to spit at you and they are less able to run away.  So they are the sort of occasions where officers need to resort to force in order to carry out a lawful function.”
Officer Safety Training Expert Nicholas Bruce Sutcliffe 


The Seclusion Room Bethlem Royal Hospital
The Second Police Restraint

"During the second period of restraint it was in my mind he might be experiencing ABD."
Bromley Police Officer PC Laura Curran

“…The difficulty with anyone with acute behavioural disturbance is that you can go on and on restraining them and you'll never get on top of it because they won't be compliant in general.  That's the whole point.  They're so disturbed that they're not going to be compliant.”
Forensic Pathologist Dr Nat Carey  

"The police called for reinforcement.  The numbers increased.  I couldn't see, but you could see there was a struggle.  The police were over him.  I couldn't even look."
"I wouldn't say they were lying on him, I think they were just struggling with him.  I thought it was too much for Mr Lewis to endure, for anyone to have to cope with that continuous struggle.  I had to look away.  'Oh gosh, this is too much' basically.  I wished that he could co-operate so that it would be easier for the police to deal with him.  I was very much concerned for his welfare.  A member of staff said 'This is too much' sort of thing, but I was just powerless."
Nursing Assistant Peter Peprah

"I came in to see PC Aldridge, PC Smith and PC Boyle restraining Mr Lewis.  He was restrained by two sets of handcuffs, his left arm across his forehead and right arm up his back.  Two sets of cuffs and leg restraints.  I took the right arm.  Cranmer took the left arm.  We got him into the recovery position essentially.  Although he was restrained in leg restraints and handcuffs, he was getting an awful lot of body movements. I had to use all my strength to get him into a position that was safe for him.  He seemed intent ongoing on his front, shouting "No, no, no", happier to lay on his front, with his head on his forearm. He was hyperventilating, incoherent.” 
Bromley Police Officer PC Ian Simpson

"As we approached I could hear shouting coming from inside.  I came in and saw Mr Lewis being restrained.  He had leg restraints and handcuffs, one hand up at his head and the other -- and the right hand behind his back, joined by handcuffs, two sets, over the right shoulder.  There wasn't really time to react.  It's not a conventional position but I've seen handcuffs put on in different ways when it's not always possible to put them on.  I took the legs from PC Smith, my left arm around the calf, forearm under his shins and legs under my armpit.  I gripped them tightly and pressed my bodyweight down to stop him from lashing out with his legs.  He was able to sort of lift that part of my body away from the floor.  He was shouting, grunting, exerting himself.  I didn't think he was having trouble breathing though.”
Bromley Police Officer PC Adam Mitchell

"I don't know how many officers, maybe now five or six in total.  I was in the observation room where I could monitor him on the mattress.  I went in to observe, taking a blood pressure machine.  I think the doctor came with me.  But Mr Lewis refused.  He fidgeted and refused.  The police told me to get out twice.  They shouted at me when I insisted.  I told them 'I need to be here to monitor the patient' and he said 'No, out, we're dealing with it'.  I was concerned and told them to be gentle with him.  When I came out I think he came off the mattress, slipped off to the floor."
Night Site Manager Hilda Abban

"The clinical evidence suggests to me that Mr Lewis was terrified.  He was paranoid and scared rigid at the thought of restraint, as he thought, in a strait jacket, but by extension being locked in a room or restrained would have had exactly the same effect.  This terror must have greatly added to his physiological disturbance, that is his heart rate increasing, his muscles contracting and the effects of his body chemistry changing."
Expert Consultant Psychiatrist Professor Bob Peckitt


"I could see PC Smith was struggling with the legs so I helped him.  I didn't know who the safety officer was.  I didn't think it was a cell extraction, I wasn't sure what was happening.  There was officers trying to contain the male and they didn't appear to be containing him.  The handcuffs were in an awkward position.”
Bromley Police Officer PC Annette Gray

"I stayed in the room just trying to help keep Mr Lewis on his side.  I wasn't physically restraining him.  I don't know in what order more officers arrived and who did what and who relieved who.  I don't know how many officers were physically applying force."
Bromley Police Officer PC Stephen Boyle

"I arrived with PC Cranmer.  I saw Mr Lewis being restrained face down in the prone position, left arm in front of the body, the face, neck area, over the shoulder, connected to the right arm, behind his back and handcuffed."
"The officers looked exhausted, sweating profusely.  I think PC Boyle told me they'd been struggling with him for 20 minutes and had already tried to leave him.  I took over the hip/thigh area.  It was necessary to hold him even though he had leg restraints.  He could kick and lift his bottom up and a person can still bite or headbutt you.  He thought things were happening that weren't, but I didn't think about ABD.  I thought his mental health wasn't in a good way and I was very aware of ABD, but it wasn't something I'd had that much training on."
Ex Bromley Police Officer Mrs Russell 


“… Someone with acute behavioural disturbance may well be fearful of being restrained or may become fearful as a result of difficulty breathing; or just discomfort in fact.  Dr Fegan Earl and myself have both been in various positions in relation to other casework and I can tell you just to be covered to the rear stack position is extremely uncomfortable.”
Forensic Pathologist Dr Nat Carey

“At that point I considered he was possibly suffering from ABD.  I didn't do anything.  I was very conscious that I was in a hospital.  There were doctors and nurses more experienced and qualified than myself in diagnosing and treating mental health conditions such as that.  I also believed the actions that the officers were trying to do to remove themselves was the correct course of action.  If I had told the officers that I thought he had ABD, I don't think it would have had any influence on their actions.  I asked a male member of staff to get some water.”
"It was very hot in there.  The water was for the officers.  Our stab-proof vests are heavy and they don't let the body breathe.  We also have kit belt and cuffs and batons.  I was concerned for their welfare.  I poured the water in the cups and saw the officers start to move Mr Lewis again.  He was growling with every breath he exhaled.  The sound and tone didn't suggest he had difficulty in breathing, more something on the inside of him, an aggression and a ferociousness that couldn't be controlled."
Bromley Police Officer PC Adam Mitchell

"I got a call to go back.  I saw Mr Lewis surrounded by police, more than three.  He was prone with his hands behind his back.  I didn't see any cuffs.  The police were trying to deescalate him.  He wasn't calming down.  I think the police were trying to say: stop struggling, calm down, because this is a situation that's not good for you and it's not good for us.  It didn't work.  He was still struggling.  More officers arrived.  They went in and relieved those who wouldn't have had the energy to keep on holding.  A few came out and they requested water.  I went and looked for water."
Nursing Assistant John Tetteh

"When he was on the floor there were some officers standing and some officers restraining.  I saw one officer kneel on his back with one knee.  I can't remember, it was on the upper back to the middle.  He had his knee there throughout the restraint, for 5 to10 minutes.  Mr Lewis was struggling, wiggling his body. I was concerned…”
HCA Ms Florence Bamigbade

“The P would be: is it proportionate?  Is what I'm doing proportionate to the circumstances I'm facing?  The second point would be is it lawful?  Is it something that the law allows me to do?  Then the final two points is: can I account for it?  And is it necessary?  So it's those four elements which actually define what "reasonable" should be.”
Officer Safety Training Expert Nicholas Bruce Sutcliffe (explaining PLAN)


“I didn't ask the staff to give medication, that wouldn't be my role.  Very soon after a nurse came in and said she needed to medicate Mr Lewis and proceeded to do.  I didn't see the doctor at the time.  I was very aware that we shouldn't be restraining whilst medication was applied.  I knew there was no team to hand Mr Lewis over to in order for them to facilitate the administration of that medication.  It was my understanding that the medication must be urgent and absolutely necessary, so I wasn't going to prevent that from happening.” Bromley Police Officer Sergeant Simon Smith

"I knew we shouldn't be restraining people so that they could be given medication, but it happened so quick."
Bromley Police Officer P.C Michael Aldridge

“Later I saw an officer at the door.  I said it needed to be locked and he asked me to go away.  He was rude.  I said 'No, this is my ward, I'm in charge'.  Well, I didn't say that because they can arrest me, they can arrest you for anything.  But I did say 'This is my ward, I have to take charge'.  He told me to go away.  I went in and  I saw Hilda Abban and a doctor by the wall.  I saw Peter Peprah by the door.  I saw the patient on the floor in a supine position on his back.  There were two female officers, one on his side -- one on this side and one on that side, and a short, plump male officer, a knee in the middle of the chest.  I didn't say anything because the emergency team leader and the doctor were both inside the confinement room and I was expecting they are in control of the situation.  It went on for 5 seconds.  Then I left and later I saw them taking the crash trolley."
Staff Nurse Adelaide Ansah

“Well, there was bruising over the back of both shoulder blades, so it would suggest a symmetrical distribution of weight.  I would usually infer that's a weight coming from the chest, pushing down onto a firm surface.”
Forensic Pathologist Dr Fegan Earl 

"I heard PC Boyle saying they were going to attempt a second cell extraction.  He asked me if I could standby the door.  I didn't ask any member of staff about the key.  But when they got him in a position slightly more central in the room he, PC Boyle, requested my assistance with removing the handcuffs and holding his left arm.  I don't know who replaced me on the door."
Bromley Police Officer PC James Smith

"I took his right arm and held it in an upward position behind his back.  Then as his left arm was also brought behind his back, I gave control of the right arm to the officer who had his legs.  Then Mr Lewis suddenly stopped struggling and resisting.  I couldn't get the leg restraints off so we called for scissors."
Bromley Police Officer PC Stephen Boyle

"Deaths in restraint often have multiple factors involved that come together and cause the heart to stop: the elevated heart rate, blood pressure, production of lactic acid, adrenaline.  And even if they are restrained so that they are not able to move, they will struggle against the restraint, so they are still using their muscles, they are still using energy."
Forensic Pathologist Dr Fegan Earl

"Probably a benchmark of 3 to 5 minutes would be when you would start to get into trouble."
Forensic Pathologist Dr Nat Carey
“So his legs are pinned up.  The two bracelets that are linked together for the two sets of handcuffs are undone, and I do remember it was PC Smith who did this.  And it's at that point Mr Lewis appeared to stop fighting.  The handcuffs are undone.  And one by one everyone's out.”
“He wasn't struggling any more.  Officers have quickly come off, done the extraction and the door has been closed.”
Bromley Police Officer P.C Michael Aldridge

"I didn't say anything because I'm junior staff.  The leg restraints and the handcuffs were removed.  They came out one by one.  Then before the last one came out we shouted 'He's not moving, he's not breathing'.  Everyone of us staff in the observation room shouted and the officer went back in quickly."
HCA Ms Florence Bamigbade

"The cuffs were released from being inter locked.  I was holding the left wrist.  I outstretched the arm to the left-hand side.  He was still struggling.  PC Stephens helped me.  We put his left arm behind his back.  Mr Lewis suddenly stopped struggling.  PC Smith told everyone to stop what we were doing.  I think the handcuffs were still on.  We had requested scissors.  I think the leg restraints were off so that PC Simpson could bring the legs up.  I called for the doctors to come in and a male I later identified as Dr Naqvi came in and I removed the handcuffs.  I could see Mr Lewis wasn't moving.  Someone said 'We need to get back in there'.” 
Bromley Police Officer PC Mick Cranmer

"PC Boyle was holding the right arm and PC Cranmer had his left arm.  I used my handcuff key to undo the two sets of cuffs to allow his arms to be separated and put out to the sides.  On the advice of PC Cranmer I loosened the cuff on Mr Lewis's arm so that it could be turned into a position for cell extraction behind his back.  I then went to the head to ensure it was still because he was still struggling.  I noticed his head became limp in my hands.  I told everyone to stop what they were doing.  I suspected he may have become unconscious or stopped breathing.  He just suddenly stopped resisting.  The handcuffs were removed, then the leg restraints were cut off.  We didn't immediately call a doctor because we weren't 100 per cent sure if he was definitely unconscious or not breathing.  We left the room in case he was feigning, passing out as a ploy to escape.  We took the opportunity to take the restraints off and leave the room.  That is what we were trying to do, to leave him alone."
Bromley Police Officer PC James Smith

"He went limp.  We were conscious it might be a ploy.  We'd already had a failed cell extraction and we didn't want to end up back in another struggle.  We had a safe and methodical method of getting out of the room and we continued that.  I was the second to last out even though I was on the legs.  I don't know why.  It was a matter of seconds before we realised and PC Aldridge was shouting 'We need to get back in'."
Bromley Police Officer PC Ian Simpson

"Someone mentioned possibly feigning, something like that.  We came out and shut the door.  The doctor didn't come in before this.  I waited 3 to 4 seconds. I couldn't see the chest rising and falling and he's still prone, so I shouted out 'Get the doors open'.  There's a delay while the key is located."
"After a few seconds me and PC Boyle went in.  I did response checks, I looked in the mouth.  We don't take a pulse, we're not trained to take a pulse.  We started CPR.  PC Boyle was doing 30 chest compressions.  I used a face shield and did two breaths.”
Bromley Police Officer P.C Michael Aldridge

"There was a split second decision of mine to take that window of opportunity to get out, to extract.  We were already on the cusp of extracting when he became still.  It's not uncommon for people to feign unconsciousness or illness as a ploy.  I just assumed the keys were in the observation area."
Bromley Police Officer Sergeant Smith

"As they got to the middle of the room the growling stopped, he stopped resisting.  I saw my colleagues stop what they were doing and their focus immediately changed to removing the handcuffs.  I could hear the officers warning each other to be careful in case Mr Lewis was feigning unconsciousness as a ploy.  They removed the cuffs very quickly and ran out.  PC Keville and I were at the door and shut it.  It locked automatically."
Bromley Police Officer PC Adam Mitchell

“What I saw going on was at a time when, apart from when Mr Lewis was let into the seclusion, I saw some nurses coming up in a panic and running towards the clinical room, and some of the nurses ran towards Gresham 1, the other side of the ward.  And these ones came back with oxygen cylinder, and the same with the group that went down there, the same kind of thing.”
Healthcare Assistant Charles Okech

"They continued to restrain him, then I heard them shout something like 'Is there a doctor in here?  Come and check if your patient is breathing'.  So the doctor went in to check, did a pulse, got the emergency bag.  Doctor took the lead.  We had the bag and the oxygen ready.  Police called on their radio for an ambulance."
Night Site Manager Hilda Abban

“I just remember being directed into the room where there were several police officers on scene.  Clearly CPR was already in progress.  There was a male on the floor that appeared not to be breathing.  One of the police officers briefly told me that there had been some sort of restraint taking place and he had been witnessed to have been unresponsive, and when they had gone to check him they believed him to be in cardiac arrest and started CPR.”
“…Obviously it was a very chaotic scene and I am very focused.  I am the only clinician there.”
“There were several people in the room. They wouldn't readily identify themselves as a doctor, like the doctors at hospital who have a stethoscope round their neck.”
Team Leader London Ambulance Service Steve Sands

“During the debriefing police came and asked about CCTV.  I told them there was none."
Staff Nurse Patricia Smith

"In the debriefing police came in and asked for CCTV footage.  The emergency team leader, Hilda Abban, said yes.  I knew there wasn't, and another nurse said there wasn't."
Nursing Assistant John Tetteh

“Clearly he suffered a cardiac arrest while he was being restrained.  Circulation was ultimately restored, so a heartbeat was regained.  However, there must have been a period of time during which his brain was critically deprived of oxygen.”
Forensic Pathologist Dr Fegan Earl

“I'm quite happy with the cause of death as provided by Dr Fegan Earl.  I think providing you take from the term "restraint" in the cause of death as equally implying struggling and a very high energy demand, that's implicit in that, and you get into a very vicious cycle where, if you apply restraint, someone in acute behavioural disturbed state struggles against that restraint, you may apply more restraint, and it's impossible really to break out of that situation, but energy demand and oxygen demand is an implicit feature of a restraint-related death.”
Forensic Pathologist Dr Nat Carey

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