Death of Olaseni Lewis

Coroner Dr Roy Palmer began investigations into Lewis's death on 13 September. He concluded the cause of death was cerebral hypoxia (lack of oxygen to the brain) brought on by restraint. Palmer noted a lack of communication between police and medical staff, that police had not administered basic life support per standard training, and that medical staff did not respond to Lewis's critical condition.[6]

Given that there was no statutory requirement for a formal investigation of deaths in police custody, Lewis's family petitioned for an investigation and worked with organisations including police death charity Inquest and mental health charity Mind.[14] Lewis died the same day as Colin Holt, another black man with mental health issues who was restrained by police.[15]

In 2011, Lewis's family attended an annual march on Downing Street to protest the deaths of Black Britons in police custody. Despite a reduction in overall deaths in police custody, the number of deaths of Black British people had not fallen. The families of others who died in police custody, including Jimmy Mubenga, Kingsley Burrell, Jacob Michael, Smiley Culture and Mark Duggan, attended the march. Labour MP Jeremy Corbyn questioned the Home Secretary in Parliament on what would be done to address the issue.[16]

Delays to the inquiry led Lewis' family to campaign for its proper conclusion, with his mother attending the United Friends and Families Campaign march in London in October 2012.[17]

In January 2015 Theresa May, then Home Secretary, met with Lewis's family to discuss the case.[18] The death of Lewis, among others, contributed to the creation of a Commons Select Committee review of Policing and Mental Health in 2015.[19]

New Scotland Yard, the headquarters of the Metropolitan Police

An initial inquiry in 2011 by the Independent Police Complaints Commission (IPCC) first cleared officers over the death and noted that no disciplinary measures were required.[20] After a new inquiry opened into the death of Sean Rigg, another Black British man with mental health issues who died in police custody, the IPCC announced it would also review its original investigation of the Lewis case.[21] The family of Lewis took their case to the High Court of Justice to challenge the inquiry. In an unusual series of events, the IPCC paid their legal fees and backed their move to quash its own inquiry, which had failed to test officers' version of events and made no investigation into whether officers had committed a criminal offence. The High Court ruled in the families favour in September 2013[20]

Following the conclusion of a second IPCC inquiry and a review by a Queen's Counsel in early 2013, the Crown Prosecution Service (CPS) noted that there was insufficient evidence to bring a conviction against the officers who restrained Lewis. The CPS referred the case back to the IPCC in order to adjudge if internal disciplinary measures were required. Raju Bhatt, the solicitor for the Lewis family, said he was not surprised by this outcome but would continued to push for full investigation of the incident in the face of "four-and-a-half years of prevarication and worse".[22]

In May 2016 a senior coroner raised concerns about the standard of statements provided by staff at Bethlem, as their impartiality would be affected by the fact that their legal representation was being paid for by their employer, South London and Maudsley NHS Foundation Trust, which was involved in the case for corporate manslaughter.[23]

A disciplinary hearing conducted by the Metropolitan Police found the six officers (PC Simon Smith, PC Michael Aldridge, PC Stephen Boyle, DC Laura Curran, PC Ian Simpson and PC James Smith)[24] had not committed misconduct and no disciplinary action was taken.[25] The hearing was criticised by the family, because it was held behind closed doors with neither press nor public scrutiny.[26]

A coroners inquest by the South London Coroners Court was completed on 28 June 2017. It noted several concerns during his investigation. He noted that the police officers had used excessive force, had poor training on restraint, were not clear on the definition of "prolonged restraint", and had no guidance on how to react if efforts to restrain had not been successful for a long period. Officers also did not properly recognise that Lewis was having an "acute behavioural disturbance" (ABD) and may be at risk of death.[6]

The inquiry remarked on the fact that ABD is a police definition with no medical basis and that officers may be better served by general guidance on risks when restraining mentally ill people. The division of duties and responsibilities between police and medical staff were unclear. It was also noted that police were called as a result of a lack of available and trained medical staff.[6]

At coroner's inquest the jury found many failures by both police and medical staff which played a part in Lewis's death. They said "The excessive force, pain compliance techniques and multiple mechanical restraints were disproportionate and unreasonable. On the balance of probability, this contributed to the cause of death." However, the jury did not record a verdict of unlawful killing.[27][28]

Police were trained to view Lewis's behaviour as a medical emergency but the jury found police failed to act on this. The jury found that "The police failed to follow their training, which requires them to place an unresponsive person into the recovery position and if necessary administer life support. On the balance of probability this also contributed to the cause of death." A doctor did not act when Lewis became unresponsive while his heart rate dramatically slowed.[1]

Deborah Coles of the charity Inquest said the jury had reached the most damning possible conclusions on the actions of police and medics. "This was a most horrific death. Eleven police officers were involved in holding down a terrified young man until his complete collapse, legs and hands bound in limb restraints, while mental health staff stood by. Officers knew the dangers of this restraint but chose to go against clear, unequivocal training. Evidence heard at this inquest begs the question of how racial stereotyping informed Seni's brutal treatment."[29]

Lewis's family worked with their solicitor, Raju Bhatt, to draft a proposed change to UK law in order to prevent unnecessary and excessive restraint in mental health units and require psychiatric hospitals to give more detailed information about how and when restraints are used. This gained the support of Steve Reed, the Labour Member of Parliament for Croydon North, who took it to the House of Commons as a private member's bill.[30] This included increased gathering and transparency of data in hospitals on incidents involving physical force, including data on age, gender and ethnicity of those restrained. All reports covering patient deaths must be reviewed by the Secretary of State in an annual review. The law also mandated the use of police body cameras when officers were engaging with vulnerable people.[31]

In November 2017 the bill, referred to as "Seni's law", was debated.[30] On its second reading it failed to pass in June 2018, despite the support of the Conservative government, due to a two-and-a-half-hour filibuster by Philip Davies, MP for Shipley, who had a history of filibustering private members bills.[31] The bill passed the commons on its third reading in July 2018.[31] In November 2018, the bill received Royal Assent as the Mental Health Units (Use of Force) Act 2018.[32][33]

In 2018, the Metropolitan Police and South London and Maudsley NHS Foundation Trust, announced the introduction of the "Seni Lewis Award", which would be awarded to people nationally at the annual Positive Practice Mental Health Awards in recognition of efforts to improve collaboration between health services and police.[34]

The case of Lewis returned to national attention in June 2020 in connection with the George Floyd protests in the United Kingdom and other protests associated with the Black Lives Matter movement. Lewis's death was highlighted as an example of the disproportionate number of black, Asian and minority ethnic people killed in police custody.[35]