9th May 2017


Before the Senior Coroner for the South London Area, Ms Selena Lynch
South Croydon Coroner’s Court
6 February - 9 May 2017

An inquest jury has today unanimously condemned police and healthcare staff actions in relation to the death of 23-year-old Olaseni Lewis, who died as a result of prolonged restraint by MPS officers at Bethlem Royal Hospital (part of the South London and Maudsley “SLAM” Mental Health Trust) on 31 August 2010.

Following 29 days of evidence, the jury’s highly critical narrative made a number of damning criticisms, including:

  • Multiple failures at multiple levels within Bethlem Royal Hospital meant that the hospital staff had to call upon the assistance of the police when Seni became unwell.
  • The force used by the police officers over two successive periods of prolonged restraint of Seni – including the use of mechanical restraints - was excessive, unreasonable, unnecessary and disproportionate, and contributed to Seni’s death.
  • The failure on the part of the hospital staff and the police officers alike to provide basic life support when Seni collapsed under restraint also contributed to his death.

According to an independent psychiatric expert witness, Professor Peckitt, clinical evidence suggested Seni was “terrified”, that he was “paranoid and scared rigid at the thought of restraint”.  He commented that being struck would have made things a lot worse: “We never, ever, ever hit patients”.

Since Seni’s death in 2010, INQUEST’s casework and monitoring statistics have identified a further 27 deaths in custody where police restraint was a feature.

Deborah Coles, director of INQUEST said:
“This jury have reached the most damning conclusions on the collective failures of police and mental health services. 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.

INQUEST’s casework and monitoring reveals that a disproportionate number of people with mental health issues and/or from BAME communities die following the use of force. That these deaths continue illustrates systemic problems in the processes for holding police to account at an individual and corporate level. Despite a plethora of recommendations arising from investigations, inquests and reviews there has been a failure of leadership to implement change in culture, approach and training.

We call in the strongest possible terms for the Metropolitan Police Service, the Home Office and Department of Health to publicly respond to the shocking evidence that has come out of this inquest”.


Seni’s parents, Aji and Conrad Lewis, said in response to today’s conclusion:
“When Seni became ill, we turned to the state in our desperation: we took him to hospital which we thought was the best place for him.  We shall always bear the cross of knowing that, instead of the help and care he needed, Seni met with his death. 

Now, after almost seven years of struggle to get here, the last three months have allowed us to hear for ourselves about what happened to Seni.  We have heard about the failures at multiple levels amongst the management and staff at Bethlem Royal Hospital: instead of looking after him, they called the police to deal with him.  And we have heard about the brute force with which the police held Seni in a prolonged restraint which they knew to be dangerous: a restraint that was maintained until Seni was dead for all intents and purposes.

In light of the evidence we have heard, we consider that the prolonged restraint that resulted in Seni’s death was not and cannot be justified, and we now look to the Crown Prosecution Service to reconsider the case, so that the officers involved in the restraint may be brought to answer for their actions before a criminal court.  This is necessary, not just in the interests of justice for Seni, but also in the public interest, so that the police are seen to be accountable to the rule of law. 

The officers involved in the restraint have not been able or willing to offer any word of condolence or regret in their evidence, in the same way that none has been forthcoming from any of their managers or superiors in the Metropolitan Police over these years.  That lack of simple human decency is telling, and the new Metropolitan Police Commissioner, Cressida Dick, has an opportunity to put it right.  We call on her to meet with us, so that we may help her to take responsibility for Seni’s death, to understand the lessons that need to be learnt, so that other families need not go through what we have had to endure.

As a family, we couldn’t have got through the last seven years without our Christian faith, the support of our family, friends and legal team, and the unending strength we have gained from the team and other families at INQUEST and the United Families and Friends Campaign.”


Raju Bhatt, the solicitor for Seni’s family, said:
“Seni’s case has revealed a mental health service and a legal system which appear unfit for purpose in the eyes of his family. They have been failed repeatedly over the years since his death in 2010: first by those responsible for the hospital at which he was restrained to death; then by the officers involved in that prolonged restraint and their managers at the Metropolitan Police; then by those at the IPCC who seemed incapable of fulfilling their responsibility to investigate the death; and, above all, by a process which allowed almost seven years to pass before this inquest could take place, the first occasion on which there has been any semblance of proper scrutiny in respect of the circumstances of the death.  That scrutiny has served only to confirm that Seni’s death was entirely avoidable, if only lessons had been learnt from the many deaths in similar circumstances in the past.  It is time that those responsible within our police service say for once and for all: no more!”

INQUEST has been working with the family of Seni Lewis since his death in September 2010. The family is represented by Raju Bhatt and Sophie Naftalin at Bhatt Murphy Solicitors and Alex Gask of Doughty Street Chambers, Inquest Lawyers Group members; and Karon Monaghan QC of Matrix Chambers.




A family statement will be read out after conclusion at South Croydon Coroner’s Court
2nd Floor, Davis House, Robert Street, Croydon CR0 1QQ.

• To arrange an interview with the family or Deborah Coles (INQUEST director) or for photographs of Seni, contact Gill Goodby and Lucy McKay at INQUEST 0207 263 1111 [email protected] (07814 693 613) and [email protected]

• For an interview with Raju Bhatt, solicitor for the family, please call Bhatt Murphy solicitors on 020 7729 1115. Read Raju's full statement here and a briefing on the case by Bhatt Murphy here


The Lewis Family have produced a chronology of transcript quotes from throughout the 37 days of evidence heard at this inquest. A copy can be found here. They have a family campaign website where more information is available: www.justiceforseni.com

The Record of Inquest with the full narrative conclusion is available for download here (PDF). 

KEY FACTS - Police restraint-related deaths:

  1. Mental health deaths involving police restraint
  • Last month, a custody sergeant and two detention officers were acquitted of manslaughter relating to the death of Thomas Orchardin October 2012. A Home Office pathologist, Dr Delaney, identified that Thomas’ death resulted from a struggle and period of physical restraint including a prolonged period in the prone position and the application of an Emergency Response Belt across the face resulting in asphyxia.
  • The majority of INQUEST’s police related cases over the past five years have involved the death of vulnerable individuals in some form of mental health crisis.
  • In 2015/16, of the 14 people who died, seven were identified as having mental health concerns. See IPCC annual statistical report here.
  • Following an eleven-year low of 11 police deaths in 2013/14, the number of deaths in or following police contact rose sharply to 17 in 2014/15. Eight out of those 17 deaths were of people identified as having mental health concerns; five were restrained.
  • This marks the continuation of a trend in mental health related deaths where in 2012/13 of the 15 people who died in or following police custody, almost half (seven individuals) were identified as having mental health concerns.
  • The circumstances of Seni’s death are strikingly similar to the death of Roger Sylvester in 1999.  Despite 11 years that separate the two deaths, both men were black, both were restrained for a prolonged period in the prone position by multiple officers in a mental health hospital setting.  Despite the training and guidance that followed Roger Sylvester’s death, the same basic failures prevailed.


  1. Race and restraint-related deaths police custody

Analysis of INQUEST’s monitoring statistics suggest that use of force/restraint is more likely to be a feature of the circumstances of BAME deaths in police custody. (Statistics collected since 1990. Analysis conducted in Nov 2016).

  • The proportion of BAME deaths in custody where restraint is a feature is over two timesgreater than it is in White deaths in custody.
    • The proportion of BME deaths in custody where use-of-force is a feature is over two timesgreater than it is in White deaths in custody.
    • The proportion of BME deaths in custody where Mental-Health-related-issues (MH) are a feature is nearly two times greater than it is in White deaths in custody.

Other relevant background relating to race in use of force/restraint related deaths:

  1. Government action – what is being done?
  • In April 2017, the European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment (CPT) published their report on the UK. The Committee highlighted the lack of a uniform approach to the use of means of restraint across the 42 police forces in England and Wales and that no reliable nationwide disaggregated data on the use of force or means of restraint was available. They expressed their concern that ‘given that detained people continue to die in police custody in England and Wales following the application of the means of restraint, such inconsistencies in rules and practices are an obvious cause for concern for a body with the CPT’s mandate’.
  • See here for INQUEST’s response to national guidelines issued in January 2017 by the College of Policing on use of police restraint in healthcare settings.
  • The publication of Dame Angiolini report has now been postponed until after the election.
    In February 2016, the Home Secretary announced anindependent review, conducted by Dame Elish Angiolini QC, into Deaths in Police Custody.  Seni’s death was one of the pivotal cases leading to that decision. INQUEST Director Deborah Coles was special advisor to the review.
  • Seni’s case (alongside the case of Sean Rigg’s) was key to the MPS decision to commission anindependent review on mental health and policing(conducted by Victor Adebowale of the charity Turning Point).
  • Evidence of Seni’s death was submitted to the Home Affairs Select Committee as part of their 2015 enquiry into policing and mental health.  Final report here.


Background case history

• Seni was a fit and healthy young man with no prior history of mental illness.  He was described in evidence as a ‘gentle giant’ who stood up to bullies. His father spoke of him as a ‘serial hugger’. He was taken to hospital by his family following a serious decline in his mental health over 48 hours.  The jury heard evidence that he was agitated, distressed and paranoid.  CCTV images showed him at the Mayday Hospital running around asking for help, “full of anxiety and fear”.  He was described as hearing voices and was shouting for help asking, “what is happening to me?” 

  • Seni was taken to Maudsley Hospital for assessment, and he was then admitted to the Bethlem Royal Hospital as an ‘informal’ patient, on the understanding that he could leave when he wished and his family would be called if any issue arose.  However, following his family’s departure with the end of visiting hours, he became increasingly frightened, agitated and disorientated. He tried to leave, but he was stopped, and he kicked a door.  The police were called by hospital staff because of ‘criminal damage’.  His family were not contacted.
  • Upon their arrival, police officers handcuffed Seni and, at the request of the medical staff,
    moved him to a seclusion room.  There he was restrained face down on the floor by a total of 11 police officers over a sustained period of approximately 30-40 minutes (across two periods of restraint).
  • Throughout much of the second period of restraint (lasting some 20 minutes), Seni was bound in two sets of leg restraints (around his ankles and legs) and two sets of handcuffs (linking his left arm in front of his face/neck with his right arm behind his back).  During his ordeal he was struck three times with the end of a police baton in what officers described as a ‘distraction technique’.  In his disorientated state, Seni was heard saying things like, “get the dogs off me”. 
  • The police officers’ evidence described a chaotic and shambolic restraint with no one officer taking the lead and a lack of clarity on what they were seeking to achieve.  They were unable to explain why they persisted with a restraint which was inherently dangerous and which went against all police training and guidance.  They insisted that, in the interests of Seni’s own safety, they had no option but to maintain the restraint until he stopped struggling.  In effect, this meant that they maintained the restraint until Seni became unresponsive.  Even then, instead of attending to his welfare, they chose to leave the room, apparently because they believed that he may have been ‘faking it’.
  • Seni never regained consciousness.  His family were finally contacted when he was transferred to Croydon University Hospital.  He was eventually pronounced dead on 3 September 2010. 

INQUEST provides specialist advice on deaths in custody or detention or involving state failures in England and Wales. This includes a death in prison, in police custody or following police contact, in immigration detention or psychiatric care. INQUEST's policy and parliamentary work is informed by its casework and we work to ensure that the collective experiences of bereaved people underpin that work. Its overall aim is to secure an investigative process that treats bereaved families with dignity and respect; ensures accountability and disseminates the lessons learned from the investigation process in order to prevent further deaths.

Please refer to INQUEST the organisation in all capital letters in order to distinguish it from the legal hearing.