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It is almost five years since David Bennett died after being restrained by staff in a psychiatric unit in Norwich. The final evidence session of the inquiry into his care and treatment is due to take place at the end of the month.

Bennett, a 38-year-old African Caribbean, died in The Norvic Clinic, a medium secure unit, at the end of October 1998. At the inquest into his death, the coroner found that the cause was "accidental death, aggravated by neglect".

Following this, an independent inquiry was set up under health service guidelines to look at the circumstances surrounding Bennett's death and to examine mental health services generally.


Bennett was by no means the first black person in psychiatric care to die in such a way. Mental health charity Mind believes that at least 27 have done so since 1980. However, as it stands, there is no central database that records serious incidents or deaths.

Consultant psychiatrist Sashi Sashidharan is the medical director of Birmingham and Solihull Mental Health NHS Trust and a member of the inquiry panel. He is also the author of Inside Outside, a report on mental health services for people from ethnic minorities published earlier this year (news, page 6, 13 March). He describes mental health services for people from ethnic minorities as "absolutely appalling".

"There is no aspect of mental health services in this country in which people from ethnic minority backgrounds do as well as white people or better," he says. "Not only are the inequalities persisting, but all the evidence shows that they are getting worse."

And problems run right through the system, says Sashidharan. Not only is access to services problematic, with GPs failing to help black people as effectively as they do white people, but once they have navigated the "tortuous routes" to specialist services they are often subject to misdiagnosis, poorer standards of hospital care and higher levels of discrimination. Furthermore, once they are discharged into the community, their follow-up care is often inappropriate, with many ending up with a "medication supervision service" rather than a more holistic care package.

But these problems are neither new nor unrecognised. Sashidharan says there is 50 years of evidence from research studies, patients, and people within the system.

"It's a scandal as far as I'm concerned. We collectively - psychiatrists, clinicians, nurses, doctors, social workers and, more importantly, policy makers and government - have got so used to it we do nothing about it. There's a sense of inaction not because we don't know what to do but almost because we are prepared to tolerate this," he says.

During the Bennett inquiry, Anthony Sheehan, the chief executive of the National Institute for Mental Health in England (Nimhe), admitted that parts of the NHS were institutionally racist, and promised "a strong and visible black presence" within Nimhe.

Mental health "tsar" Louis Appleby told Community Care that he agreed institutional racism was present within mental health services "as long as what is meant by that is that the service doesn't operate equally to the benefit of all ethnic groups, so some people are disadvantaged by the way the system works".

However, he does not think there is "overt and deliberate racism" within mental health services.

"The problem is how the system works, and whether we can put our hand on our heart and say we provide care that is equally appropriate for all ethnic, cultural and religious groups, and I don't think we can sensibly say that we do," he confesses.

Appleby says that, after admitting this on television, he received more mail than in relation to any other issue. Most of it came from people pleased about his openness towards the problem, but two clinicians wrote that what he had said was disgraceful, and gave the impression that nobody cared about the issue.

Several things need to happen in order to improve services for people from ethnic minorities, says Appleby. With evidence indicating that people from ethnic minorities prefer to be treated at home rather than in hospital, he says that services need to be less conventional. More support should be given to the voluntary sector, which he says has performed better than the statutory sector on this issue and deserves proper status "so it's not seen as providing an alternative". In addition, trusts should have someone on their boards who can represent ethnic minority views, he says.


One way to ensure trusts take the necessary steps would be to include ethnicity in their assessment criteria. Appleby admits that, at the moment, there is not an adequate performance indicator on the subject. He explains that one had been wanted this year but the information systems were not suitable. Instead, it was made a requirement for trusts to record patient information, which they will be assessed on in this year's star ratings. A better ethnicity indicator will be introduced, he promises, but doing so "takes a frustrating amount of time".

"My guess is that it might be another two years before we've got a pure ethnicity indicator. That's because a lot of the indicators that will be judged next year are already planned," he explains.

A possible contender is an indicator based on the number of people from ethnic minorities detained under the Mental Health Act 1983, but there are worries that this could create "a perverse incentive" not to use the act when necessary, such as where someone is at risk of suicide.

Control and restraint have been key topics during the Bennett inquiry, given the circumstances in which Bennett died. The Mental Health Act Commission told the inquiry that, around the time that Bennett died, control and restraint may have been a factor in the deaths of 22 detained patients. After this, the number of deaths rose to 24 in 2000 before falling to 10 in 2001 and seven in 2002. Appleby says that national guidance and training are needed, and says that the National Institute for Clinical Excellence is preparing guidance on the management of violence.

He says that, throughout his professional life, it has been clear that there have been problems in providing satisfactory mental health care for people from ethnic minorities. Little progress in addressing the issue has been made because the NHS has not responded appropriately, he says, with mental health failing to reach the top of the priority list.

But Sashidharan takes a stronger view of why there has been so little progress. "The Department of Health and the NHS are paralysed in relation to race and ethnicity," he says. "Whatever might be the recommendations arising out of major events or investigations, institutions that have no commitment to challenging and eradicating ethnic inequalities will not be able to implement them."

The report resulting from the David Bennett inquiry is expected towards the end of the year, and the government has a duty to respond.

"Why will it happen differently this time? Because we won't allow it to drift this time," says Appleby. He is aware that his personal reputation is at stake should mental health services for people from ethnic minorities fail to improve.

"It goes beyond being a health issue. It's a social and moral issue," Appleby says. "There probably isn't a single area of mental health that is more important to get right. There will come a time when I will hang up my Department of Health boots, and I want to be able to say several important things have changed as a result of my time in the DoH. And one of them has got to be this."