Family and experts cast doubts on proposals in David Bennett report

How much cultural awareness training does a qualified nurse need
to realise that using excessive force against someone on the ground
will kill them?

The question was asked at last week’s launch of the report into the
death of David Bennett, a black man who died while being restrained
by staff in a medium secure unit.

As the question implies, it is debatable how much difference
cultural awareness training would have made in Bennett’s case. Yet
a deficiency in such education was the issue that alarmed the
independent inquiry panel investigating his death to the extent
that its main recommendation was for all staff in mental health
services to receive cultural awareness and sensitivity
training.

Precisely what that means is not clear. Inquiry chairperson Sir
John Blofeld said the details of the exact content would be a
matter for the experts. Clearly, there was not enough training and
staff needed to know more about the different ethnic groups. “Until
they do it’s quite difficult for them to appreciate, however well
meaning they are, what their needs are,” he said.

But he added that the training should not be so lengthy and
complicated that “nobody except those holding a university degree
can understand it”. Nor should it have such an impact on staff time
that they are unable to look after their patients.

Unlike other recommendations, the stipulation for cultural
awareness training appears to have the government’s full backing.
Mental health tsar Louis Appleby agrees that more focus is needed.
“I would be in favour of a proper nationally driven programme,
which might be locally commissioned, to ensure that everyone in
front-line care gets proper training,” he says.

Training priorities are not usually prescribed in the NHS, he says,
but “this is sufficiently important for us to do something more
than we usually do”.

However, not everyone is convinced that more cultural awareness
training will bring about the dramatic changes needed to overhaul a
service branded as institutionally racist.

Joanna Bennett, David’s sister and a mental health professional
herself, has reservations. “I don’t think cultural awareness is the
issue. But it is difficult at the moment in terms of the
terminology used historically to look at what is needed in terms of
training practitioners to be competent in working with people from
black and minority ethnic backgrounds,” she says.

Racist perceptions and assumptions that people hold may not be
about others’ cultures. So, in the mental health environment, where
black men are more likely to be sectioned and given high dosages of
medication, is knowing more about their culture going to change
practice? Not, it would seem, while individuals are typecast.

Bennett says: “There’s stereotyping that goes with racism, such as
a big, dangerous black person needing higher dosages of medication.
People need to understand racism within a historical context and
understand how racist stereotypes and assumptions influence
people’s attitudes and behaviour.”

For too long, practitioners who are themselves from ethnic
minorities have had to fight the cause on behalf of their clients,
she says, adding that it was about time the problem is seen as a
mainstream issue that concerns everyone.

But Bennett does not believe that if you match service users with
practitioners in terms of ethnicity, better care will automatically
follow.

She says: “It doesn’t mean that a black person’s key worker will
understand the issues for that particular individual because they
have black skin. Service users like to see representation of
themselves in the services they use but I’m not sure that’s going
to be the thing to change services.”

Another sceptic is Errol Francis, joint manager of an African-
Caribbean project at the Sainsbury Centre for Mental Health. He
points out that, far from being a new concept, cultural awareness
training has been tried but proven not to work.

Despite social workers receiving this sort of training, it has
failed to remedy the disproportionate number of black people who
are sectioned or who have their children taken into care, Francis
says. Consequently, he is cynical about any attempts to retread the
cultural awareness path.

“I myself have delivered training of that nature and have come to
question it because I don’t think it changes anything. Why do it
again in the NHS when it has been tried elsewhere and it hasn’t
worked?” he asks.

Instead, a “quality control” approach is needed, comparable to the
way faulty products in a factory would be examined.

Francis says: “We’d look at how a particular organisation is
performing on certain factors. And we’d look at how the staff are
making decisions and try to bring it to their attention where their
decision-making is faulty.

He believes that it is through their work that individuals,
unwittingly or otherwise, may demonstrate racist attitudes. “If I’m
a nurse or a social worker and I have got private racist views,
only the most outrageous will express these in public,” he
says.

“Where my views will become clear is in procedures such as whether
to section a person, how much medication to give and how to deal
with conflict on the ward. The big, black and dangerous stereotype
that people might hold privately will be expressed in how they
handle these procedures.”

That cultural awareness training alone will not transform mental
health services is a view also shared by Shahid Sardar, a liaison
officer for mental health charity Mind.

He compares its potential effects to the experiences of the police
service. After the Stephen Lawrence inquiry, thousands of police
hours went into similar training, but racist incidents still occur,
he says.

“It’s obvious and clear to everyone that that is not necessarily
the complete solution,” Sardar says. “The type of training given to
NHS staff has to be more about values, about how to deal with
mental health patients as individuals and to work with difference.
Every individual is unique with their own beliefs, preferences and
needs.”

Staff must not assume that individuals will follow certain cultural
norms or behave in ways they perceive to be standard for
individuals with a similar background.

There is little doubt that the way ethnic minorities are treated by
mental health services must be better. Improving cultural awareness
training will be part of the answer, but progress may only be
achieved by challenging the racist stereotypes that are embedded in
society as a whole.

Death on the ward

David Bennett died in October 1998 after being restrained by
staff in the Norvic Clinic, a medium secure unit in Norwich. He was
a 38-year-old African-Caribbean who had been diagnosed with
schizophrenia. On the evening of his death he had been subjected to
racist abuse by another patient. After hitting a nurse he was
restrained by nurses face down in a prone position for about 25
minutes. During the struggle he collapsed.

Institutional racism

“Institutional racism is the collective failure of an
organisation to provide an appropriate and professional service to
people because of their colour, culture or ethnic origin. It can be
seen or detected in processes, attitudes and behaviour which amount
to discrimination through unwitting prejudice, ignorance,
thoughtlessness and racist stereotyping, which disadvantage
minority ethnic people.” 

– Definition set out by Sir William Macpherson in the Stephen
Lawrence inquiry

Bennett inquiry key recommendations

• All staff in mental health services should receive training in
  cultural awareness and sensitivity.
• There needs to be ministerial acknowledgement of institutional
  racism in mental health services and a commitment to eliminate
  it.
• A national director for mental health and ethnicity should be
  appointed.
• Racist abuse by anyone, including patients, should be
  addressed.
• Workforce should be ethnically diverse.
• Under no circumstances should a patient be restrained in a
  prone position for longer than three minutes.
• A national system of training in restraint and control should
  be published.