It is a pleasure to serve under your chairmanship, Ms Buck. I congratulate my hon. Friend Neil Coyle for a very moving opening speech. It was a very brave speech, because he was sharing difficult personal experiences, and that made it all the more compelling.
I want to focus on the use of restraint, which is one of the four key issues that the review covers. Last year, Parliament passed my private Member’s Bill, which became known as the Mental Health Units (Use of Force) Act 2018, but is better known as Seni’s law. I was very grateful to the Minister for her support on the Bill, which introduced a system for reducing the use of abusive and coercive restraint in mental health settings. It establishes in law, for the first time, some very important principles, including the need for trauma-informed care. Some of the principles in the Act, which was of necessity relatively narrowly drawn, could and should be applied more widely. That is the point I hope to impress on the Minister this afternoon.
Perhaps I can remind colleagues of the human story behind Seni’s law—the Minister knows it, but other colleagues might not. Seni Lewis was a young graduate aged just 21. His parents found him having a traumatic mental health episode at home one Sunday morning, something he had never experienced before. They took him to the local hospital, expecting to find the care that he needed and deserved. He ended up at the Bethlem Royal Hospital, where his parents stayed with him until late evening before leaving to go home. Seni became very alarmed when he found out that he was alone, and he tried to leave. The hospital staff decided to section him and therefore tried to stop him leaving.
There were never any allegations that Seni threatened or assaulted anyone, but the hospital called the police. It ended up with 11 police officers dragging Seni, with his hands cuffed behind his head and legs in braces, into a seclusion unit, where they took turns sitting on him as he was pinned down on the floor. Seni’s spinal column was broken and he went into cardiac arrest, then into a coma. He died shortly afterwards.
Looking at the pictures of people who have died in mental health detention, we see many young black faces like Seni’s. Widely held prejudices about young black men and psychosis, drugs and aggression lead them to be subject to more severe treatment than other patients. In extreme cases such as Seni’s, it leads to death. It is a form of institutional racism, and we need to call it out and confront it.
I first met Seni’s parents three years after his death, just after I had been elected to Parliament in a by-election. They came to see me three years after this terrible incident because there had still been no inquest into his death, no public explanation of how or why their beloved son had died, no learning to prevent similar deaths in the future, no closure and no justice for Seni’s deeply distraught family. It was only after a very long public campaign and the intervention of the then Minister for mental health, Norman Lamb, and the then Home Secretary, Mrs May, that an inquest was finally opened, seven years after Seni’s death. It found that Seni had been subject to severe and prolonged restraint that had caused his death. It castigated the police and the mental health services and warned that, without change, other people in the mental health system would die in the future, just as too many have died in the past.
Seni’s law began as a cross-party attempt to start the process of change by creating a new national system for recording the use of restraint in mental health settings. We will soon be able to see what is happening in different mental health trusts and hospitals, and compare like with like to identify and spread best practice in reducing the use of abusive and coercive restraint. However, the same system needs to be extended to all settings where people with mental ill health might be subject to restraint, and I invite the Minister to comment on any plans she has to do that.
[David Hanson in the Chair]
The review makes it clear that we need to do more. Deaths in mental health settings should be investigated in the same way as deaths in any other form of state detention are investigated. When someone dies in prison or in a police cell, there is an automatic external investigation by an independent national body, which publishes a final report and shares what it has found. However, when someone dies in a mental health setting, as Seni Lewis did, there is no such fully independent investigation. In Seni’s case, the health trust investigated itself, and lessons that needed to be learned were not learned. Owing to errors by the Independent Police Complaints Commission, the Metropolitan police were able to block an inquest for a full seven years after his death. It should not be possible for the organisation under investigation to control the scope, timeliness, quality and content of the report on their own potential failure, because of the risk of a cover-up.
I pay special tribute to the powerful campaigning work on this issue that has been carried out by the charity Inquest. I fully support its demand for non-means-tested legal aid to be available to families at inquests, so that there is a level playing field between the bereaved family and the well-funded organisations accused of potential wrongdoing. Such investigations must be conducted by fully independent bodies that command the confidence of the public and bereaved families. By failing to learn from preventable mental health deaths, we condemn other vulnerable people to the same tragic fate.
Seni Lewis died in the most horrific circumstances, and his parents then had to fight for justice over seven years, just to find out what had gone wrong. Seni’s law stands as a testament to his life, but it is time to go further. The review of the Mental Health Act 1983 creates an opportunity to do so. We need to ensure that every bereaved family can get the justice they deserve. We need to ensure that, through a fully independent system, every lesson we need to learn is learned and acted on, so that we can keep every vulnerable person with mental ill health safe in future.