The death of Olaseni Lewis (Seni) in 2010 after he was restrained face down at a mental health unit by up to 11 police officers led to tough new guidance to end the practice. But despite the efforts to bring it to an end, new figures show face-down restraint is still in widespread use across England.
Olaseni Lewis was a 23-year-old IT graduate who had voluntarily admitted himself into Bethlem Royal Hospital, Beckenham, for mental health treatment on 31 August 2010. When he asked to leave a few hours later, a doctor called the police to ask for their assistance in detaining him under the Mental Health Act.
He was then held for around 30 minutes during two face-down restraints, and although he lost consciousness, instead of rushing to get him the medical attention he so desperately needed, the police officers who subdued him initially failed to respond to his worsening condition.
The officers said they believed 23-year-old Olaseni Lewis, who was in hospital after suffering an acute psychotic illness, was faking unconsciousness.
Though a second inquest found the restraint, described by hospital staff as “violent”, was disproportionate, six of the 11 officers who were investigated for gross misconduct were cleared in closed police hearings.
Olaseni Lewis’s parents, Conrad and Ajibola Lewis, were determined that the death of their Masters’ student son, who had no history of violence or mental health problems, would be the catalyst for change.
Alongside their local Labour MP, Steve Reed, the south-east London family’s efforts led to the introduction of the Mental Health Units (Use of Force) Act 2018 or “Seni’s Law”. The Act was designed to protect patients from excessive force by ensuring better record-keeping and increased transparency.
It also stipulated that the police should wear body cameras when attending mental health units where reasonable. In addition, any non-natural death in a mental health unit now automatically triggers an investigation under the legislation.
Guidance under the Act states that “there must be no planned or intentional restraint of a person in a prone or face-down position on any surface, not just the floor”.
A 2020 report found that 2,060 people with a learning disability and/or autism were locked away in inpatient units, of which 205 are children. There were high levels of restrictive interventions, with 4,810 recorded instances of restrictive interventions (like physical, prone, mechanical and chemical restraint) in July 2020, of which 660 were against children.
Lewis’s death is not the only fatality since 2010 linked to restraint. The police’s inappropriate use of restraint on Kevin Clarke, who had paranoid schizophrenia, was found to have contributed to his death. In 2020, an inquest jury ruled that the police restraint “probably more than minimally or trivially” contributed to the 35-year-old’s death in Lewisham Hospital.
In February 2015, a Home Affairs Committee documented how black people more commonly reported force and those with autism or a learning disability were also at additional risk.
But new figures obtained by the Liberal Democrats suggest the most controversial form of restraint, ie where patients are held in the face-down position that resulted in Olaseni’s death, is still in widespread use.
Overall, the figures obtained through a freedom of information (FOI) request show that while between 2022 and 2023, face-down restraint increased by around a third, it fell again by around the same amount in 2024. between 2022 and 2023. Of the 30 trusts that responded to the FOI request, there were 3,944 face-down restraints in 2022, 5,247 in 2023 and 3,732 in 2024.
The Cumbria, Northumberland, Tyne, and Wear mental health trust resorted to face-down restraint most often, with 495 incidents recorded in 2024. This was followed by Birmingham and Solihull on 489 incidents and East London on 348. But all three trusts recorded substantial drops in face-down restraint in 2024 compared to a year earlier.
The figures also show the number of overall restraints, and not just those where patients were held in a prone position, fell by almost 14% from 16,920 in 2023 to 14,642 in 2024.
North East London had the highest average number of restraints per patient in 2024 at 25, followed by Nottinghamshire at 13. The lowest figures were recorded by Greater Manchester at 0.029 and the Black Country at 1.61. There were 702 incidents overall where a patient was injured due to restraint. Remarkably, almost a third of these, 231, occurred at just one trust — Mersey Care.
Of course, it is not just patients who are at risk from restraint – staff too can be vulnerable when incidents get out of control. Up to 1,885 injuries to staff were recorded across the trusts, the equivalent of five per day.
Speaking about the figures, Mrs Lewis said the continued widespread use of facedown restraint was putting the lives of patients and staff “at risk”. She said she also feared a repeat of her son’s death “if people don’t change the way they work.”
Mrs Lewis believes the root of the problem lies in staff too readily resorting to a dangerous restraint technique that has become part and parcel of their way of working. She said, “Why are people so lazy? There are other ways of getting people to acquiesce.”
The 75-year-old mother added, “This is what they fall back on, and they’re not properly trained. And part of Seni’s Law is the training – there has to be proper training.”
The Lewises were supported in their fight to uncover the truth about Olaseni’s death by the state-related deaths charity Inquest.
Deborah Coles, director of Inquest, said, “Disproportionately restraint is used against black and racialised people, women and children, young people, autistic people and people with learning disabilities.”
She added that Seni’s Law must be fully implemented to ensure “greater transparency and accountability” and to “drive the cultural change” needed to end the dangerous use of restraint.
The Liberal Democrats are calling for an urgent investigation into the use of physical and face-down restraint.
Their mental health spokesman, Danny Chambers, blamed the former Tory government for failing to reform mental health services. However, he said the new administration must now take action.
Chambers said, “That some institutions are physically restraining mental health patients far more than others shows that our NHS mental health services have been neglected and overlooked for far too long.”
MP for Winchester Chambers added, “The new government must launch an investigation into the excessive use of physical restraint to prevent both staff and patients coming to harm and put mental health on the same footing as physical health.”
The figures only partially represent the true extent of the use of restraint as just 30 of the 58 mental health trusts in England responded to the FOI request.
In a statement, the Department for Health and Social Care said the findings were “concerning”.
They said face-down restraint should only ever be used as a “last resort” and patients deserve “safe, high-quality care, and to be treated with dignity and respect”.
A spokesperson added that the government’s Mental Health Bill, which is currently being considered by Parliament, will usher in key reforms.
The bill will ensure those with the most severe conditions get “better, more personalised treatment that is appropriate, proportionate, and compassionate to their needs”.
“We will also work with the NHS to transform care and recruit 8,500 more mental health workers across children and adult services to reduce delays and provide faster care,” added the spokesperson.
