Excessive force and police restraint led to the death of a South Norwood IT analyst at a Beckenham psychiatric hospital, a jury has found.
Olaseni Lewis, 23, died after being restrained by up to 11 police officers at Bethlem Royal Hospital in Monks Orchard Road on August 31.
He fell into a coma and died three days later at Croydon University Hospital.
After an inquest lasting 10 weeks at Croydon Coroner's Court, a jury found that police and hospital failings, including use of “unnecessary and unreasonable” excessive force, contributed to Mr Lewis’s death.
Police restraint contributed to Mr Lewis’ death on the “balance of probability”, the jury found.
Olaseni Lewis died after being restrained by 11 police officers. Photo: Lewis family
The first ‘prolonged’ restraint lasted around 10 minutes and was found to be “unnecessary and unreasonable” as Mr Lewis was held face down in the prone position.
The second prolonged period of police restraint lasted over 20 minutes and the force, pain compliance techniques and multiple mechanical restraints were found to be “disproportionate and unreasonable”.
Police did not consider acute behavioural disorder as a medical emergency and training was inadequate in its definition of “prolonged restraint” for people exhibiting signs of ABD.
In the second period of restraint Mr Lewis became unresponsive and a doctor recorded a pulse of 45 to 50 beats per minute but did not respond to the emergency.
Police and hospital failures contributed to Mr Lewis' death. Photo: Lewis family
The jury found that police had failed to follow their training and did not put Mr Lewis in the recovery position or administer basic life support.
In a narrative conclusion jurors said the admission process onto Gresham 2 ward was “unsatisfactory”.
They highlighted that there was no full doctor’s assessment, inadequate risk assessment and “failure to acknowledge the calming influence of family members”.
Mr Lewis was given prescription medication which was ineffective in treating his “escalating agitation”.
The jury also found that the lack of communication between police and medical staff was a failure.
Olaseni Lewis as a baby. Photo: Lewis family
The Metropolitan Police has said it will begin disciplinary proceedings against the officers involved.
Deputy Assistant Commissioner Richard Martin, responsible for professionalism, said: “Seven years ago Olaseni Lewis died in tragic circumstances.
"I would like to say sorry to Mr Lewis’ family and friends for their loss, and the circumstances in which he lost his life.
“Today, the jury who have heard all the evidence relating to his death, have raised serious concerns about the actions of our officers on that day.
“That is clearly of grave concern for us and we must now fully consider the detail of their narrative verdict.
“We will seek to speak to the Independent Police Complaints Commission, who independently investigated Mr Lewis’ death, to understand the next steps regarding the misconduct process facing our officers.
“What is clear is that given the length of time since Mr Lewis died, that process must be as prompt as possible.”
Olaseni with his grandmother. Photo: Lewis family
The Independent Police Complaints Commission released a statement following the conclusion.
Commissioner Cindy Butts said: “It has been my ongoing commitment, since taking on the oversight of our second investigation into the circumstances surrounding the tragic death of Seni, to obtain answers for his family.
"The IPCC has been clear about the mistakes made in the past and I have personally apologised to the Lewis family in public and in private.
“The Metropolitan Police have been directed to carry out disciplinary proceedings which I hope will take place as soon as possible.”
Olaseni Lewis as a teenager. Photo: Lewis family
Dr Matthew Patrick, chief executive of South London and Maudsley NHS foundation trust, passed on his condolences to Mr Lewis’ family and said improvements would continue to be made.
He said: "The organisation has learnt a great deal and made changes to how we work as a result of Mr Lewis' death.
“Since the incident occurred we have addressed many of the important issues that were identified today by the jury.
“New processes have been put in place to improve how we train and support staff so that they can deliver safe care to people who become mentally unwell, and working alongside the police, we have improved how staff communicate and collaborate with them in high risk situations.
“We will now take time to give close scrutiny to the jury's narrative to ensure that we make any further changes that are necessary to reduce the possibility of this ever happening again.
"I think that we now have a responsibility to build on our work with service users, carers and our local communities to ensure that our services are high quality, effective and properly responsive to the needs of local people.
"At this very difficult time my thoughts and those of my colleagues are with the Lewis family."