What happened
Orville Blackwood, 31, was a Jamaican-born British father in south London, known to mental health services since January 1982. In 1991 he was detained under section 37 of the Mental Health Act 1983 and admitted to Broadmoor Hospital at Crowthorne in Berkshire.
On the morning of 28 August 1991 he refused to attend his occupational therapy session and made his own way to the seclusion room. When a group of health professionals entered several hours later he became aggressive. On his physicians’ instruction he was held down and injected with 150mg of promazine, which the campaign record calls three times the recommended limit, and with fluphenazine. He had been stripped and left alone. He died almost immediately after the dose was given.
His was the third death of a Black patient at Broadmoor within seven months.
The outcome
A 1991 inquest returned a verdict of accidental death. His mother campaigned for a judicial review, the verdict was quashed, and a second inquest in 1993 returned the same verdict.
A committee of inquiry chaired by Professor Herschel Prins, for the Special Hospitals Service Authority, reported in 1993 as “Big, Black and Dangerous?” It examined his death alongside those of Michael Martin and Joseph Watts, was highly critical of his care, and made 47 recommendations. The pathologist gave the cause as “cardiac failure associated with the administration of phenothiazine drugs”.
What went wrong
The inquiry found the service given to Blackwood took little account of the stresses of his background and relied instead on “the preconceptions and expectations of him through racist labelling”. Nobody asked why he did not want to attend his occupational therapy session.
It found a pattern wider than one ward. Black patients were more likely to be admitted through the police into secure care, to be diagnosed with schizophrenia, and to be prescribed higher doses. Broadmoor was “a white, middle-class institution in rural Berkshire” with an “almost exclusively white workforce”. Staff used the phrase “big, black and dangerous” often enough that the committee made it the report’s subtitle.
What it teaches
Chemical restraint is restraint. A dose given to a man already held down is one intervention with one set of risks, and needs to be taught, assessed and recorded as one. A service that counts only the holds in its restraint data is not counting this.
The committee found its pattern by following a pathway from admission to diagnosis to dosage, not one incident. A ward team can read its own restraint and rapid tranquilisation data the same way.
Questions for the room
- Nobody asked why he would not go to his session. What would that question have changed before staff entered the room?
- You are the nurse in charge when a patient refuses an activity and later turns aggressive. When does the plan move from persuasion to restraint, and who decides?
- A patient is held down and injected in the same minute. Which record captures that, and who reviews it?
Evidence and limits
Confidence: confirmed, on archive sources rather than a court or coroner record. The inquiry’s title, publisher and chair are confirmed by the Statewatch bibliographic record. The death, restraint, dose, both verdicts and the inquiry’s findings come from INQUEST’s case profile. Wikipedia was also read and agrees on the dose and verdicts.
No dated court or coroner record was obtained, so no date is given for the second inquest beyond its year. The three-times-the-limit characterisation comes from the campaign record; the inquiry report itself was not read. No member of staff is named, and no prosecution is recorded in the sources opened.
Sources
Our physical interventions training treats restraint and medication given together as one risk.
Reviewed 20 October 2026.