What happened
On 31 August 2010 Olaseni Lewis, known as Seni, was taken by his family to Mayday University Hospital in Croydon after 48 hours of agitated, paranoid behaviour. He was 23, physically well, with no psychiatric history. He was admitted to Bethlem Royal as an informal patient, free to leave, on an undertaking that his family would be called if anything arose.
After they left he became frightened and disorientated, tried to leave, and kicked a door. Staff called the police for criminal damage and did not contact his family. Officers handcuffed him and, at medical staff’s request, took him to a seclusion room, where eleven officers held him face down over two periods lasting 30 to 40 minutes. For about 20 minutes of the second he was held with two sets of leg restraints and two sets of handcuffs, left arm in front of his face and neck, right arm behind his back.
He collapsed, never regained consciousness, and died on 4 September 2010.
The outcome
An inquest ran from 6 February to 9 May 2017 before Senior Coroner Selena Lynch, with 29 days of evidence (INQUEST). The jury found the force used over two successive periods of prolonged restraint, including mechanical restraints, was “excessive, unreasonable, unnecessary and disproportionate” and contributed to the death. It also found that staff and police failed to give basic life support when he collapsed, which contributed.
The coroner issued a Prevention of Future Deaths report, 2017-0205, on 28 June 2017, to the Metropolitan Police and South London and Maudsley. No criminal conviction of any officer appears in the sources cited here.
What went wrong
No officer took charge, and nobody was clear what the hold was meant to achieve. Officers could not explain why they continued with a hold that was dangerous and against police training, saying only that they would keep it until he stopped struggling.
The one task that mattered had no owner. A police inspector who teaches restraint told the inquest that the officer at the head leads, because that is where breathing and colour are monitored. With eleven officers on one man, that job dissolved into the group. When he collapsed, basic life support did not follow.
What it teaches
The airway watcher is a named role, not an assumption. It should be spoken aloud before the hold goes on, and that person needs the authority to call a stop.
A general ward with no mental health plan is a restraint setting with no restraint skill in the room. The staff there chose a criminal complaint over a call to a family whose number they held.
Questions for the room
- The officer at the head leads because that is where breathing is seen. Who was at the head, and what did they report?
- Eleven officers, two agencies, no lead. Who is in charge once police are in a clinical space?
Evidence and limits
Confidence: confirmed, on the inquest record and the coroner’s Prevention of Future Deaths report 2017-0205.
Sources disagree on figures. INQUEST records 29 days of evidence where a family chronology says 37, and describes the restraint as 30 to 40 minutes across two periods where BBC London reported 45 minutes and three separate restraints. This page uses the INQUEST figures and does not settle the difference. The record puts the finding more narrowly than the précis, as “unnecessary and unreasonable” where INQUEST adds “excessive” and “disproportionate”.
This entry was drafted from the case record and the case précis, which quote the coroner’s report. The report and the press coverage were not re-opened for it.
Dynamis training related to this case: [restraint reduction](/training-solutions/restraint-reduction-rrn).
Sources
- INQUEST, May 2017
- BBC News, September 2017
- Bhatt Murphy, notable custodial death cases
- Courts and Tribunals Judiciary, PFD report 2017-0205, 28 June 2017
Reviewed 20 October 2026.