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“The time around his anniversary is always difficult,” says Aji Lewis, mum of Olaseni Lewis, who was known to his family and friends as Seni.

Seni died due to prolonged restraint by police officers on 3 September 2010, while he was a voluntary patient at a psychiatric hospital. He was 23 years old.

“Seni was very driven, he wanted to do his PhD in America. He hated any form of bullying or injustice, and always fought to do the right thing,” says Aji.

Now Aji and the trust in charge of the hospital where Seni died are trying to ensure that his story is not only remembered, but used to save lives.

Training programmes have been created and developed with the input of Seni’s family and health care professionals, including ¾ÅÓÎÌåÓý members. The aim is to shift the focus from how to restrain safely, to how to avoid restraint in the first place.

“Aji is amazing,” says ¾ÅÓÎÌåÓý Mental Health and Learning Disability Adviser Professor Ben Thomas. “Continuing this work is essential. Unfortunately, people with mental health problems are still being restrained every day across the country.”

What happened to Seni

Seni had no previous experience of mental illness. But after showing acute signs of restlessness and paranoia over just a few days, it became apparent that he was experiencing a mental health crisis. “He wasn’t himself at all,” Aji says. “We saw the signs and he made the decision that he wanted to go to hospital.”

Aji remembers seeing good practice from police, before Seni was assessed. They first encountered Seni after being called to a railway station, where he’d gone after initially leaving hospital. Aji says they did a good job in de-escalating the situation, persuading him to come back.

Similarly, back at the hospital, Aji saw officers "talking to him at his level”. They were sitting with Seni on the floor in a 136 suite (a mental health room). They’d taken off their hats and jackets and were laughing and talking together.

After his assessment, Seni agreed to be admitted as a voluntary patient at Bethlem Royal Hospital, part of South London and Maudsley NHS Trust (SLaM) in Bromley. Aji says they were assured he could leave at any time.

Later, when visiting hours were over and his parents had reluctantly left, Seni decided he wanted to go home. But a member of staff said he couldn’t, and he became agitated. Staff called the police, who agreed to take Seni to a seclusion room in the hospital. He was co-operative until he stopped at the doorway of the room. When he stopped, police officers pushed him inside and forced him face down to the floor.

Seni was held down by 11 police officers, with restraints put on his arms and legs. He lost consciousness during 45 minutes of restraint and, despite being resuscitated, remained in a coma and never recovered.

Aji says that even when Seni went limp, he wasn’t treated as a medical emergency because police officers thought he was faking it. She says nurses and a doctor were outside the room telling police to stop, but were “unable or unwilling to intervene”.

While all this happened, Seni had been sectioned under the Mental Health Act, though his family didn’t get the section notice until after he’d died.

Campaigning for change

Seven years later, an inquest jury concluded multiple failings by police officers contributed to Seni's death, including that the restraint used was disproportionate and unreasonable. The jury also found there was a lack of communication between police and medical staff, and highlighted failures in staff training.

The police watchdog carried out investigations into the officers’ conduct, but they were cleared of gross misconduct, an outcome that Seni’s family fought against.

“It was relentless,” Aji says, “but we had to keep going.” Following the inquest in 2017, Seni’s family and their local MP Steve Reed campaigned for better legislation around use of force in mental health settings, which ultimately led to the passing of Seni’s Law.

But the family’s work isn’t over. They’re now training people in how to implement Seni’s law. Aji says: “I talk to different trusts, service users, schools and communities.”

Taking accountability

For SLaM, Seni’s death revealed deep-rooted issues around the culture and practices of restraint, and a need for serious change.

Lewys Beames, a consultant nurse in restrictive practice, leads on the redevelopment of the training at SLaM. “Unless you’ve been in that situation as a patient or member of staff, you don’t know what the true immediate and long-term impact of experiencing restraint is,” he says.

Beyond physical injury, restraint has the potential to break the trust between staff and patient, creating major setbacks in treatment and recovery and even leading to post-traumatic stress disorder.

The experience is also often morally distressing for nursing staff, who feel they have failed to deliver the best care.

• Read more: Racial disparities a key topic for ¾ÅÓÎÌåÓý in new Mental Health Bill

The trust had to look inwards too. “We had to look at systemic and structural racism,” Lewys says. “People from Black and racially minoritised backgrounds are more likely to be affected by restraint. We wanted to ask why, if you're Black, are you more likely to be sectioned and brought into hospital, in a position where you're more likely to experience restraint?

“Who are the people most affected by this issue? Their voices have to be in this.”

Lewys says they sought out local community organisations, such as and to help them find the right people.

“We’re starting from a place of serious distrust,” Lewys says. “We have to rebuild this relationship before we can do anything else.”

Preventing restraint

The new training is certified against the , a document for which Seni’s parents Aji and Conrad wrote the introduction.

Lewys says shifting the focus to prevention is one of the most important goals. "Before you even get to those situations where restraint might be necessary, if people are starting to become distressed, how do we support them to avoid an escalation in that distress?” he says. Situations will still arise where restraint is used as a last resort, and staff should be fully briefed to ensure that everyone is safe, both patients and staff, Lewys explains. Tactics that cause fear, pain, or danger, such as prone restraint, must be avoided.

Now that the training has been running for two years, plans are in place to expand it to community mental health settings. Lewys says: “We have to change the perception of mental health settings and our assumptions of people using them, to encourage more staff to work in mental health and to ensure those in need see us as a safe space.”

The ¾ÅÓÎÌåÓý’s Ben Thomas wants to see staff recruitment from local communities, to ensure mutual respect and trust. “We know a shortage of nursing staff has an impact on the quality and safety of care for people in mental health wards,” Ben says.

“Mental health nursing is based on building meaningful therapeutic relationships with the people they care for and providing personalised care.”

Seni’s legacy

Aji is determined that the work done in Seni’s name will make a difference. She highlights for the RRN’s standards, which says: “He was our baby and a gentle giant.

“If we can make sure this never happens to anyone else, that would be an amazing legacy for Seni.”

When we ask Aji what Seni would have thought about the work his family has been doing in his name, she says: “We know the sort of person Seni was. He would do it for us if the tables were turned. It’s worth it, every minute.”