Those who knew Rocky well spoke of how likeable he was at times of calm. He was a Rastafarian, a good drummer and talented footballer who was offered a traineeship by Chelsea football club in his late teens.
But there were other times during his 18 years of treatment for mental illness when he became violent. The evening of his death was one of them.
At about 10pm he went to make a call from the patients’ phone on the clinic’s Drayton ward. Another patient was using it. After asking politely how soon the phone would be free, Mr Bennett went off and returned in angry mood. A struggle developed as he tried to seize the receiver. He threw a punch at the other patient’s face, making his lip bleed. The other patient responded with a torrent of racist abuse, calling Mr Bennett “a black bastard” and saying: “You niggers are all the same.”
Staff tried to calm the men down, but after less than an hour decided it would be safer for all concerned if one of them was sent overnight to another ward. They decided to move Mr Bennett.
According to the report of an inquiry led by Sir John Blofeld, a retired high court judge, the nursing staff did not respond to his perception of what was being done to him. He thought he was a victim of racist threats who was being shifted because he was black, while the white perpetrator stayed on Drayton ward. The inquiry said staff treated Mr Bennett as “a lesser being … who should be ordered about”. They were unaware of the “corrosive and cumulative effect of racist abuse upon a black patient”.
He was taken to Thorpe ward and seemed calmer for a while. But when a woman staff nurse told him he would be kept there overnight he punched her, landing three “horrendous blows” on the left side of her face. Other staff went immediately into control and restraint mode.
They held him face down on the floor as he thrashed about trying to break free. For a few minutes, five nurses were involved in pinioning his limbs, later reduced to four. The inquiry found that was one too many throughout the procedure. The injuries he sustained under restraint were “consistent with excess pressure being used”.
There was no evidence of deliberate misbehaviour, but the male lead nurse was “negligent” in not acting to support Mr Bennett’s head to spot signs of distress.
The nurses did not release Mr Bennett until he “went quiet”. By then it was too late. There was conflicting evidence about whether his pulse was weak or non-existent. Staff tried in vain to resuscitate him with oxygen. By the time an ambulance arrived, he had been unconscious for 10 minutes. Shortly afterwards he was pronounced dead.
The senior nurse on duty declined to give evidence to the inquiry. It concluded: “The restraint was mishandled by the nursing staff.” Mr Bennett’s capacity to breathe was restricted and the restraint “continued for substantially longer than was safe”. This was due to “a serious failure of training”, common across the NHS at that time.
There was inadequate resuscitation equipment in the ward. A doctor who might have been able to help took more than an hour to arrive at the clinic, due to a mix-up at the taxi company sent to fetch him.
The inquiry team said foolproof arrangements should always be in place, wherever a mentally-ill patient is detained, for a doctor to be available within 20 minutes. More than five years after Mr Bennett’s death, these are not yet in place.
There were irregularities in the way Mr Bennett was prescribed heavy doses of three anti-psychotic drugs. The inquiry said this was bad practice, but accepted it was not likely to have had a significant influence on his death.
The report went on to castigate the authorities for their “inhumane” treatment of Mr Bennett’s family, denying them timely information about what happened.
Some of its most disturbing findings were directed at deficiencies in the treatment given to Mr Bennett over the 18 years of his mental illness.
He was born in Jamaica in 1960 and came to England in 1968 to join his family in Peterborough where his father worked as an engineer with the London Brick Company. One of eight siblings, he gained five CSEs at school, the equivalent of today’s lower grade GCSEs. He worked as a signwriter for three years before his health began to fail.
Initially his doctors thought his mental health problem was cannabis-induced psychosis. After moving in and out of prison, he was eventually diagnosed with schizophrenia in 1985. But his progress through the NHS was marred by persistent failure to recognise the difficulty he faced as a black man in a largely white medical establishment.
The inquiry found the NHS did not try hard enough to engage his family in his treatment. He was managed “at times with intolerance and at times as if he were a nuisance who had to be contained”.
It found no evidence of deliberate racism at the Norvic clinic. Individual nurses were kind and generous with their time and money. They took him regularly to Norwich City football matches. But insufficient attention was paid to Mr Bennett’s cultural, social and religious needs.
In 1993 he wrote to the nursing director pointing out: “As you know, there are over half a dozen black boys in this clinic. I don’t know if you have realised there are no Africans on your staff.”
Before his death a black Zimbabwean nurse became his key worker. But the inquiry concluded: “There was evidence of institutional racism from time to time through the lengthy period Mr Bennett was suffering from mental health problems … They indicate that institutional racism has been present in the mental health services, both NHS and private, for many years.”