Black communities, mental health and the criminal justice system

Mental health and crime briefing 20071Black communities,mental health and thecriminal justice systemContentsIntroduction page 1The criminal justice system page 2The mental health system page 3Government strategy and policydevelopment page 5Effecting change page 6Conclusion page 8Nacro believes that responses to mentallydisordered offenders should focuson their care and treatment rather than onpunishment. To help bring about thischange, Nacro campaigns for:more effective working partnershipsbetween agenciesthe development of specialist skills inthe criminal justice systembetter information sharingthe education and training of staff sothat they have the skills andencouragement they need towork with a group who can be difficultand unrewarding.Nacro’s Mental Health Unit has beenworking to tackle problems faced bymentally disordered offenders since 1990.We work with government agencies at anational and local level to develop moreeffective ways to deal with mentallydisordered offenders. We provide a rangeof services: information and advice; policydevelopment and other consultancyservices; and training. We also run a majorannual conference on mental health andcrime.Nacro has a specialist mental healthwebsite which offers information andsupport for practitioners and policymakersworking in the field of criminaljustice and mental health. To find outmore, visit www.nacromentalhealth.org.ukor contact the Mental Health Unit on020 7840 6718, 020 7582 6500 or atmentalhealth@nacro.org.ukwww.nacromentalhealth.org.ukNacro is a registered charity no.226171IntroductionResearch studies and data monitoring have consistently shown that ofall the black and minority ethnic (BME) groups in Britain, those fromblack communities in particular are disproportionately represented inboth the criminal justice and the mental health systems. 1 This anomalyis compounded by the fact that both systems seriously disadvantageblack people once within their remit. This briefing examines the extentof these two interconnected problems, the underlying causes andrecent policy and strategy developments, before makingrecommendations for change.Despite various policy initiatives in recent years, little progress hasbeen made in tackling this important subject. Home Office statisticshave consistently borne out the discrimination experienced byblack people who come into contact with criminal justice agenciesand the Department of Health has admitted that there is an undueemphasis on coercive models of treatment for black mental healthpatients, with organisational requirements often taking precedenceover their individual needs. 2 Figures show that black people areincreasingly over-represented at each heightened level of securityin the psychiatric process from informal to civil detention, and thenin detention on forensic sections within the courts and criminaljustice system. 3 Moreover, the fact that there are such highnumbers of black people coming into criminal justice settings,coupled with the discrimination they experience once there, resultin the criminal justice system often acting as a gateway to themental health system for many black offenders. Indeed recentfigures show that black communities are over 40% more likely thanaverage to be referred to mental health services through thecriminal justice system. 4 With this in mind, this briefing looks inparticular at black mentally disordered offenders who are exposedto both systems.Given the unequal treatment and over-representation that exists inboth these fields, it is crucial that the health, criminal justice andsocial care agencies find ways of working with black communitiesto address these problems. In focusing on the precise nature of thediscrimination in the system, the actual pathways which bring blackpeople into the criminal justice and mental health systems, the typeof treatment and care black mentally disordered offenders receiveas well as shortcomings in current policy, this briefing seeks tocreate further awareness of this important topic for all thoseworking in the system, as well as making suggestions forpractitioners in order to improve practice.

2Black communities, mental health and the criminal justice systemThe criminal justice systemDiscrimination from criminal justice agenciesHome Office statistics produced annually undersection 95 of the Criminal Justice Act 1991 revealthe extent of the disproportionate involvement ofblack people with criminal justice agencies assuspects, defendants and prisoners. To fullyappreciate the implications of the following figures,it should be remembered that of the population inEngland and Wales, just 1.1% are Black Caribbean,0.9% are Black African and 0.2% are from other blackgroups. 5 The statistics for 2004-5 6 show that:Black people were six times more likely thanwhite people to be stopped and searched undersection 1 of the Police and Criminal Evidence Act1984 compared to Asian people who were twiceas likely as white people to be stopped andsearched.Searches recorded by police under section 60 ofthe Criminal Justice and Public Order Act 1994show that 56% of searches were of white people,24% were of black people, while 17% were ofAsians.Of the searches made under Sections 44 (1) and44 (2) of the Terrorism Act 2000 73% were ofwhite people, 8% were of black people and 11%were of Asians, with 5% being carried out onthose of ‘Other’ ethnic origin.Of the 1.3 million arrests made for notifiableoffences, 9% of them were black people, 5% Asianpeople and 1.5% came from ‘other’ ethnic groups.Black people were more likely than white peopleto be committed at magistrates’ courts to betried by a jury at the Crown Court.The proportion of black prisoners who areBritish nationals in the prison population is fivetimes higher than for white people.In addition, higher proportions of black people(particularly young people) were likely to bestopped by police, arrested and once arrested, lesslikely to be cautioned. Similarly, black people weremore likely to be remanded in custody, more likelyto plead not guilty and where found guilty theywere also more likely to receive longer custodialsentences than their white contemporaries. 7 Evenbefore coming to trial, an analysis of 13,000 casefiles carried out by the Crown Prosecution Servicefound that there were more likely to be objectionsto bail for black males than for white males. 8Figures such as this reveal that black communitiesare over-represented at each stage of the criminaljustice process from initial contact right throughto sentencing.There are various criminological explanations as tothe root of this anomaly which include policediscrimination, socio-demographic factors, and thefact that black people who have previouslycommitted offences are known to the police and aretherefore perhaps more easily detected. However,the figures cannot just be explained away by thenotion that black people are more likely to offendthan other groups. 9 Indeed the lifetime offendingrate for black males is in fact significantly lowerthan that for white males. 10GenderGiven that there are higher rates of black women inprisons than men, and that there is a higherincidence of black women within psychiatric carethan white women, it is concerning thatexamination of the needs of black female mentallydisordered offenders is so conspicuously absentfrom research literature and policy initiatives. InJune 2004, the percentage of foreign nationalwomen in prison made up 25% of the female prisonpopulation. Notably, over 50% of female foreignnational prisoners were from Jamaica with over 90%of these receiving custodial sentences for drugimportation. 11 Usually minor players inconsiderably larger operations, these womenundergo the trauma of separation from family,children and their homeland for what are often verylengthy periods, which is bound to have adebilitating effect on their mental health.Immigration and asylumIndeed foreign nationals make up one third of allprisoners who are either black or minority ethnic. 12The proportion of foreign nationals amongst thenumber of black mentally disordered offenders islikely to increase further in future, given theintroduction of the Asylum and Immigration Act2004 which has, for the first time, made it acriminal offence for someone to enter the UK whodoes not have a passport or who has destroyedtravel documents or who, once within the UK,refuses to co-operate with arrangements for theirremoval. Those claiming asylum or refugee statusare likely to have undergone considerable mentalstress and trauma and, if this is not effectivelyaddressed, the trauma of the asylum experiencecould potentially bring to the surface any latentdistress they may have experienced previously. 13ResettlementDiscrimination experienced within the criminaljustice system is compounded for many blackpeople by difficulties they encounter followingrelease. A 2005 study by Nacro found that blackprisoners are less likely than their whiteNacro mental health and crime briefing

4Black communities, mental health and the criminal justice systemstereotypical views can often combine with thestigma and anxiety associated with mental illness toundermine the ways in which mental healthservices respond to black communities, affectingdecisions about treatment, medication andrestriction. NIMHE has noted the disproportionatelyhigh rate of schizophrenia diagnosed among blackmental health patients and the fact that blackpatients generally remain in hospital on a sectionfor longer than their white contemporaries. 30The fact that there are disproportionate numbers ofblack people coming into the mental health servicesfrom a criminal justice context means that thisgroup of mentally disordered offenders is oftenviewed by staff as presenting an increased securityrisk compared to that posed by other groups. Astudy into decision-making in the mental healthsectioning process showed professionals made astrong link between black patients and a notion ofheightened risk, 31 with the result that additionalsafety precautions were frequently seen asnecessary. For example approved social workers(who play a key role in the civil sectioning process)are more likely to request a police presence whentaking a black patient to hospital. Prins et al whoseinquiry examined the treatment of black mentallydisordered offenders found they are also morelikely to be detained in the locked wards ofpsychiatric hospitals and more likely to betransferred to higher security facilities (and forlonger) than white patients. 32NIMHE has also found there is a greater likelihoodof the use of coercive treatments for black patientsthan white. 33 Figures for 2005 show that blackpatients are more likely to experience physicalseclusion and restraint than other groups, 34 withthe most recent figures for 2006 revealing aparticularly high rate of hands-on restraint for thisgroup. 35 Set against this backdrop, it is perhapsunsurprising that black patients are also less likelyto receive benign forms of psychotherapeutictreatment such as psychotherapy and counsellingthan their white counterparts and more likely toreceive higher doses of medication, being ‘oftensubjected to heavy doses of drug cocktails whichhas led to deaths in HM prisons and specialhospitals’. 36Inquiries such as those into the death of OrvilleBlackwood have raised concerns about the use ofsuch force and increased medication as a means ofcontrolling the perceived increased security riskassociated with some black patients. Furthermore,the government has openly admitted the scale ofthe problem. In February 2004, in a speech inresponse to the publication of a report into thedeath of David Bennett, a black patient who died ina medium secure setting after being restrained bystaff, the then Secretary of State for Healthconceded there was both direct and indirectdiscrimination in services, admitting ‘Behavioursand processes that have grown up in mental healthservices mean that there is particular inequity inthe provision of care and outcomes for people fromblack and ethnic minority groups.’Alternative servicesThe use of inappropriate treatment anddiscriminatory processes within mental healthservices is not a recent phenomenon. In the lateeighties and early nineties, there was increasingdiscussion on providing more appropriatetreatment and care for mentally disorderedoffenders in hospitals and care settings, asexpounded in the Home Office Circular of 1990Provision for Mentally Disordered Offenders. 37 But bythis time, given the disproportionately high use ofpsychiatric remands by magistrates and a similartrend in the use of transfers from prison to securemental health settings, many black communitiesand mental health groups had become increasinglyaware of the risk of a ‘double jeopardy’ scenariowhere diversion could effectively mean the transferfrom one potentially discriminatory and damagingsystem to another. They realised there mightactually be too much diversion from criminaljustice to psychiatry for black people without theactual benefit of them then receiving appropriatetreatment and care. In response, some blackcommunities started developing their own distinctservices.One such initiative was established in the Midlandswhich strove to divert African Caribbeans awayfrom psychiatric hospitals to community settings attheir first point of contact with the psychiatricservices. 38 Intense support was provided to patientsat a location of their choosing and both users andcarers were closely involved with the process.Admissions to hospital for the client group in thislocality were significantly reduced during the life ofthis initiative. While this alternative is notnecessarily appropriate for all mental healthpatients, it illustrates the fact that blackcommunities were sufficiently disaffected byexisting provision to implement alternatives, andserves as an indicator of the additional work thatneeds to be done by criminal justice, health andsocial care agencies to engage black communitiesand to gain their trust in the mainstream diversionand assessment process.Following the publication of the report into thedeath of David Bennett, 39 there has been increasingdebate about separate services for ethnic minoritiesNacro mental health and crime briefing

5in general psychiatry and in some parts of the USA,separate in-patient services have been developed. 40It has been argued that separate services mightbetter serve black, as well as other minority ethnic,patients and there might perhaps be increasedemphasis on communicating (between patient andpractitioner) in a culturally informed way. 41 Thecounter-argument is that the creation of separateservices risks the development of a divisionbetween those professionals who ‘know’ how totreat and care for patients from minority groups,and those who ‘do not know’. The creation ofseparate services would appear to be an admissionof failure, not only of the current system’s ability toprovide adequate support and training withinexisting psychiatric services, but also of its abilityto address the fundamental question of why blackpatients, and especially black mentally disorderedoffenders, are treated differently to white people inpsychiatry.Government strategy and policydevelopmentThe Reed ReviewIn the early 1990s The Review of Health and SocialServices for Mentally Disordered Offenders (knownas the ‘Reed Review’) by the Home Office and theDepartment of Health reported its findings. In its1994 volume entitled Race, Gender and EqualOpportunities, it recognised that African Caribbeanswere experiencing particular problems (as distinctfrom those encountered by BME communities as awhole) and that therefore their involvement wascrucial for improving service provision for thefuture, stating:‘It is important that diversion schemes providea service which is appropriate and acceptable.This will require the involvement of membersof the Afro-Caribbean community indeveloping the service, as well as theinvolvement of staff who are sensitive to theissues of race and culture and the implicationsof socio-economic disadvantage for ethnicminorities.’ 42It is significant that over a decade after the ReedReview, the over-representation and discriminationexperienced by black people in the mental healthsystem has still not been effectively addressed.However, there have been some strategy and policydevelopments in this area in the meantime.‘Culturally capable’ servicesIn 2003 NIMHE set out in the progressive document,Inside Outside, its strategic objectives for improvingmental health services for BME communities inEngland. 43 These included the need to:reduce and eliminate ethnic inequalities inmental health service experience and outcomesdevelop a mental health workforce that iscapable of delivering effective mental healthservices to a multi-cultural populationenhance and build on capacity within BMEcommunities and within the voluntary sector fordealing with mental ill healthInside Outside discussed strategic tools that wouldhelp realise these objectives and advancedproposals to expedite the development of so-called‘culturally capable services’ which included settingnational standards to improve access, experienceand outcomes for BME users and making researchand development more culturally relevant.However, there was little focus on either forensicissues or on the role of the criminal justice systemand offending in mental health.The Bennett InquiryThe inquiry into the death of David Bennett in 2003made a series of recommendations which also heldimplications for the treatment and care of black, aswell as minority ethnic, individuals held in securesettings. 44 These included the following:All mental health services should have a writtenpolicy dealing with racist abuse and records ofsuch incidents should be kept.The mental health workforce should beethnically diverse and, where appropriate, stepsshould be taken to recruit, retain and promotestaff from BME communities.A national staff training programme in restraintand control methods should be instituted asquickly as possible – and certainly within twelvemonths.No patient should be restrained in a proneposition for more than three minutes. Allpsychiatric units should keep records of the useof control and restraint of all patients. Thesereports should be audited by the Department ofHealth.The recommendations above were accepted withoutamendment by the Department of Health, with theexception of the final one. (The wording preferredby the government in its response to the fourthrecommendation was that any physical interventionshould be used only as a last resort, in the safestway possible, and for the shortest period of timethat is necessary for patient and staff safety.)

6Black communities, mental health and the criminal justice systemThese recommendations and others, by virtue ofthe fact that they cut across mental health care ingeneral, will consequently impact on black peoplewith mental health problems who are also involvedin the criminal justice system. But it remains thecase that provision for black mentally disorderedoffenders in particular, has received little specificfocus from the Home Office or Department ofHealth since the commission of the Reed Reviewover a decade ago.Working togetherDelivering Race Equality in Mental Health Care(DRE), produced by the Department of Health in2005, 45 proved a useful document as it recognisedthat in the debate about black over-representationin mental health, a shift had generally taken placeaway from notions of deviancy, dangerousness andgenetics and towards socio-cultural explanations inline with the concept of ‘institutional racism’. 46Certain authors, such as Fernando 47 had beenespousing similar concepts for some years.However the shift was important, as it broadlymirrored the parallel development in the field ofrace and criminal justice where, in the light of theMacPherson Inquiry Report into the death ofStephen Lawrence, criminal justice agencies(principally the police) began to accept the conceptand existence of institutional racism and to modifypolicies and procedures accordingly.Importantly, DRE set out a national strategy forgreater community engagement and partnershipwork between mainstream and statutory services onthe one hand, and black and other minority ethniccommunity and mental health groups on the other,in recognition of the key role the latter have to playin the development and provision of services. Itresolved to recruit 500 community developmentworkers nationally who would be expected to workat a senior level and alongside the regional RaceEquality Leads within health and social care,focusing on improving commissioning, access,experience and outcomes for all ethnic minoritycommunities. It also recognised the need forstatutory services to be involved in:forming partnerships with faith communitiesensuring that representatives of BME voluntarysector partners are of comparable seniority tostatutory sector representativesfunding or section 64 (Department of Health)grantspractically supporting the capacity of BMEgroups to become involved in the planning,designing and delivery of servicesputting in place mechanisms to facilitate mutuallearning between BME-delivered services andmainstream servicesThis is a useful framework for engagement and hasechoes of a recommendation from the Reed Reviewwhich stated that: ‘…all agencies involved withmentally disordered offenders should establishstrong pro-active equal opportunities policiesrelating to race and culture which should bereflected in staff training and allow for consultationwith representatives of ethnic minority groups inthe planning, development and monitoring ofservices.’ 48 However, while community engagementis central to the arguments within DRE, it should benoted that it did not specifically relate thearguments and recommendations to mentallydisordered offenders from black or minority ethnicgroups. When developing ways of working inpartnership to provide services and engaging withservice user groups, it is important that blackcommunity groups are not perceived as beingrelevant solely to issues seen as tangible ‘black’issues, and that there is also an awareness of raceand faith considerations.New initiativesThere are some new initiatives underway though toimprove services for mentally disordered offenders.Health and Offender Partnerships (HOPs) is apartnership directorate between the Home Office(NOMS) and the Department of Health (Care ServicesDirectorate). HOPs includes the Home Office MentalHealth Unit and Prison Health at the Department ofHealth and its core initiative is to tackle healthinequality and reduce offending. Currently, it isdeveloping an offender health strategy whichfocuses on all parts of the criminal justice system,including the large body of offenders beingsupervised in the community. However, the key testin respect of approaches to mentally disorderedoffenders from the black community will bewhether this development will be able to marrysome of the innovative ideas from initiatives suchas DRE with the more mainstream thrust of HOPs.commissioning BME specialist services on thebasis of needs assessment and overall servicestrategyidentifying BME voluntary sector groups thatmight be potential candidates for TreasuryEffecting changeBringing about change in the future will require aconcerted and systematic approach: there needs tobe a new drive towards working in partnership withNacro mental health and crime briefing

7black groups, and an improved focus on thedevelopment and delivery of services. To achievethis, reform needs to focus on the following threeareasChanges in monitoring and funding procedures.Increasing staff and practitioner awareness ofthe needs of the black community and a renewedcommitment to dealing with their needseffectively and fairly.Successfully engaging and fully involving blackcommunities in the reform of services.Monitoring and funding proceduresThe precursor for any initiative developed,however, is the need for robust ethnic monitoringdata across both systems. To improve bothmonitoring and funding procedures, the followingmeasures need to be implemented:All criminal justice and mental health agenciesshould adhere to the ethnic category dataguidance produced by the Department of Healthand statistics collected by the Home Office onmentally disordered offenders should be brokendown by ethnicity.Criminal justice mental health liaison schemes(and in particular court-based schemes) shouldhave rigorous, effective ethnic monitoringprocedures in place which collect useful andcomparable data.The data, once collected, must be properlyanalysed and made available to funders, schemesteering groups and strategic multi-agencyforums (where they are in place) who must thenbe prepared to act on the data provided in orderto improve services for black communities.Resources and funding should be made availableboth from the centre and locally, so as tominimise barriers to the implementation ofrecommendations made by mental health andblack community organisations, and otherrelevant bodies.Increased awareness of staff and practitionersStaff working with black mentally disorderedoffenders have a crucial part to play in improvingservices. Making good practice guidance availableto staff and practitioners in this area would greatlyassist this process. Resettlement work and workwith black female mentally disordered offenders aretwo areas where improving practice is particularlyimportant.It is vital that resettlement staff work alongsidefamilies and community and faith groups so thatsuccessful programmes can be developed. Inaddition, it is imperative that staff build stronglinks with black mental health and communitygroups and service user groups, so that staff cannotify them of any mental health problems orfeelings of exclusion due to ethnicity which blackex-offenders might be experiencing.Practitioners need to be aware too of the manyprejudices that female black mentally disorderedoffenders face in particular. In light of this, theyneed to take into account the following issues intheir practice:The resettlement needs of black women.The planning and development of communityprovision for black women.The needs of women asylum seekers and thoseseeking refugee status.Engaging black women’s groups when buildingand sustaining partnerships with voluntarysector groups.The trauma caused by separation from theirfamilies and children for black women detainedin the criminal justice and mental healthsystems, especially for foreign national womenwhose families and children may live in adifferent country.Working in partnership with the black communityTo achieve better outcomes for black mentallydisordered offenders, primary care trusts andmental health trusts should consider taking thefollowing steps:Involving black community and mental healthgroups in the development and running ofcourt-based diversion, liaison or assessmentschemes.Ensuring local mentally disordered offenders’steering groups include representation from arelevant local black mental health or communitygroup, in order to include a black perspective onthe development of strategic plans for servicesfor mentally disordered offenders.Involving local black community and mentalhealth group representation in Section 136 MHAmonitoring groups.Encouraging the creation of an effective andauthoritative association of black service users.Involving black health groups in a wide range ofissues rather than solely with what areconsidered to be ‘black’ issues.

8Black communities, mental health and the criminal justice systemConclusionThere is clearly a continued need for governmentdepartments and criminal justice and mental healthagencies to tackle the many difficult issues thatpersist in the relationship between blackcommunities, criminal justice and psychiatry. Thekey strategy documents of recent years have addedlittle of substance to the material produced in thelast two decades and many have avoided the focusof black mentally disordered offenders altogether.Not only is progress needed in the key areasmentioned above (eg rigorous ethnic monitoring incourt diversion and criminal justice liaisonschemes; greater black representation on schemeand section 136 steering groups; central monitoringof the ethnicity of black mentally disorderedoffenders; improved service delivery and bettercommunity engagement) but there is also a need fora concerted and inclusive strategy towards blackand minority ethnic mentally disordered offenderswhich cohesively tackles the particular problemsthey experience in areas such as immigration,asylum and resettlement. Given that the criminaljustice system can act as a gateway to the mentalhealth system, the need for comprehensive actionthat reforms both systems is all the more pressing.The danger, if this does not happen, is that policymakersin this field will find themselves perpetuallyaddressing the symptoms rather than the causes ofthese inequalities.References1 Fernando S (1991) Mental Health, Race and Culture London:Macmillan/MIND Publications2 Department of Health (2003) Inside Outside: Improving MentalHealth Services for Black and Minority Ethnic Communities inEngland London: Department of Health3 Cope R (1989) ‘The Compulsory Detention of Afro-Caribbeansunder the Mental Health Act’ New Community 15 (3) pp. 343-3564 Healthcare Commission (2007) Results of the 2006 NationalCensus of Inpatients in Mental Health and Learning DisabilityServices in England and Wales London: Commission forHealthcare, Audit and Inspection5 Office for National Statistics (2003) Census 2001: Ethnicity andreligion in England and Wales London: Office for National Statistics6 Reza B and Magill C (2006) Race and the Criminal Justice System:An overview to the complete statistics 2004-2005 London: CriminalJustice System (Race Unit)7 Fitzgerald M (1993) ‘Ethnic Minorities and the Criminal JusticeSystem’ Royal Commission on Criminal Justice Research Study 20London: HMSO8 John G (2003) Race for Justice: A review of CPS decision makingfor possible racial bias at each stage of the prosecution processLondon: Crown Prosecution Service9 Sharp C and Budd T (2005) Minority Ethnic Groups and Crime:Findings from the Offending, Crime and Justice Survey 2003.Home Office online report 33/0510 Reza B and Magill C (2006) Race and the Criminal Justice System11 HM Inspectorate of Prisons (2005) Women in Prison London: HomeOffice12 Reza B and Magill C (2006) Race and the Criminal Justice System13 Baluchi B (1999) Beyond Urgent: Towards a strategy for refugeehealth London: Kimia Institute14 Nacro (2005) Integrated Resettlement: Putting the pieces togetherLondon: Nacro15 ibid16 The Housing Corporation (1998) Black and Minority EthnicHousing Policy London: The Housing Corporation17 Healthcare Commission (2005) Count Me In: Results of a nationalcensus of inpatients in mental health hospitals and facilities inEngland and Wales London: Commission for Healthcare, Audit andInspection18 Office for National Statistics (2003) Census 200119 Healthcare Commission (2007) Results of the 2006 NationalCensus of Inpatients20 Department of Health (2003) Delivering Race Equality – AFramework for Action: Mental health services consultationdocument London: Department of Health21 Nacro (1990) Black People, Mental Health and the Courts: Anexploratory study into the psychiatric remand process as it affectsblack defendants at magistrates’ courts London: Nacro22 Browne D (1997) Black People and Sectioning: The blackexperience of detention under the civil sections of the MentalHealth Act London: Little Rock Publishing23 Smaje C (1995) Health, Race and Ethnicity: Making sense of theevidence London: King’s Fund Institute24 Healthcare Commission (2005) Count Me In: Results of a nationalcensus of inpatients25 Healthcare Commission (2007) Results of the 2006 NationalCensus of Inpatients26 Healthcare Commission (2005) Count Me In: Results of a nationalcensus of inpatients27 Nacro (1990) Black People, Mental Health and the Courts28 Prins H, Blacker-Holst T, Francis E and Keitch I (1993) Report of theCommittee of Inquiry into the Death in Broadmoor Hospital ofOrville Blackwood and a Review of the Deaths of Two Other Afro-Caribbean Patients. Big, Black and Dangerous. London: SpecialHospitals Service Authority29 Cope R and Ndegwa D (1990) ‘Ethnic differences in admissions toa regional secure unit’ Journal of Forensic Psychiatry 1(3) pp. 365-37830 Department of Health (2003) Inside Outside31 Browne D (1997) Black People and Sectioning32 Prins H et al (1993) Report of the Committee of Inquiry into theDeath in Broadmoor Hospital33 Department of Health (2003) Inside Outside34 Healthcare Commission (2005) Count Me In: Results of a nationalcensus of inpatients35 Healthcare Commission (2007) Results of the 2006 NationalCensus of Inpatients36 Prins H et al (1993) Report of the Committee of Inquiry into theDeath in Broadmoor Hospital37 Home Office (1990) Provision for Mentally Disordered OffendersCircular 66/90 London: HMSO38 Francis E, David J, Johnson N and Sashidharan S P (1989) ‘BlackPeople and Psychiatry in the UK’ Psychiatric Bulletin 13, pp. 482-48539 Norfolk, Suffolk and Cambridgeshire Health Authority (2003)Independent Inquiry into the Death of David Bennett Cambridge:Cambridgeshire Health Authority40 Bhui K and Sashidharan S P (2003) ‘Should there be separatepsychiatric services for ethnic minority groups?’ British Journal ofPsychiatry, 182, pp. 10-1241 Lyall M. (2005) ‘Should there be separate forensic psychiatryservices for ethnic minority patients?’ Journal of ForensicPsychiatry and Psychology 16 (2) pp. 370-37942 Reed J (1994) Vol 6: Race, Gender and Equal Opportunities (Reviewof Health and Social Services for Mentally Disordered Offendersand Others Requiring Similar Services) London: HMSO43 Department of Health (2003) Inside Outside44 Norfolk, Suffolk and Cambridgeshire Health Authority (2003)Independent Inquiry into the Death of David Bennett45 Department of Health (2005) Delivering Race Equality in MentalHealth Care: An action plan for reform inside and outside services(including the Government’s response to the independent inquiryinto the death of David Bennett) London: Department of Health46 Vige M ‘Race and Mental Health Treatment’ Criminal JusticeMonthly 61 pp. 28-3147 Fernando S (1991) Mental Health, Race and Culture48 Reed J (1994) Vol 6: Race, Gender and Equal OpportunitiesNacro mental health and crime briefing