David Bennett was a 38-year-old African-Caribbean patient, who had had mental illness for 18 years, and had a diagnosis of schizophrenia.
The inquiry concluded that this is due to institutional racism within the mental health services.
The inquiry into the death of David 'Rocky' Bennett recommended that training in cultural competencies should become of paramount importance (Department of Health, 2003).
The resentment of being targeted for blame has been understandably linked to his physical attack on a nurse afterwards.
His subsequent physical restrainment included giving a dose of medication that is above the recommended limit (in the British National Formulary), and this directly preceded his tragic death.