Been here before - a death in custody
23-year-old Seni Lewis was in the midst of his Master's Degree studies in IT and Business and letters from his University show he was held in high regard by his peers and professional staff.
Seni began to display uncharacteristic behaviour after a night out in August over the Bank Holiday weekend.
After two days of unpredictable mood swings and feeling that her son was possibly heading towards a breakdown, Bola Lewis convinced her son and the remainder of her family that they needed to seek professional medical help.
They took Seni to A&E at the Mayday Hospital in Croydon. After admitting him under a temporary mental health sectioning order for his own safety, he showed a continued pattern of unpredictable behaviour which gave everyone, including Seni according to his parents, real cause for concern.
Seni was admitted to the Maudsley Psychiatric Hospital on 31 August. The family recall being told there were no beds and that the only options were to release him into his mother's care or to admit him to Bethlem Royal in Bromley.
Despite the fact that Seni had no previous mental health issues, the family accept they did not feel able at that point to give their confused and vulnerable son the care he needed. A voluntary agreement was arrived at to keep Seni at Bethlem as long or short as he wanted.
Bola Lewis says this was her fatal mistake. With hindsight she and husband Conrad wish they had not left their son behind after visiting hours ended at 8pm.
Bola toyed with the idea of sleeping in her car in the hospital car park just so she could be close by. Instead she left her numbers with hospital staff and went home in the knowledge that her son was in the care of professionals.
But whilst she and Conrad were returning home things were beginning to take a turn for the worse at Bethlem. The facts will only be fully known once the Independent Police Complaints Commission has completed its investigation and that has been scrutinised by the Coroner's Court in Croydon.
But it is understood that around 9.30pm police were called to an incident at the hospital involving Seni. He was forcibly restrained, it's believed by up to seven police officers and the rest we know.
The first call the parents received was not to ask for their assistance with their vulnerable son, but to tell them that some time before midnight on the 31st, less than four hours after they'd left him, their son had been admitted to the Mayday Hospital in a coma. He died four days later.
And so the Lewis' will have to travel the well trodden path that the Sylvester family went down between 1999 and 2003 to discover what happened to their son Roger in Tottenham.
And the four-year journey the family of Frank Ogboru travelled between 2006 and 2010 to discover how he died whilst being restrained by police officers in Woolwich.
But this time the questions may be asked more urgently elsewhere about how effectively police officers use restraint techniques.
In April this year, another Coroner asked similar questions on the use of restraint whilst looking into the death of Frank Ogboru.
In a very firm set of recommendations to the Metropolitan Police Commissioner, Coroner Selena Lynch reflected: "Whether this means more training, different training, or training that is delivered in a different way is something that might be usefully considered."
Have these questions been addressed by Sir Paul Stephenson?
In the meantime the Lewis family are left reeling from the shock of having buried a vibrant and healthy son prematurely.