Lord Patel of Bradford: Evidence based changes needed for patient restraint

David ‘Rocky’ Bennett died in a mental health unit in 1998 after being restrained by NHS staff. The inquiry into his death made it clear that he had not been treated with dignity or respect, but had been racially abused by another patient. His request for protection led to the decision that he would be moved to another ward, rather than the perpetrator. He resisted this, was restrained and held in a prone position for a long period of time, which resulted in his death.

After 15 years I hoped that such cases would be a thing of the past but the events at Winterborne View showed that physical restraint is common despite evidence recommending less coercive measures to manage violent and aggressive patients. In 2005, NICE stated that physical restraint should only be used as a “last resort” to manage unwanted or harmful behaviours [1]. Yet data obtained by  Mind [2] shows alarming figures - there were around 40,000 recorded incidents of all kinds of physical restraint during the 12 month period, resulting in at least 1,000 injuries to people with mental health problems, and 13 restraint-related deaths under the Mental Health Act 1983 in England since 2000.  Mindalso reported that a quarter of frontline staff involved in restraint had not had face-to-face training on physical restraint techniques in the last 12 months.

Restraint is a physical intervention and like all other physical interventions should be based on evidence of efficacy, safety and acceptability. So, isn’t it time that this issue was reviewed by NICE and clear recommendations made based on evidence? Work must done around the likelihood and probability of physical and psychological harm against each restraint technique in each position undertaken by appropriate medical experts if we are to develop appropriate regulations and develop consist training for staff. CQC should also review their actions and ensure that a robust inspection process is in place that covers not only how the process of restraint is used in care home but also the training that staff receive.

Dealing with violence and aggression can be stressful for staff especially if they feel inadequately trained to deal with it, but physical restraint is ethically unacceptable in all but the most extreme circumstances. However, the approach to restraint has been confusing and shambolic within mental health and we have a long way to go before achieving the quality standard set by NICE [3]:

"People in hospital for mental health care are confident that control and restraint.........will be used competently, safely and only as a last resort with minimum force."

[1] National Institute for Health and Clinical Excellence (2005) Violence: The short-term management of disturbed/violent behaviour in psychiatric in-patients and emergency department guidelines. London: NICE.

[2]  Mind sent Freedom of Information (FOI) requests to all 54 mental health trusts in England requesting information about how they use physical restraint in their trust, the impact of physical restraint and the procedures and training in place which govern its use. They received responses from 51 trusts.

[3]  http://www.nice.org.uk/guidance/qualitystandards/service-user-experience-in-adult-mental-health/UsingControlAndRestraintAndCompulsoryTreatment.jsp

Lord Patel of Bradford (Labour) sits on the House of Lords Mental Capacity Act 2005 Committee