Medical practice

Charity calls for ban of 'face-down restraint'

The use of physical restraint in psychiatric hospitals has been widely reported after the publication of a report by the mental health charity MIND on the use of the practice in England. The report said that last year almost 40,000 incidents of physical restraint were recorded, with almost 1,000 cases of physical injury after a patient had been physically restrained.

MIND is particularly concerned about the use of "face-down restraint", which it says can be life-threatening and was used more than 3,000 times last year. The government is said to be considering a ban on the practice and has reportedly ordered an investigation into its use in two English trusts.

The charity's report says that from the figures it has compiled, it is clear there is "huge variation" in the use of physical restraint across England. It is calling for the government to establish national standards for the use of physical restraint and accredited training in its use for healthcare staff.

What is physical restraint in mental healthcare?

MIND quotes one definition of physical restraint from the Care Quality Commission, which says it is "the physical restraint of a patient by one or more members of staff in response to aggressive behaviour or resistance to treatment".

MIND defines "face-down restraint" as when someone is pinned face down (prone) on the floor and is physically prevented from moving out of this position. The charity says this is dangerous and can be life-threatening because of the impact it has on breathing.

Why did MIND investigate the use of physical restraint?

MIND points out that healthcare staff have a challenging job – physical intervention is often used to manage a person's behaviour if they are deemed to be a risk to themselves or others as a result of their mental health problems.

It says the issue poses a huge challenge to clinical staff, as well as those managing healthcare: "We have a huge responsibility to ensure that as clinicians the power invested in us is not abused."

What does the law say about physical restraint?

The law says that if someone is detained in hospital under the Mental Health Act (1983), staff are entitled to exercise a degree of control over them. For example, staff are allowed to prevent someone detained under the act from leaving hospital.

Under the law, force may be used to achieve this if necessary, but it must be reasonable and proportionate. The act's code of practice explains that restraint is a response of last resort and gives detailed guidance for managing disturbed or aggressive behaviour.

How did MIND uncover the extent of the use of physical restraint?

The charity sent requests under the Freedom of Information Act to all 54 mental health trusts in England, asking how they used physical restraint and the procedures and training in place governing its use. They asked for a range of data for the year 2011-12, with information broken down by both gender and ethnicity.

It received responses from 51 trusts, one of which declined the request on the grounds of cost and time. The charity says it did not approach independent providers, and further research is needed in the use of physical restraint in independent mental health units.

The charity also commissioned an independent inquiry into mental healthcare in 2010-11. Its report, published in 2011, included patients' experiences of being physically restrained.

What did MIND find out about physical restraint?

  • The charity says it found a "staggering" variation in the use of physical restraint in mental health trusts. In a single year, one trust reported 38 incidents, while another reported 3,346. In total, 39,883 incidents were reported. The level of variation is "appalling", MIND says, with the data suggesting that some people may be being restrained repeatedly.
  • Only half of the trusts contacted reported the use of face-down restraint, which was used in more than 3,439 incidents overall. More than half these incidents occurred in just two trusts. Four mental health trusts reported there had been no use of face-down restraint.
  • Just over half of trusts responded to questions on the use of physical restraint to administer medication. More than 4,000 such incidents were reported.
  • Half the trusts responded to questions about police involvement in physically restraining patients, with 361 such incidents reported.
  • There were 949 incidents of physical injury following physical restraint, reported by 62% of trusts. Recorded incidents of harm varied from zero to 200.
  • One quarter of trusts reported incidents of psychological harm following physical restraint, of which there were 96.
  • There were 111 complaints about physical restraint reported by 68% of trusts.

The charity also says it received very little information on ethnicity and gender, with many trusts saying they did not collect this information. Failure to record ethnicity of patients being physically restrained is worrying, MIND says, given that people from black and ethnic minority backgrounds are "over-represented" in hospitals as detained patients.

What do people who have been physically restrained say?

MIND includes in its report some quotes from people who have experienced or witnessed physical restraint. It says many are taken from interviews it conducted earlier this year, although it does not give details of the patients.

For example: "It was horrific … I had some bad experiences of being restrained face down with my face pushed into a pillow. I can't begin to describe how scary it was, not being able to signal, communicate, breathe or speak."

Another recalled: "It made me feel like a criminal, like I had done something wrong, not that I was just ill and needed to get better."

And another person told MIND: "I've suffered physical abuse when I was younger, and being held down where someone forces their weight on you is triggering for me … it's the last thing that's going to make me conform; I don't want them touching me."

What does MIND recommend?

MIND is calling on the government to urgently ban face-down physical restraint in all healthcare settings and to include its use in the list of "never events" – events that should never occur in a healthcare setting.

It also wants the government to introduce national standards for the use of physical restraint and accredited training for healthcare staff in England. The principles of the training should be "respect-based" and endorsed by people who have experienced physical restraint. MIND has called on NHS England to introduce standard methods of fully recording the details of cases of physical restraint.

The charity also wants staff working in mental health units to commit to working without coercion, to use alternatives and communication skills to build relationships, and to ensure that physical restraint is only ever used as a last resort.

MIND also points out that overcrowded, noisy wards with "limited therapeutic input" can be a trigger for patient distress and challenging behaviour. It says that the aim of inpatient mental health wards should be to provide a safe and therapeutic environment encompassing the patients' needs. Better communication with patients and creating care plans that respond to their needs and identify triggers for distress can all help staff manage crises.

What happens now?

According to a BBC News report, health minister Norman Lamb is "very interested" in "just banning face-down restraint". He has also reportedly ordered a "specific investigation" into the use of face-down restraint in two English trusts: Northumberland, Tyne and Wear (where face-down restraint was reportedly used 923 times in 2011-12) and Southampton.

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