A Blog on the Use of Restraint

This blog discusses an extremely important and emotive issue; that of restraint. The ‘laying on of hands’ and physical restraint of a person can be extremely traumatic and emotional for all involved. This blog cannot cover or address all such issues however, we must recognise that restraining a person against their will can stir up a myriad of memories and emotions and in some cases physical restraint has even been described as dehumanising. This only reinforces the need for staff to be aware of all potential risk factors and employ the least restrictive approach possible. In 2015, the Mental Health Act Code of Practice called on mental health services to reduce restrictive interventions. These practices include the use of restraint, seclusion and rapid tranquilisation. Specific guidance and resources from the Royal College of Psychiatrists are available here.

As this is such a wide issue, this blog concentrates on the role of Healthcare Security Officers are permitted and expected to restrain patients held under MHA sections as the Trust is legally responsible for their care and as such, are responsible for ensuring that they do not abscond.  The case of Webley v St George’s NHS Trust and the Metropolitan Police Service illustrates the need to ensure robust security is in place when monitoring mental health patients.

The background to the case

The Police transported a patient to St George’s Hospital, ED where he was triaged by an ED Sister, it was noted in his records that he was a ‘high risk patient, risk of absconding’, Police officers remained in the ED until hospital security officers came and took over responsibility for his ongoing detention.  The Police left around 3pm and two hospital security officers, along with staff in the ED, became responsible for his security and immediate welfare. Around 4:30pm, Mr Webley managed to leave cubicle 9 in the ED and walk out to a nearby ramp and jump from a height of fifteen feet.  He sustained a significant head injury which has caused permanent damage and had a lasting effect.  The hospital and in particular the security officers were found to have failed in their duty to safeguard the patient.

The full case review can be found here.

The Court examined in detail the movements of the security officers and whether or not they were actively monitoring/observing the patient or actively guarding him.  The court rejected suggestions that a less intrusive, less restrictive approach was reasonable as the Police had highlighted the risks and potential for Mr Webley to abscond.  In particular, there were two doors in the cubicle where the patient was detained and the security officers did not position themselves in such a way as to block both exits.  The second security officer, who arrived after the police left, had not been briefed on the issues highlighted by the police about the risk of absconding.

The court found the hospital trust liable for the injuries that Mr Webley suffered and the fact that he is now in a secure hospital facility, detained under s3 of the Act having suffered life-altering injuries.

It was argued that the Police should not have handed over responsibility of Webley to two security officers, especially as 6 Police officers had been involved in his initial detention.  It is arguable that the receiving NHS Trust can refuse to accept responsibility for a person under Police escort, especially in situations such as this.

During the Webley case Stephen MILLER QC accepted that the Police common law duty of care was not discharged until they released the person into a safe environment.  If we can demonstrate that the ED is not a safe environment due to capacity, staffing and the behaviour / risks posed by the individual, we can therefore refuse to accept responsibility for the patient.

Sections 5 and 6 of the MCA offer protection from legal liability for certain acts of restraint – provided those acts are reasonably believed to be in the best interests of the individual. In this context restraint means using or threatening to use force to make a person do something they are resisting, or may resist, or restricting the person’s liberty of movement, whether or not the person resists.

In considering the use of restraint, decision-makers should carefully take into account the need to respect an individual’s liberty and autonomy.2 Section 6 of the MCA states that, in addition to needing to be in the best interests of the person who lacks capacity in respect of the relevant decision, acts of restraint will only be permitted if:

  • The person taking action reasonably believes that restraint is necessary to prevent harm to the person who lacks capacity, and
  • The amount or type of restraint used and the amount of time it lasts is a proportionate response to the likelihood and seriousness of that harm.

The use of physical restraint or force may be required when removing a person, or in a place of safety, for the protection of the person or others (such as the public, staff or patients). If physical restraint is used, it should be necessary and unavoidable to prevent harm to the person or others, and be proportionate to the risk of harm if restraint was not used. The least restrictive type of restraint should be used. There should be a clear local protocol about the circumstances when, very exceptionally, police may be asked to use physical restraint in a (health-based) place of safety.

The size and physical vulnerability of children and young people should be taken into account when considering physical restraint. Physical restraint should be used with caution when it involves children and young people because in most cases their musculoskeletal systems are immature which elevates the risk of injury.

Physical restraint refers to any direct physical contact where the intention is to prevent, restrict, or subdue movement of the body (or part of the body) of another person.

Patients should not be deliberately restrained in a way that impacts on their airway, breathing or circulation. The mouth and / or nose should never be covered and there should be no pressure to the neck region, rib cage and / or abdomen. Unless there are cogent reasons for doing so, there must be no planned or intentional restraint of a person in a prone position (whereby they are forcibly laid on their front) on any surface, not just the floor.

Full account should be taken of the individual’s age, physical and emotional maturity, health status, cognitive functioning and any disability or sensory impairment, which may confer additional risks to the individual’s health, safety and well-being in the face of exposure to physical restraint. Throughout any period of physical restraint:

  • A member of staff should monitor the individual’s airway and physical condition to minimise the potential of harm or injury. Observations, including vital clinical indicators such as pulse, respiration and complexion (with special attention for pallor/discolouration), should be conducted and recorded. Staff should be trained so that they are competent to interpret these vital signs;
  • Emergency resuscitation devices should be readily available in the area where restraint is taking place, and;
  • A member of staff should take the lead in caring for other patients and moving them away from the area of disturbance.

Where physical restraint has been used, staff should report the matter via their local Incident reporting system (Datix , Ulysses Safeguard for example) recording the decision and the reasons for it, including details about how the intervention was implemented, the duration, staff involved and which part of the body they restrained and the patient’s response.