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Death in restraint: lessons

  • Hadrian N. Ball (a1)
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Abstract
Copyright
This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
References
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Chan, T. C., Vilke, G. M., Neuman, T., et al (1997) Restraint position and positional asphyxia. Annals of Emergency Medicine, 30, 578586.
Morrison, A. & Sadler, D. (2001) Death of a psychiatric patient during physical restraint. Excited delirium – a case report. Medicine, Science and the Law, 41, 4650.
National Institute for Clinical Excellence (2005) The Short-Term Management of Disturbed/Violent Behaviour in Psychiatric In-Patient Settings and Emergency Departments (available at http://www.nice.org.uk/pdf/cg025niceguideline.pdf).
Norfolk, Suffolk and Cambridgeshire Strategic Health Authority (2004) Independent Inquiry into the Death of David Bennett (available at http://www.nscha.nhs.uk/4856/11516/David%20Bennett%20Inquiry.pdf).
O'Halloran, R. L. & Lewman, L.V. (1993) Restraint asphyxiation in excited delirium. American Journal of Forensic Medicine and Pathology, 14, 289295.
Reay, D.T., Howard, J. D., Figner, G. F., et al (1988) Effects of positional restraint on oxygen saturation and heart rate following exercise. American Journal of Forensic Medicine and Pathology, 13, 578586.
Reay, D.T., Fligner, C. L., Stilwel, A. D., et al (1992) Positional asphyxia during law enforcement transport. American Journal of Forensic Medicine and Pathology, 13, 9097.
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BJPsych Bulletin
  • ISSN: 0955-6036
  • EISSN: 1472-1473
  • URL: /core/journals/bjpsych-bulletin
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Death in restraint: lessons

  • Hadrian N. Ball (a1)
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eLetters

Physical restraint in developing countries

K.A.L.A. Kuruppuarachchi MD,MRCPsych(UK), Professor of Psychiatry
17 January 2006

Sir

The editorial on “Death in restraint: lessons “ by Hadrian N. Ball was read with interest (Psychiatric Bulletin, September 2005,29,321-323). The content of the article is very relevant to the practice of Psychiatry in developing countries as well. Physical restraint in various forms is still used in many units, particularly during the initial period of assessment and management. Shortage of trained staff, inadequate facilities for seclusion and overcrowding contribute further to this problem (even though it may be inappropriate to restrain disturbed patients when these factors are present). For instance in Sri Lanka, the admitting medical officer may recommend the physical restraint depending on the nature of the problem and the presentation. The disturbed patient is usually tied to a bar bed using folded cloths to minimize the disturbance.

Studies have demonstrated that the duration of restraint has beencorrelated with the patient- staff ratio and with more patients per staff member, the episodes have been longer (Psychiatric Services, December 1999, 50; 1637- 1638). There will be more deleterious consequences when numbers of trained staff is less. Continuous monitoring is strongly recommended during the restraint and each episode of restraint or seclusion should be regarded as a new episode ;requiring new orders and evaluation (Supplement to Journal of Psychiatric Practice, The Expert Consensus Guideline Series, November 2005, vol.11, suppl. 1, 31-32). It is note-worthy that lack of proper mental health acts can contribute to the physical restraint of the mentally disturbed.Improvement on the policy can improve the restraint pattern. A Polish study demonstrated that the use of restraint was less arbitrary after replacing local institutional guidelines by national policy with regard tothe use of restraint (Psychiatric Services, December 1999, 50:1637-1638).In developing countries such as Sri Lanka it is imperative to highlight this important issue to educate the mental health care workers, to do more research work and to look for alternative management strategies of disturbed patients that will improve the quality of care. It is essential to update the existing mental health acts to provide a comprehensive care to the mentally ill.

References

Ball, H.N.(2005) Death in restraint : lessons , Psychiatric Bulletin, 29 , 321-323.

Allen, M.H., Currier,G.W. , Carpenter,D., et al (2005) Treatment of Behavioral Emergencies 2005 , Supplement to Journal of Psychiatric Practice , The Expert Consensus Guideline Series , vol.11 , suppli.1 , 31-32.

Kostecka, M., Zardecka,M. (1999) The Use of Physical Restraints in Polish Psychiatric Hospitals in 1989 and 1996 , Psychiatric Services , 50 , 1637-1638.

Mohr,W.K., Petti, T.A. , Mohr B.D. (2003) Adverse Effects Associated With Physical Restraint , The Canadian Journal of Psychiatry , 48 , 330-337.
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Conflict of interest: None Declared

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The wider implications of the Blofeld report

D B Double, Consultant Psychiatrist
13 September 2005

Hadrian Ball (Psychiatric Bulletin, September 2005, 29, 321-323) usefully highlights some of the lessons from the death under restraint of David Bennett in the forensic unit in Norwich. Coincidentally, Ball's editorial appears in the same month as a special section on seclusion and restraint in the journal Psychiatric Services (Busch, 2005). This special section highlights the importance of the culture of mental health services in limiting the use of such restrictive procedures. This culture has been affected over recent years in the UK by an emphasis on the control and containment of psychiatric patients by, for example, the obligation on health authorities since 1994 to hold an independent inquiry in cases of homicide by those who have been in contact with psychiatric services. The recent debate about reform of the Mental Health Act has stressed the potential for increasing coercion in the treatment of the mentally ill. More generally a risk-averse approach has encouraged practice to err on the side of caution and as a consequence to become increasingly defensive and bureaucratic, ostensibly to avoid litigation. In this context, it may be more difficult to appreciate that restraint may be better seen as an indication of treatment failure, rather than treatment as such. Staff should be engaged with therapeutic and not just custodial practice. The lessons of David Bennett's death are, therefore, wider than the recommendations of the independent panel report in relation to procedures involved in restraint. Of course Hadrian Ball is aware of this fact. To his credit, in his evidence to the independent panel, he is quoted as saying that "patients who came into medium secure units from general psychiatric services in civil detention, rather than through the criminal justice system, [are not] done any good by their detention" (Norfolk, Suffolk and Cambridgeshire Strategic Health Authority, 2004). We do need to focus on the implication for the culture of mental health services of why David Bennett was detained under civil powers in a forensic unit so long. Improving the skills of staff working in inpatient settings is not just about control and restraint, especially when what evidence there is about the effectiveness of such training is contradictory and inadequate (Wright, 2003). Mental health services need clear direction to respond to the challenge of finding positive ways of supporting people in crisis. This is what users themselves want. Their negative perceptions of restraint have empowered the survivor movement in psychiatry, perhaps particularly as such trauma may commonly repeat early abusive experiences. Services need to work in alliance with survivors. I agree with the implication of what Hadrian Ball says about the need for the Department of Health to take a lead on these issues. BUSCH, A.B. (2005) Introduction to the special section on seclusion and restraint. Psychiatric Services, 56, 1104.NORFOLK, SUFFOLK AND CAMBRIDGESHIRE STRATEGIC HEALTH AUTHORITY (2004) Independent Inquiry into the Death of David Bennett (available at http://www.nscha.nhs.uk/4856/11516/David%20Bennett%20Inquiry.pdf).Wright S. (2003) Control and restraint techniques in the management of violence in inpatient psychiatry: A critical review. Medicine Science and the Law, 43, 31-38. ... More

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