Tully and colleagues ^{Reference Tully, Hearn and Fahy1} justify the introduction of electronic monitoring of medium secure patients without indication of the size of the problem of absconding or the incidence of serious harm other than to reference an article in The Sun newspaper, which is neither informative nor free of bias.

Decisions around leave for patients detained within a medium secure unit are clearly complex. Consideration should always be given to the risk of absconding and associated risks if the patient were to abscond. Thus, patients who are at high risk of absconding and a serious risk to the public would not receive leave, whether they were tagged or not. Another factor is the clinical team’s trust in that patient to use leave appropriately. Tagging patients would be a very clear indicator of a lack of such trust.

The suggestion that patients enter into electronic monitoring with consent is questionable: many patients in our experience abide by suggestions of their clinical team in order to progress through the system. Given that there is yet to be a strong argument that tagging is necessary and primarily in the patient’s best interest (as opposed to a matter of public protection), can one justify this coercion? We would be very interested to know the process in which patients’ perspectives were taken into account and whether this has altered the intervention.

Electronic monitoring would inform the clinical team if the patient were to breach the conditions of their leave in terms of approximate location and time of leave; however, it would not inform the team as to what that patient was doing with their leave and would not necessarily prevent serious incidents occurring, as suggested. The use of a device whose main purpose has been pioneered by the criminal justice system seems to take us closer to making our hospitals prisons. A recent report published by the Criminal Justice Joint Inspection reiterates their 2008 findings that enforcement thresholds were not sufficiently stringent. ² With notable problems implementing this system within the criminal justice system, is it justifiable to implement it within the forensic services, given the cost of such a system? ^{Reference Shaw3}

Given the recent concerns about certain international security companies, the provision of such tags also raises ethical issues. Confidentiality must also be considered - would said companies have access to patient names and locations? The comparison of electronic monitoring with other uses of technology within psychiatry, such as mood monitoring via text message, is bizarre. The principles approach ^{Reference Gillon4} gives us a framework in terms of judging whether an intervention respects autonomy, beneficence, non-maleficence and justice. Debate of these principles will exceed the remit of this letter; however, it is worthwhile considering autonomy and beneficence in particular relating to the patient: we suggest that there is a breach in both. The weighing of these principles will not be easy and it will be a matter of debate whether the principle of justice will outbalance the former.

As the authors state, robust research in this area is needed, and we look forward to reviewing the evidence.