Journal of Learning Disabilities and Offending Behaviour
Emerald Article: Deaths in custody: the role of restraint
Joy Duxbury, Frances Aiken, Colin Dale
To cite this document: Joy Duxbury, Frances Aiken, Colin Dale, (2011),"Deaths in custody: the role of restraint", Journal of Learning Disabilities and Offending Behaviour, Vol. 2 Iss: 4 pp. 178 - 189
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Joy Duxbury, Frances Aiken, Colin Dale, (2011),"Deaths in custody: the role of restraint", Journal of Learning Disabilities and Offending Behaviour, Vol. 2 Iss: 4 pp. 178 - 189http://dx.doi.org/10.1108/20420921111207873
Joy Duxbury, Frances Aiken, Colin Dale, (2011),"Deaths in custody: the role of restraint", Journal of Learning Disabilities and Offending Behaviour, Vol. 2 Iss: 4 pp. 178 - 189http://dx.doi.org/10.1108/20420921111207873
Joy Duxbury, Frances Aiken, Colin Dale, (2011),"Deaths in custody: the role of restraint", Journal of Learning Disabilities and Offending Behaviour, Vol. 2 Iss: 4 pp. 178 - 189http://dx.doi.org/10.1108/20420921111207873
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Joy Duxbury, Frances Aiken and Colin Dale
Purpose – The practice of restraint is controversial as deaths in care or custody have been a
consequence of restraint. The purpose of this paper is to clarify research from national and international
literature to ascertain any common findings in order to provide guidance for staff on safe and effective
restraint techniques where there is no other resort in the management of violent and aggressive
Design/methodology/approach – The researchers undertook a review of the literature on the medical
theories relating to restraint-related deaths and an analysis of deaths in custody in the UK for the timeperiod 1 Jan 1999 to 1 Jan 2010.
Findings – Findings showed that certain groups are particularly vulnerable to risks while beingrestrained. There are also biophysiological mechanisms which staff need to be aware of when
restraining an aggressive or violent individual.
Originality/value – It is evident that those in vulnerable groups when restrained in a prone position, or ina basket hold, for a prolonged period and who are agitated and resistive, are most at risk of death incustody. Consistency in reporting relevant deaths locally and nationally is necessary to facilitate analysisof key information and prevent deaths in custody in the future. Staff training and awareness are also keyfactors.
Keywords Deaths in custody, Restraint techniques, Control, Management of violence and aggression,Training, Police custody, Patients
Controversy and debate is the consequence of any deaths that occur in custody andhealthcare. These cases distress the victims’ family and community; they also affect staff inall parts of the medical-legal community. Service reputations and community relationshipsmay be damaged. Further complicating the situation is the fact that there are often minimalphysical findings at autopsy, accompanied by sparsely detailed case information. Wherethese deaths have involved the use of restraint they can be among the most controversialbecause they have occurred as a result of the actions of representatives of the state. Thedeath of David ‘‘Rocky’’ Bennett in 1998 in a healthcare setting is an example of restraint-related deaths that demonstrate the need for clarity on methods of physical restraint that aresafe and humane in the management of aggressive or violent individuals.
The Independent Advisory Panel (IAP) which forms the second tier of the Ministerial Councilon deaths in custody, commissioned this review of the medical theories and researchrelating to restraint-related deaths. The researchers sought to clarify research from nationaland international literature to ascertain any common findings in order to provide guidance forstaff on safe and effective restraint techniques where there is no other resort in themanagement of violent and aggressive individuals. The methodology used was a literaturereview, analysis of cases reported in the press for the given time period, a gap analysis
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Emerald Group Publishing Limited, ISSN 2042-0927 DOI 10.1108/20420921111207873
and gathering expert opinion. The findings of the literature review and case analysis aredescribed below.
There are statistics held by the IAP on deaths in custody from the custody sectors onrestraint-related deaths. The Independent Police Complaints Commission also record deathsin police custody; these statistics include those who died under restraint (Grace, 2011). In theperiod of 2010-2011 seven people fell ill or were identified as being unwell at the point ofarrest. Of these seven cases, four of these were pronounced dead at the scene of arrest andthree were taken to hospital and died within an hour of arrival. Four involved some form ofrestraint by the arresting officers. There were also two restraint-related deaths reported for thisperiod where the death was in or following custody. There were also two restraint-relateddeaths where police had contact with the individual; in both these cases the police werecalled to a mental health hospital to assist staff with a patient. The IAP reported that betweenthe 1 January 1999 and the 31 December 2009, there were 6,151 deaths in state custody inall services. In 22 of these cases, restraint was identified as a cause of death at the coroner’sinquest (Independent Advisory Panel on Deaths in Custody, 2010).
Characteristics of individuals in UK restraint-related deaths 1999-2010
On analysis of the reports found through searching databases for this study the followingfeatures were found:
16 out of the 38 cases found that died between 1999 and 2010 had a history of mentalillness, specifically psychosis.
Three had a learning disability or pervasive developmental disorder such as autism.
15 were of Black or Minority Ethnic (BME) origin.
15 were males in the 30-40 years age group (only one was female). 12 were males in the40-50 years age group. One was a young male.
The deceased who had a history of mental illness may have been receiving neurolepticmedication which can have life-threatening adverse effects.
Six of the 38 had pre-existing conditions that may have increased the risk of cardiacarrest: one had ischemic heart disease, one had diabetes and four had epilepsy.
Five swallowed a drug package whilst being restrained, leading to leakage and a fataloverdose.
Positional asphyxia appears to be implicated for at least 26 of the 38 deaths (whether ornot given as a verdict) because of struggle/physical stressors prior to restraint, number ofstaff involved and, in particular, because of the length of time of the restraint and positionof the individual.
Verdicts of fatal excited delirium were given for five deaths. Accounts describe the individualas being restrained in a prone position, either flat or over a mattress/chair. The number ofstaff involved in the restraint was between two and 15 staff; the length of restraint wasbetween 10 minutes and 1 hr 40 minutes. Police were involved in the restraint incident for29 of the deaths, hospital staff for seven and Youth Offender Institute staff for one of thedeaths. Location of death was not always specified in reports. It is unclear from the accountswhether exhaustion due to prolonged struggle was a factor as the length of time of thedisturbed behaviour before the restraint incident has not been given.
Throughout the literature, research studies and debates there is evidence that certain groupsare more vulnerable to risks when being restrained, whether because of biophysiological,
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interpersonal or situational factors or attitudinal factors. These groups may be vulnerablebecause they are over-represented in the detained population in any case or through attitudesand situations they encounter whilst being detained and consequently restrained. There arealso others who are susceptible to medical harm because of biophysiological features suchas pre-existing conditions.
There is increasing awareness that people with a learning disability are likely to experiencemore health problems than the average person in the general population. Further, they mayhave higher levels of unmet healthcare needs, experiencing unrecognised and thus untreatedhealth problems including hypertension (Kerr, 2004). Particular problems identified, whichoccur with increased frequency in association with learning disability, include obesity, which isthe most commonly reported health problem, and heart disease (Disability Rights Commission,2004; Emerson and Baines, 2010). These health problems could adversely affect the individualin any restraint situation.
The increased prevalence of hearing and/or visual impairment (Vitiello and Behar, 1979) mayalso affect the person’s ability to communicate their distress or understand and respond torequests during restraint. This could perhaps increase the likelihood of a prolonged struggle,with its concomitant risks. When individuals with severe atypical autism are restrained theymay be unable to calm down as the physical restrictions will continuously trigger the fight/flightresponse leading to prolonged restraint with possible adverse reactions.
Compared with the general population, rates of sudden death are reported to be higher amongmental health service users for several reasons, including general neglect of health andincreased rates of damaging personal habits, for example, smoking, alcohol and othersubstance abuse, and poor diet (Mohr et al., 2003). In the community where police are called tothe scene of an incident where an individual is aggressive or violent, the arresting officer has tomake a rapid assessment of the individual and this requires basic mental health awareness,knowledge of local mental health services and an awareness of their legal powers. Watson andAngell (2007) and Cooper et al. (2004) suggest police officers routinely decide if the mentallydisordered person they are managing would be admissible or not to hospital or other carefacility. If arrested, the custody suite can be chaotic and the custody officer may have to makedifficult decisions, in particular, whether the individual has a severe psychotic illness or is underthe effects of drugs or alcohol. An appropriate place of safety under S.136 where permanent,full-time qualified staff can prevent aggression or manage someone with serious mental illnessmay not always be available. If the individual is drunk they may refuse to admit them:
Even when Section 136 units are operating successfully many will refuse to take detainees whoare violent or intoxicated as an assessment cannot be conducted unless a detainee is relativelycalm and sober (The Police Foundation, 2009).
Patients with dual diagnosis (mental illness and substance misuse) in a study by Wright et al.
(2002) were more likely to report a lifetime history of both offending and violence than patientswith psychosis only. Schizophrenia and other psychoses have been associated with violenceand violent offending with increased risk linked with substance abuse comorbidity (Fazel et al.,2009). Violence and aggression in prison as a result of untreated or deteriorating mentalhealth, and/or substance misuse, may increase the likelihood of being restrained.
Since David Bennett’s death after being restrained in 1998 there are still complaints of racismin healthcare: the Mental Health Act Commission’s (2008) 12th Biennial report found that:
Patients complained that nurses relied upon restraint, medication, and confinement to managethem. All this is occurring disproportionately to African-Caribbean’s who, as the Commission’s
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Count Me In Census 2007 indicates, are over-represented in acute settings as a proportion of thepopulation as a whole.
The National Mental Health Development Unit (2011) found no consistent evidence thatpeople from BME communities are subject to greater use of seclusion or physical restraintalthough patients in the hospitals with higher number of patients from BME communities dogenerally report feeling more coerced. However, African Caribbean service users are morelikely to be misdiagnosed and diagnosed with psychotic conditions and treated usingmedication, which is often of a higher dosage (Sainsbury Centre for Mental Health, 2002).
Keating and Robinson (2004) in a study of treatment of Afro-Caribbean people with mentalillness found that when service users were seen as dangerous, aggressive or difficult tomanage, staff were said to employ control and restraint but culturally appropriate andacceptable behaviour has been wrongly interpreted as symptoms of abnormality oraggression (Inquiry into the death of David ‘‘Rocky’’ Bennet, 2003). Fear of mental illnessalso leads to a fear of rejection by others, and therefore, people who experience mentalhealth problems will make considerable efforts to hide this aspect of their lives (Keating andRobinson, 2004).
Obesity is known to increase the work of breathing (Hough, 2001) and reduce diaphragmmovement in the prone position (Hollins, 2010). Atypical anti-psychotic drugs can increasethe risk of obesity so making those with serious mental illness more vulnerable. Obesity wasalso one of the predisposing risk factors to police custody deaths in studies by Hick et al.
(1999), O’Halloran and Lewman (1993) and Southall et al. (2008). In Stratton et al.’s (2001)study of deaths from excited delirium, where obesity was defined as having a body massindex (BMI) . 29, 56 percent of the cases were obese. In O’Halloran’s (2002) study the casesof obesity (BMI . 25) was 75 percent.
Although females in acute mental health settings are restrained, for example, Whittington et al.
(2006) found that 46 percent of the incidents involved female patients, men are more likely tobe violent or aggressive and then restrained. In research in an acute mental health care trustthe mean age for men involved in restraint incidents was 35.0 years (Lancaster et al., 2008). Instatistics for restraint-related deaths, Stratton et al. (2001) give the mean age as 31 years old,Grant et al. (2007) as 38.5 years. In the literature review by the Task Force on excited delirium inthe USA (2009) more than 95 percent of all published fatal cases were males with a mean ageof 36. In O’Halloran’s study of 21 cases of restraint asphyxia, all were males with a median ageof early 30s.
Young people (under the age of 20) are vulnerable to harm when restrained because ofphysiological immaturity. The independent review of the use of restraint in juvenile securesettings (Smallbridge and Willaimson, 2008) found widespread acceptance that it wassometimes necessary to use force to restrain children in the secure estate (for those 17 yearsand under), where their behaviour posed a high degree of risk to themselves or others.
However, on the evidence available, they did not feel able to state that any one restrainttechnique would be completely safe to use on everyone in the juvenile secure estate. Sincethen, in the second inquest on Adam Rickwood in January 2011, the jury found that he hadbeen subjected to an unlawful restraint technique (face down) and hurt in a way (nosedistraction technique) that contributed to his taking his own life. This inquest came after threejudicial reviews challenging the first inquest; a high court judge then ruled the first verdictunlawful and ordered a second examination of the circumstances of his death. The Court ofAppeal in 2008 ordered that previous Amendment Rules for Secure Training Centres shouldbe quashed because they violated Articles 3 (right to be protected against torture
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or to inhuman or degrading treatment or punishment) and the right to private life under Article8 of the European Convention on Human Rights (The Children’s Commissioner, 2008).
The Royal College of Nursing’s (2010) guidelines state that restrictive physical intervention(direct physical contact between persons where reasonable force is positively appliedagainst resistance to either restrict movement or mobility or to disengage from harmfulbehaviour displayed by an individual) should only be used to prevent serious harm.
In one UK study volunteers with stable chronic obstructive pulmonary diseases (Meredith et al.,2005) were randomly allocated to five positions. The response to the prone position with orwithout wrist restraint appeared highly individual, with some individuals tolerating the proneposition with no measurable clinical effects and others suffering a clinical worseningof symptoms. The reasons for this individual variation remained unclear. The small number ofsubjects in this study and the difficulty in applying it to mental health or custodial settingsdecrease its validity and relevance.
Exercise-related collapse in individuals with sickle cell anaemia is a rare but seriouscomplication. Local hypoxia causes intravascular sickling, in turn causing vascular occlusionand organ and tissue damage. This can result in rhabdomyolysis (the breakdown of musclefibres resulting in the release of muscle fibre contents into the bloodstream), myocardialischemia, arrhythmias and sudden death (Scheinen and Wetli, 2009). Incidence of restraint-related deaths of individuals with sickle cell anaemia is extremely rare but Dyson and Boswell(2006) found that:
Statistically, sickle cell could not possibly explain the highly raised overrepresentation of deathsof African-Caribbean males in custody.
This over-representation of Afro-Caribbean males is also evident in mental health settings.
The Mental Health Act Commission (2006) one day census found that Afro-Caribbean malesare three times more likely to be admitted to hospital and 44 percent more likely to besectioned under mental health legislation.
An abnormally enlarged heart has been reported as one of the predisposing factors that canlead to restraint-related death (Laposata, 2006; Southall et al., 2008). This abnormality hasbeen linked to chronic stimulant drug abuse (Schmidt and Snowden, 1999). In O’Halloranand Frank’s (2000) study of 21 cases of restraint-related deaths, on autopsy, 15 had heartdisease including an enlarged heart. Byard et al. (2008) stipulate that:
There may certain cases where underlying organic illness, such as cardiovascular or respiratorydisease is present that may be either unrelated to the terminal episode or, alternatively, may havepredisposed to positional asphyxia.
Chronic cocaine misuse has been found in a recent study (Aquaro et al., 2011) to lead tocardiac structural involvement which could lead to cardiac damage and become evidentlater in life. The researchers found that 83 per cent of people using cocaine over long periodshave suffered major structural damage to their hearts.
Post ictal aggression in epilepsy can occur when physical restraint is applied to a delirious orconfused patient. In particular, this can lead to a vicious circle of attempts to restrain andresulting resistive violence with fatal results (Devinsky, 2003).
Sudden unexpected deaths in epilepsy (SUDEP) may be caused by respiratory events,including airway obstruction. In addition, cardiac arrhythmia, during both the ictal andinterictal periods, leading to arrest and acute cardiac failure, play an important role(Harrison and Asplund, 2007). The additional factor of extreme exercise as in struggling inrestraint is therefore still unknown although in the UK one patient (Godfrey Mayo) died afterbeing restrained during a seizure:
It is currently unknown whether or not epileptics are more vulnerable to SUDEP if they choose toengage in vigorous physical activity. However, one could postulate that as physical exertion canlead to dehydration, electrolyte imbalances, hyperventilation secondary to increased oxygen
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demand, and hyperthermia – all of which are well known to decrease the seizure threshold in anepileptic (Harrison and Asplund, 2007).
In diabetes low blood sugar may precipitate sudden mood swings that could appear assudden anger or crying, sweating, nervousness, rapid heartbeat, confusion, and seizures.
Aggressive behaviour may appear similar to acute behavioural disturbance (ABD)(Padder et al., 2005).
The physiology of deaths under restraint in any setting where there is a duty of care, isdifficult to investigate as internationally the numbers of restraint-related deaths are small andclassification by pathologists varies in different countries. Findings from experimentalstudies are not completely valid as there is limited generalisabilty to the real physicalrestraint situation, they are run in a laboratory setting in controlled conditions and there is asubject selection bias as most subjects are healthy volunteers.
Ventilation in a healthy human involves two key factors: movement of the ribs by theintercostal muscles and movement of the diaphragm (Parkes, 2000; Reay et al., 1992). Thechest expands and the diaphragm contracts, drawing air into the lungs (inhaling). The ribsand diaphragm then relax, releasing air from the lungs (exhaling). When an individual isrestrained or contained in a prone position, three things happen that compromise the body’sability to breathe:
1. There is possible occlusion of the respiratory orifices (Belviso et al., 2003).
2. There is a compression by weights or restriction to movement of the ribs limiting their
ability to expand the chest cavity and breathe (Parkes, 2000; Stratton et al., 2001).
3. The abdominal organs may be pushed up, restricting movement of the diaphragm and
further limiting the available space for the lungs to expand (Parkes, 2000; Reay et al.,1992).
Consequently, even without any other contributing factors, simply restraining an individual ina prone position may be seen as restricting the ability to breathe, so lessening the supply ofoxygen to meet the body’s demands. Restriction of the neck, chest wall or diaphragm canalso occur when the head is forced downwards towards the knees. Asphyxia as a result ofrestriction under restraint has also been called ‘‘restraint asphyxia’’.
Parkes (2002) postulated that breathing can be reduced by 15 percent in a face downposition and by 23 percent if the person is bent in a face down position. Paterson andBradley (2010) state that the prone position is actually a range of procedures incurringpossible risks:
These multiple versions of prone actually share only one variable, which is that the individual isheld against resistance face down either by being physically held, via control of the limbs, theapproach most commonly used in the UK.
Excited delirium and acute behavioural disturbance
The state of excited delirium has been described as an agitated, aggressive, paranoidbehavioural disturbance where the individual also has great strength and numbness to pain(Paquette, 2003). It is a form of ABD:
Of all the forms of acute behavioural disturbance, excited delirium is the most extreme andpotentially life threatening (Faculty of Forensic and Legal Medicine, 2010).
Fatal excited delirium was first described in seven cocaine users between April 1983 andMay 1984 in the USA (Sztajnkrycer, 2005). Incidence of increased drug-related deaths alongwith violent behaviour and use of restraints has coincided with increased cocaine use in theUSA (Grant et al., 2007). However, the exact incidence of excited delirium is impossibleto determine as there is no current standardised case definition to identify this state
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(American College of Emergency Physicians, 2009). It is currently not a recognised medicalor psychiatric diagnosis according to either the Diagnostic and Statistical Manual of MentalDisorders (DSM-IVTR) of the American Psychiatric Association or the InternationalClassification of Diseases (ICD-9) of the World Health Organization (Samuel et al., 2009).
There are relevant research findings which have been published, mostly from the USA. In areview of excited delirium deaths during custody, victims were predominantly male(97 percent), had an average weight of 220 lbs. and a mean body temperature of 1048F (Ross,1998). Mash et al. (2009) found that victims were young (mean age 34.2), males, with a highbody mass. Mean body temperature was 40.78C, seizures were observed in 13 percent ofcases. Many of the deaths occurred one hour after initial police contact, cardiac arrestoccurred shortly after use of restraints.
The most striking feature of the excited delirium syndrome is the extreme hyperthermia(Bunai et al., 2008). Struggling while being restrained will also raise body temperature:
Being placed in police custody prior to death can also raise body temperature through increasedpsychomotor activity if the victim struggles in the process (Mash, 2007).
Otahbachi et al. (2010) found that the pathogenesis of excited delirium deaths was multifactorialand included positional asphyxia, hyperthermia, drug toxicity and/or catecholamine-inducedfatal arrhythmias. These deaths, he concluded, were secondary to stress cardiomyopathy.
Sudden death in adults, particularly young adults who are asymptomatic, may occur from theonset of ventricular tachycardia (a type of rapid heart rate) or other dangerous arrhythmias.
A genetic factor appears to influence which people with hypertrophic cardiomyopathy aremore prone to sudden death. In restraint-related deaths, extreme physiological stress andsudden exercise, e.g. violence and struggling, in an individual with genetic predisposingfactors, may result in fatal hypertrophic cardiomyopathy as has been seen in the suddendeath of young athletes (Maron et al., 1996; Frenneaux, 2004).
Recent research (Ho et al., 2009) indicates that physical struggle is a much greatercontributor to catecholamine surge and metabolic acidosis than other causes of exertion orstimuli. Michalewicz et al. (2007) saw catecholamine hyperstimulation as one of the riskfactors of restraint-related deaths.
Hick et al. (1999) found in five cases of sudden death that there may have been exacerbationof exercise-induced lactic acidosis by sympathetic-induced vasoconstriction, enhanced bythe actions of cocaine in at least some cases. Alshayeb et al. (2010) also noted that peopleexercising intensely, who are highly aggressive and then restrained, and have takencocaine, may develop lactic acidosis and subsequently suffer cardiac arrest. This process istypically not responsive to advanced cardiac life support.
Alcohol abuse is a predisposing factor for violence and aggression. Sudden death of anindividual with a history of alcohol abuse, and under the influence of alcohol, may occur duringa struggle. Alcohol is a recognised cause of a variety of atrial and ventricular arrhythmias.
A prolonged QT interval, a problem associated with sudden death, as well as increased levelsof norepinephrine may be present in prolonged alcohol abuse. These predispositions toarrhythmias can be exaggerated by catecholamines released during a violent struggle.
Paterson et al. (2003a, b) found that administration of neuroleptics increased the risk ofdeath during restraint by weakening the individual’s ability to swallow or expel leading to anincreased risk of the inhalation of vomit. In large well-conducted population studies the risk
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conferred by QT prolongation when taking antipsychotics, particularly thioridazine,droperidol, sertindole and ziprasidone, appears to be a modest increase in mortality andsudden death. Co-morbid physical illness, especially cardiovascular disease, is a furtherrisk factor (Abdelmawla and Mitchell, 2006).
Psychotropic medication given (pro re nata (p.r.n) or as required) has been noted asfrequently given for agitation or aggression in addition to prescribed antipsychotics withfurther risks of side effects and long-term implications to health (Joukamma et al., 2006).
Baker et al. (2008) found that p.r.n medication was an under-researched intervention andside-effects were not closely monitored:
Typical antipsychotic PRN undoubtedly contributes to antipsychotic polypharmacy and highdoses that individuals may receive.
After reviewing the comparisons of restraint-related deaths in the UK from 1999 to 2010 withthe literature available and then benchmarking the findings with expert opinion, it is evidentthat those in vulnerable groups when restrained in a prone position, or in a basket hold, for aprolonged period and who are agitated and resistive, are most at risk. The findings of thisresearch demonstrate that there are no absolute safe restraint positions. Mechanicalrestraints, fixation, confining the limbs to bed or a chair (as used in parts of Europe) all haverisks such as deep venous thrombosis (de Hert et al., 2010). Seclusion may be seen as theleast harmful method of managing a violent individual. However, this will be likely to mean theindividual has to be restrained first with the concomitant risks:
Getting a violent individual into seclusion against his/her will almost invariably involve some formof physical intervention and mechanical restraint as observed is clearly not without its own risks(Paterson and Bradley, 2010).
There is also no safe time limit for duration of any restraint; staff must be aware during anyphysical intervention of the signs of a medical emergency and have life support skills andequipment to respond to any emergency. They also need to bear in mind that cessation ofaggression may indicate collapse rather than the individual’s co-operation.
Early warning predictors and markers should be noted by staff for those who are becomingunwell with a pre-existing condition before potential collapse. Assessment of othervulnerabilities, such as mental health status, must be carried out by trained personnel incustodial settings. Consistency in reporting relevant deaths locally and nationally isnecessary to facilitate analysis of key information and prevent deaths in the future. NHSreporting systems (Mental Health Minimum Data Set Version 4.0, National Health ServiceConnecting for Health, 2011) now include recording restraint incidents; restraint-relateddeaths should also be a mandatory category.
1. Physical restraint is defined in this article as the lawful use of force involving the restriction of
2. David Bennet, a 38-year-old black man who died in the Norvic clinic in Norwich in October 1998. He
was restrained by at least three staff after attacking a female member of staff and his heart stoppedduring the restraint.
3. Deaths following police contact that are subject to an IPCC independent investigation.
4. When the state takes away the individual’s liberty and places him in custody or under the mental
5. For example, a previous death in 1995 of Zoe Fairley, a young woman with intellectual disabilities
suffocated and died when restrained face down for 50 minutes.
6. Atypical (second generation) antipsychotics are used in the acute phase of schizophrenia and
related psychoses and for long-term maintenance and prevention of relapse.
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There are no absolute safe restraint positions; mechanical restraints, fixation, confining the limbsto bed or a chair (as used in parts of Europe) all have risks such as deep venous thrombosis (deHert et al., 2010). Seclusion may be seen as the least harmful method of managing a violentindividual. However, this will be likely to mean the individual has to be restrained first with theconcomitant risks. There is also no safe time limit for duration of any restraint; staff must be awareduring any physical intervention of the signs of a medical emergency and have life support skillsand equipment to respond to any emergency. They also need to bear in mind that cessation ofaggression may indicate collapse rather than the individual’s co-operation. How ‘‘hazardous’’a restraint position is may be quite individualised, depending on characteristics of the personheld, the length of time, the forcefulness of the hold and a range of other factors including factorssuch as the levels of stress. Early warning predictors and markers should be noted by staff forthose who are becoming unwell with a pre-existing condition before potential collapse.
The end point of physical interventions is to return the individual to normative behaviours. Thereshould be use of a range of options to achieve this, e.g. time out, medication, with ongoingevaluation of effectiveness.
Consistency in reporting relevant deaths locally and nationally is necessary to facilitate analysis ofkey information and prevent deaths in the future. NHS reporting systems (Mental Health MinimumData Set Version 4.0) now include recording restraint incidents; restraint-related deaths shouldalso be a mandatory category.
Staff training in all services needs to include immediate life support skills as a minimumcertification level and advanced skills as a maximum level (for those working in emergencydepartments and acute medical admissions and paramedics). These skills and course providedto develop them are laid out by the Resuscitation Council (UK) (www.resus.org.uk/siteindx.htm).
There needs to be dissemination of medical theories into practice, e.g. dangers of restraint in aseating position. It is also about managing those risks. Effective training is about the cycle ofdecision making.
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