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Review of medical theories on restraint deaths published

Caring Solutions (UK) Ltd have published their review of the medical theories and research behind restraint deaths.  At the Ministerial Board on 4 March 2010, the IAP presented its progress report on the physical restraint workstream.  This contained three recommendations, one of which was to commission an analysis of the medical theories and research relating to restraint related deaths, given the significant debate which surrounds the subject. Following an open procurement exercise, Caring Solutions (UK) Ltd, in conjunction with the University of Central Lancashire was awarded the work in February 2011.   The report evidences that certain groups are more vulnerable to risks associated with restraint – both intrinsically, and because they are more likely to be restrained. These groups are those with serious mental illness or learning disabilities, those from Black and Minority Ethnic communities, those with a high body mass index; men age 30-40 years and young people (under the age of 20).  The report also highlights the following medical concepts and theories:

  • Positional asphyxia
  • Excited delirium
  • Acute behavioural disturbance
  • Pre-existing conditions
  • Stress related cardiomyopathy
  • Thromboembolic disease
  • Catecholamine hyperstimulation
  • Acidosis
  • Alcohol abuse
  • Neuroleptic medication
  • Neuroleptic malignant syndrome
  • Serotonin syndrome
In terms of next steps, the Panel are particularly interested in focussing on the following key issues which are highlighted in the report: Reporting mechanisms on restraint At an expert seminar in June 2011, involving key medical and legal practitioners, there was a consensus on the under reporting and recording of restraint deaths in state custody.  This was particularly acute for secure in-patient health settings.  The Panel will meet with the Department of Health and CQC in the coming months to discuss this issue. Mental health awareness  The Panel believe that the interface between the police and mental health settings could benefit from greater focus.  This interface can cause difficulties in identifying clear lines of authority, accountability and awareness on who should apply the restraint.  The Panel believe that there would be value in joint working initiatives between the police and mental health trusts, similar to the one undertaken by Leeds Partnerships NHS Foundation Trust and West Yorkshire Police in 2008.  This collaboration allowed trainee police officers to shadow a mental health setting in the Trust, which helped increase understanding of each service’s roles as well as a greater understanding of the challenges of dealing with mental illness from both staff groups’ perspectives. The Panel will discuss with the Department of Health and the Association of Chief Police Officers on how this could be taken forward. Restraint reduction programs The use of de-escalation during a restraint incident is acknowledged as an intervention in the prevention, management and reduction of violence and aggression within custodial settings.  De-escalation techniques, which can include verbal and non-verbal communication skills, are usually deployed once the restraint dynamic is in progress. Pilot programmes in the U.S. and Australia have sought to avoid the need to use restraint altogether.  Studies trialling the use of restraint reduction programmes, which advocates the elimination of restraint, have been used in a number of U.S. mental health settings.  The studies showed that in a three year period for one hospital, there was a 90% reduction in the use of restraint.  The IAP acknowledges that there has been no similar study in the UK to look at these programmes and that the need to avoid the use of restraint may not be reasonable in some situations.  There would, however, be value in custody sectors considering whether they could run similar pilots to identify whether restraint reduction programmes could form a key part of their restraint training packages.  The IAP will discuss this suggestion with key stakeholders.


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