Illustration: RESTRAINT ASPHYXIA – SILENT KILLER
UK: In May, 24-year-old Azrar Ayub, a patient at the Edenfield secure mental health unit, part of Prestwich hospital near Manchester, died after being restrained by hospital staff.
It was a tragic reminder of the death of the 38-year-old mental health patient David "Rocky" Bennett in similar circumstances in a Norwich hospital in 1998. Bennett's death caused a public outcry and resulted in an official inquiry, which led earlier this year to the issuing by the National Institute for Clinical Excellence (Nice) of new guidelines on the use of restraint.
So why, six years after Bennett's death, does it appear that deaths as a result of restraint are still occurring?
First, the big picture. There were 116,000 incidents involving violent or verbal abuse in the NHS in England and Wales in 2002/03. About half were in mental health settings. Many of these would have involved a patient being restrained. It is generally believed that deaths caused by restraint are rare, but there are no reliable figures on injuries or deaths.
Restraint is often regarded by mental health nurses as a vital, if undesirable, measure of last resort for dealing with violence on wards. Establishing why some techniques might lead to injury or death is not easy. Each individual case is different, and a range of factors need to be taken into account - for example, whether staff were trained properly or whether the technique had been applied incompetently.
The Nice guidelines were designed to help guide staff and trusts on what is acceptable, but have been criticised for not going far enough to protect vulnerable mentally ill people against, in particular, prone restraint, where the patient is held face down, and which risks death from asphyxiation.
At a conference called Care or Abuse? last week in Derby, more than 100 mental health professionals, trainers, educators and service users discussed and challenged some of the most controversial and questionable restraint methods. During one dramatic presentation, a former mental health service user recounted - at times in tears - what it was like to come close to death while being held face down on the floor by four nurses when she suffered a "psychotic episode" in 2003.
One mental health trust director called for a ban on methods that, in his view, caused distress or pain to patients. He claimed that at his trust, such methods had been abandoned, leading to a cut in the number and severity of violent incidents. But he was accused by one delegate (a restraint trainer) of being sensationalist. Their exchange illustrated that even after the Bennett inquiry and the Nice guidelines, there is still a fissure in the mental health establishment over what is and what is not ethical and acceptable practice when it comes to restraint.
The conference shed light on why some forms of restraint remain problematic. Some acute mental health services in the UK are managed badly and are short of cash and staff, putting extraordinary pressure on nurses to react to incidents by restraining patients rather than talking to them to defuse potentially violent situations. These difficulties are exacerbated because trusts do not agree on which restraint methods to use or when to apply them.
There are around 2,500 restraint techniques currently being taught by a multitude of private companies, but there has never been a national evaluation to standardise training. Some research has been conducted but it is patchy and the results are far from conclusive. The Department of Health has plans to collect more accurate figures on injuries and deaths caused by restraint, but scepticism persists over their reliability because of fears of under-reporting.
In the absence of robust evidence on physical restraint or injuries caused by it, we are gambling with the lives of some of the most vulnerable people in our society. It is a matter of urgency that we identify what works, what does not, and that we act on it.
By Mary O'Hara posted 27 October 05
Ohio's Abu Ghraib
In January 2001, Charles Austin and 28 other prisoners filed a lawsuit claiming that Ohio had violated their Eighth Amendment rights. The prisoners argued that medical and psychiatric care and recreation were inadequate at the supermax, and physical restraints were too harsh. Prisoners received medical injections through their narrow food slots, for example, and had both hands handcuffed to the wall during medical exams.
Abu Ghraib, USA
In another incident reported by Amnesty International that happened during McCotter's watch, an inmate at the Utah State Prison "was shackled to a steel board on a cell floor in four-point metal restraints for twelve weeks in 1995. He was removed from the board on average four times a week to shower.
On Solitary Confinement
I have witnessed prison guards from 2002 to 2004, while I was in Angola's even more restrictive punishment unit, who have thrown buckets of ice water (in winter) on men who were in 4- point restraints, wearing only paper gowns.