Care & Support Services - Safeguarding Standards

Control

Control

Any individual with a learning disability may, at some point in their life, undergo physical restraint to minimise risk of harm to either themselves or another person.

Physical intervention is only used in response to challenging behaviour and restricts the movement and mobility of the person concerned.

Each social care facility, as part of best practice, should have in place policies which reflect current legislation and case law, as well as government guidance and professional codes, as to when an individual requires control or restraint.

This section explains:

- What is perceived as permissible forms of control
- Legal definitions of restraint
- Use of physical interventions and restrictions
- Policies
- Staff training
- Impacts on staff

The relative merits of different approaches to restraint are not explored here, but reference is made later to a training accreditation programme run by the British Institute of Learning Disability (BILD).

Formal description of physical intervention or control and restraint

In considering physical intervention and managing challenging behaviour, BILD uses the following definition:

Physical intervention is: "A method of responding to the challenging behaviour of people with a learning disability and/or autism, which involves some degree of direct physical force, which limits or restricts the movement and mobility of the person concerned".

BILD also states, "50 percent of people with intellectual disabilities and challenging behaviour will have physical interventions used on them at some point in their lives".

A Consumer View

The Blofeld Report (2004), also known as 'The inquiry into the death of David Bennett', reported on the circumstances surrounding the death of psychiatric inpatient David Bennett. Amongst its findings were specific recommendations regarding restraint (see later). Shortly after the release of this report, Phillip Davis, who was a former mental health nurse and hospital patient, described his own perceptions of being restrained in the Mental Health Nursing Journal (May 2004):
"For me the real issue is not so much about restraint per se, but about restraint carried out by people who think restraining a patient is not a violent act. There may be times when it is a necessary violent act, but it is always a violent act. A person who knows this, and believes violence to be basically wrong, will strive to minimise the violence. A person who thinks restraining a patient is not a violent act will not. They will also not understand why someone would be upset by being restrained and will not be in a position to deal with that upset in a positive way".

Legal context

It is a criminal offence to use physical force, or threaten to use force, unless circumstances give rise to lawful justification for the use of that force. Ultimately, the inappropriate use of physical intervention may give rise to an action in either criminal or civil law if it results in physical injury or psychological trauma to an individual.

The Mental Health Act Commission, reporting to Parliament at the 'Joint Committee on Human Rights - Third Report' (December 2004) on 'Restraint and Seclusion', estimated that one patient per annum had died over the last seven years whilst restraint was being administered. The Commission had previously reported in 2001 in their document 'Deaths of Detained Patients', that between 1997 and 2000 two people had died whilst under restraint and four people had died within 24 hours of the incident. There were also 22 instances in which restraint had been used in the week prior to the death of the patient.

The Joint Committee on Human Rights (as above) also says of restraint:
'Human rights standards and the principle of proportionality require that any form of physical restraint should be a last resort. Staff should therefore be equipped with a range of skills to deal with and de-escalate potentially violent situations, as well as a range of restraint techniques that will allow for use of the minimum level of force possible. Restraint in detention should be a rare event and should never be used as a matter of routine'.

This is clearly saying that the scale and nature of any physical intervention must be proportionate to both the behaviour of the individual to be controlled and the nature of the harm they might cause. The use of force must be the minimum necessary.

To assist with providing safer services, the Department of Health and the Department for Education and Skills issued a guidance document for schools and care settings in the field of learning disabilities in July 2004. The document was called 'Guidance for Restrictive Physical Interventions - How to provide safe services for people with learning disabilities and Autistic Spectrum Disorder'. This guidance was extensive and included contributions regarding:
- Definitions of physical interventions
- Legality
- Risk assessment
- Proactive and emergency use of physically restrictive interventions
- Policies and recording of information
- Post-incident management
- Staff training and implementation
Such Government guidance was prepared in the context of The Human Rights Act (1998) (please click here to see separate section on rights in this website) and the United Nations Convention on the Rights of the Child (ratified 1991).

The Human Rights Act (1998) states a person has a number of rights including, for example:
- Right to liberty and security
- Right not to be subjected to inhuman or degrading treatment
- Respect for private life
- Right not to be discriminated against
Further legal responsibilities are placed on staff who are deemed to have a 'duty of care' and are required to take reasonable measures to safeguard from harm the people they are looking after. From an employer's perspective they are responsible for the health, safety and welfare of their employees in the working environment.

The use of force with physical intervention is likely to be only legally defensible when it is required to prevent:
- Self harm
- Injury to others
- An offence being committed
- Damage to property

Use of physical interventions and restrictions

Physical interventions can be employed in difficult situations to achieve a number of different outcomes:
- To break away or disengage from dangerous or harmful contact
- To separate a person from a 'trigger' setting which is likely to set off a course of events
- To protect someone from a dangerous situation

Physical interventions can also be considered as either:
- Planned interventions, where staff employ pre-arranged strategies and methods. An identified staff member who has undertaken appropriate training provided by an accredited organisation in Restrictive and Physical Interventions will lead in this case. The intervention strategies will have evolved from multi-disciplinary or team working and after appropriate risk assessment. Documentation will be clear about the requirement for such measures and how they address the needs of the individual. Such plans will be a formalised part of a person's care plan.
- Emergency or unplanned interventions, which are a response to unforeseen events.

Policies

The starting point for establishing good practice in the use of physical or restrictive interventions is the development of organisational policies which reflect current legislation and case law, as well as Government guidance, professional codes of practice and local circumstances.

Agencies are expected to have a policy on the use of physical and restrictive interventions. The amount of detail needed will depend upon local circumstances, but would be expected to cover areas such as (Section 10.8 - Guidance for Restrictive Physical Interventions):
- Strategies for preventing the occurrence of behaviours which precipitate the use of a physical intervention
- Strategies for 'de-escalation' or 'defusion' which can avert the need for a physical intervention
- Procedures for post-incident support and de-briefing.

The concept of reasonable force where 'reasonableness' is determined with reference to all the circumstances, including:
- The seriousness of the incident
- The relative risks arising from using a physical intervention compared with using other strategies
- The age, cultural background, gender, stature and medical history of the service user concerned
- The application of gradually increasing or decreasing levels of force in response to the person's behaviour
- The approach to risk assessment and risk management employed
- The distinction between seclusion, time out and withdrawal
- The distinction between planned physical interventions (where incidents are foreseeable) and the use of force in emergency situations (which cannot reasonably be anticipated)
- First aid procedures to be employed and those responsible for implementation in the event of an injury or physical distress arising as a result of a physical intervention
- Policies should clearly describe unacceptable practices that might expose service users or staff to foreseeable risk of injury or psychological distress

Post-incident management

Following an incident and when composure has been recovered, both staff and users should be given separate opportunities to talk about what happened. This process should be designed to discover exactly what occurred and not to apportion blame; it should also be a transparent one and include consultation with family and advocates.

Staff training

Staff should have induction training before beginning to care for people who present challenging behaviour. Training should make explicit reference to the values which underpin its programme. Those staff who are expected to employ restrictive physical interventions will require additional and more specialised training. There should be regular updates for those who have undergone previous training.

The Department of Health and the Department of Education and Skills have been working with BILD to establish an accreditation scheme for those who offer training on physical interventions.

Minimising risk and promoting well-being

Risks to a person being restrained can be seen to increase with regard to a number of factors. Two of those appear particularly significant and deserve some further comment, namely the use of 'prone position' and 'excited delirium'.

Use of the prone position

There has become increasing concern about a person being in the prone position (lying face down on the floor) whilst being under restraint. The Blofeld Inquiry into the Death of David Bennett (2004) saw it important to recommend that people should not be restrained in the prone position for longer than three minutes.

Prone restraints are considered dangerous because:

- The mechanisms of breathing (diaphragm, muscles of the chest wall) are physically restricted which can cause positional asphyxia. This is significantly increased if pressure or weight is applied to a person's chest or back
- There is a reduction of the amount of air that can be ventilated
- The prone position potentiates other risk factors, i.e. obesity, other medical conditions

Excited or agitated delirium

This is where a state of high mental and physical arousal exists. Extreme exertion and struggle can produce lactic acid and acidosis which, if not cleared effectively by the body, can lead to cardio-vascular complications and potential collapse.

The psychological consequences to experiencing restraint can be enormously traumatic for anyone (witness Phillip Davis comments earlier) but the implication for individuals with a learning disability or autism may be even greater. Some people from this client group can experience hyper-stimulation or may have experienced physical abuse in the past and then they may find the situation so horrifying they may risk struggling to the point of exhaustion. This reaction is considered similar to a physical state technically called 'capture myopathy'.

Impacts on staff

Employers have a duty of care to their staff and, despite the training they may have been given, it is important to understand that being involved in physical restrictive procedures can be distressing for them. Post-traumatic experiences can be an issue for staff on occasions, especially if they have been injured or involved in managing a particularly violent episode. It is therefore essential that post-incident support should recognise their needs along with others.