Do no harm? Use of restraint in mental health inpatient care

It also marks two years of the government failing to implement this vital piece of legislation so that children and adults are protected from excessive and abusive use of force.

Seni’s Law was proposed by Steve Reed, the MP for Croydon North, after the appalling death of his constituent Seni Lewis in 2010. 

Aged just 23, Seni died after being restrained on a mental health ward by 11 police officers. The inquest into Seni’s death found that the restraint used was excessive, unreasonable and disproportionate and Seni's family have campaigned tirelessly since to change the law around the use of force.

Seni’s Law requires mental healthcare providers to actively take steps to reduce the use of force against patients, including by providing better training on managing difficult situations, and to keep records on the use of force. 

Each mental health unit should publish its policy on the use of restraint and designate a person responsible for implementing the policy.

But we are still waiting for the statutory guidance necessary to support implementation of the Mental Health Units (Use of Force) Act before it has any effect. 

Over the summer the parents of Seni Lewis alongside other campaigners, wrote to the mental health minister, Nadine Dorries, calling for the government to set a commencement date for the Act as soon as possible.

This lack of progress is all the more alarming in light of the continuing misuse of restraint on children and young people in mental health inpatient care. 

Restraint should already be a last resort and “proactive, preventative, non-restrictive approaches adopted in respect of behaviour that challenges”. 

Yet, in England in 2018/19, a staggering 1,049 children and young people aged under 20 were subject to ‘restrictive intervention’ with a total of 32,221 interventions used (an increase of over 5,000 on the previous year). 

This included physical and chemical restraint, seclusion and segregation. Over a third (369) of the children and young people were subject to prone (face down) physical restraint, a particularly harmful and dangerous form of restraint that government guidance on the treatment of adults states should not be used at all.

It is notable that official data does not separately report on the use of force on children, which was one of several things charities lobbied for during the passage of the 2018 Act.

Children and young people who are distressed, in pain or frustrated with situations or rules they do not understand are not always able to communicate this verbally and directly; these feelings often show themselves in behaviour. 

It takes skilful and well-supported staff, working within a positive human rights framework, to stop coercive cultures emerging, where children’s actions and forms of communication are perceived as ‘bad’ and wilful, and physical forms of control become accepted and normal – as the only way to deal with ‘challenging behaviour’. 

In May 2020, 55 children with learning disabilities and/or autism were subject to 845 (recorded) instances of restraint, including 85 instances of prone restraint used on 20 children. 

Had it been implemented, Seni’s Law could have helped to avoid these incidents by ensuring staff receive appropriate training and support and by driving wider cultural change. 

Last month’s report from the Care Quality Commission Out of sight – who cares?, looked at the use of restraint, seclusion and segregation for autistic people, and people with a learning disability and/or mental health condition. 

Reviewing the experiences of both children and adults, the CQC found “too many examples of undignified and inhumane care, in hospital and care settings where people were seen not as individuals but as a condition or a collection of negative behaviours. The response to this has often been to restrain, seclude or segregate them”. 

Low-quality care was often due to staffing and inadequate training, and a lack of individual care planning. 

As part of Article 39’s research on the experiences of children in mental health units, independent mental health advocates have highlighted the extent to which inappropriate (potentially unlawful) use of restraint is not followed up by healthcare providers, even when formal complaints are made. 

As the government recognises, the use of restraint and restrictive interventions can be painful, traumatising, and indistinguishable from abuse and violence. It can have long-term consequences on the health and wellbeing of children and young people. It can be life-threatening. 

Seni’s Law will help reduce the use of force and ensure that children and young people in inpatient care are kept safe and treated with respect, dignity and compassion but only if the government treats this issue with the urgency it demands.

Kamena Dorling is head of policy and advocacy at Article 39