Mechanical restraint for children banned in inpatient mental health settings

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The Mental Health Commission has issued a ban on the use of mechanical restraint for children, following a comprehensive review and consultation process on the rules and code of practice governing the use of restrictive practices in inpatient mental health settings in Ireland.

The outcome of the review, which began more than 18 months ago, sees the introduction by the MHC of new rules for seclusion and mechanical restraint, and a new code of practice for physical restraint, all of which will come into force on January 1, 2023.

The new rules include an outright ban on mechanical means of bodily restraint for children, including the use of hand and leg cuffs. They will also require all public and private services to publish information about their efforts to reduce and, where possible, eliminate the use of restrictive practices.

The new rules and code were published at the end of September, in tandem with the 2021 Restrictive Practices Activities Report, which documents the use of these practices across 67 inpatient mental health centres in Ireland in 2021. Although the report showed that there had been a substantial reduction in episodes of restraint and seclusion since 2020, the MHC said the purpose of the new rules and code of practice was to bring about further improvements and ensure that these practices were only used in exceptional circumstances.  

The MHC said that in addition to carrying out a rigorous review of the published national and international academic evidence, the MHC also met and spoke with people who had experienced restrictive practices, as well as staff and clinicians in mental health services.

“It is clear from the evidence and from the people who took part in our review that restrictive practices are not therapeutic and, indeed, have the potential to cause very serious physical and psychological harm,” said the Director of Regulation for the Mental Health Commission, Gary Kiernan. “As well as physical injuries, the use of these interventions may increase the risk of trauma and trigger symptoms associated with previous experiences of trauma. Therefore, they must only be used in rare and exceptional circumstances as an emergency measure to keep the person or those around them safe.

“The published evidence shows that children and young people are particularly vulnerable to trauma and injury as a result of these practices.
We have paid particular attention to this area, and introduced a number of new provisions to protect children, including a complete ban on mechanical means of bodily restraint for children.”

“The point of the revised rules is that we want to ensure that services intervene with restrictive practices only when absolutely necessary and prioritise positive engagement and empowerment of the person to regain self-control,” said Mr Kiernan. “We believe that our requirement for services to publish information about their efforts to reduce and eliminate these practices will help to hold organisations and their leaders to account.

“Many Irish mental health services have already successfully adopted this approach. They have shown – particularly over recent years – that they are actively working to reduce restrictive practices. The MHC’s 2021 activity report shows further significant reductions in episodes of seclusion and physical restraint. However, we need to see further reductions and a continuation of this downward trend in line with contemporary and international best practice.”

The Chief Executive of the Mental Health Commission, John Farrelly, said that although restrictive practices might, on occasion, be necessary to maintain safety in the day-to-day environment of an acute mental health service, the MHC still expected to see reductions in the use of these practices from 2023.

As with the current rules and code of practice – which came into effect on January 1, 2010 – the revised rules and code will be applicable to all inpatient mental health services in the public, voluntary and independent sectors from January 1, 2023.  

The MHC has documented the use of restrictive practices across 67 inpatient mental health centres in Ireland in 2021. It showed that there were a total of 4,636 episodes of seclusion and physical restraint recorded nationally, which involved 1,790 residents of approved centres. This represented a decrease from 2020, where there were a total of 5,830 episodes of seclusion and physical restraint, involving 1,880 residents.

In 2019, there were a total of 6,747 combined episodes of seclusion and physical restraint, involving 1,803 residents. The use of mechanical restraint also decreased in 2021 in comparison to 2020, and its use as a restrictive practice in approved centres remained low.

In terms of intervention types, there were 3,460 episodes of physical restraint in 2021. This represented a decrease from 3,990 episodes in 2020 and a significant decrease compared to 5,029 episodes in 2019. A total of 1,145 people were physically restrained in 2021, compared to 1,211 residents in 2020. In 2021, a total of 287 hours and 16 minutes of physical restraint were reported nationally, significantly lower than in both 2020 (402 hours 20 minutes) and 2019 (632 hours 53 minutes).

Physical restraint was the most frequently used of the restrictive interventions monitored by the MHC. It was used in the majority of approved centres and accounted for 75% of monitored restrictive interventions in 2021, excluding mechanical restraint. This compared to 68% and 75% of restrictive interventions in 2020 and 2019 respectively.

Seclusion accounted for 25% of restrictive interventions in 2021, compared to 32% in 2020 and 25% in 2019. There were 1,176 episodes of seclusion reported by 27 approved centres in 2021, a large decrease from the 1,840 episodes reported by the same number of services in 2020. This represents a significant reduction in seclusion episodes between 2020 and 2021.

A total of 645 people were secluded in 2021, a decrease from the 699 people secluded in 2020. Seclusion was used in 40% of approved centres in 2021, compared to 41% in 2020. The duration for a single episode of seclusion in 2021 ranged from 3 minutes to 8,759 hours (1 year).

In 2021, 6% of episodes of seclusion lasted for longer than 72 hours, higher than in both 2020 and 2019 (4%). Fourteen approved centres recorded episodes of seclusion lasting 72 hours or longer in 2021, compared to 13 in 2020 and 12 in 2019. The data indicated that while the number of episodes of seclusion decreased between 2020 and 2021, the duration of seclusion episodes increased.

The use of mechanical restraint continued to be relatively uncommon. In 2021, only one approved centre, the Central Mental Hospital, reported the use of mechanical restraint (25 episodes). The minimum duration of mechanical restraint was 17 minutes, and the maximum duration was four hours. Handcuffs were used in all episodes. “In 2021, episodes of mechanical restraint to prevent an immediate threat to the self or others had a total duration of 49 hours and 14 minutes. This is a significant decrease on the total duration for 2020, which was approximately 3,452 hours,” said the report.

The report also examined some of the published activity data from 2008 to 2020 in order to identify trends. The MHC said, “There has been a general increase in the number of physical restraint episodes between 2008 and 2021, with a sharp increase in 2017 and 2018, followed by a decrease in 2019, 2020 and 2021. The number of residents experiencing physical restraint has increased slightly between 2008 and 2021. The increase in physical restraint episodes may be a result of increased numbers of resident admissions.

“Seclusion episodes have generally decreased since 2008, with the number of residents undergoing seclusion remaining relatively static. The reduction in episodes and number of residents undergoing seclusion may be as a result of approved centres implementing measures to reduce and avoid these practices, such as the MHC’s ‘Seclusion and Restraint Reduction Strategy’.”