Prone restraint in mental health hospital

My partner and I recently finished Season 4 of Orange is the New Black (highly recommend), and one episode particularly resonated with me. In fact, it made me cry, and I’m not a crier.

The episode centred around an inmate named Poussey, who, in the midst of an ‘incident’ within the prison, was forcibly held to the ground by a prison guard for an extended period of time, whilst the prison guard was being tackled by another inmate.

My partner had no idea what the result of this act would be. I knew, through my work within Public Law and mental health, and I knew that the use of such restraint can bring about death.

Prone restraint is where a person is held to the ground in a face-down position and is physically prevented from moving from that position. Too much force and the result can be fatal. The concern is that prone restraint can result in dangerous compression of the chest and airways, thus placing the person being restrained at a huge risk.

The majority of NHS Trust policies on the use of such restraint suggest that it ought to be used only as a last result, following unsuccessful attempts at de-escalation. Unfortunately, I am aware of incidents where prone restraint appears to be used as a first port of call, often on those with severe learning disability, and often in mental health hospital.

I appreciate that professionals within such a setting must keep themselves, the service user and other patients’ safe, but it is frightening that use of prone restraint remains commonplace, and remains the norm, despite policy suggesting that it should be used only in the most extreme circumstances.

There is a reason that prone restraint ought to be used as a final option – in 1998, a 38 year old gentleman named David Bennett was held in the prone restraint position by 5 staff members for a 25 minute period, resulting in his death. An independent inquiry (bbc article 18/06/13) found that Mr Bennett died as a direct result of prolonged face-down restraint and the amount of forced used by staff.

Did this end the use of prone restraint? No. According to Mind (2013), there have been 13 reported incidents of restraint related deaths in the UK since this. This figure is only for those detained under the MHA 1983 and included only those deaths which were actually reported. The figure is therefore likely to be higher, particularly taking into account the years following the study.

Shockingly, as someone living and working in the North East of England, Northumberland Tyne and Wear NHS Foundation Trust responded to a freedom of information request from Mind and stated that, in 2011-2012, prone restraint was used 923 times.

This is not uncommon, however, with Stewart et al (2009) finding that manual restraint is used 5 times per month on an average mental health ward. According to Mind, one Trust which responded to an FOI request stated there had been 38 incidents of prone restraint, whilst another said there had been over 3000 incidents.

Mind’s recommendation from the 2013 research was, of course, that the government ought to end the use of face down physical restraint.

Has this happened? Of course it hasn’t. The figures speak for themselves. Prone restraint continues to be used, on a large scale, and for as long as this is the case, there will be more and more restraint related deaths.

Not only ought the risk of death be enough for professionals to use every possible de-escalation technique available, but the use of such restraint can cause physical injury and psychological harm. Mind (2013) provided a quote from someone who had experienced such restraint; “it made me feel like a criminal, like I had done something wrong, not that I was ill and needed to get better”.

The free reign to use prone restraint is frightening. The fact that it is used to varying amounts across the country is worse, because it suggests either that instances of prone restraint often aren’t reported, or that staff aren’t provided with the same training across the board. I fear that both are correct.

Those detained under the MHA 1983 are in hospital, usually, for assessment and/or treatment. The mental health hospital ought to be viewed as a place of safety, where care is provided to those in crisis. The possibility of attending hospital and dying there due to an excessive use of force by those who were supposed to be caring for you, is a frightening concept, but it is one that is all too real.

Patients need to feel safe in the hospital environment. The use of prone restraint must be ended.

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Oh the places you’ll go…

“You have brains in your head. You have feet in your shoes. You can steer yourself any direction you choose. You’re on your own. And you know what you know. And YOU are the one who’ll decide where to go…”
Dr. Seuss, Oh, The Places You’ll Go!

For those who regularly read my bog and twitter feed (@AC_MentalHealth) you will have noticed that there has been a distinct lack of posts recently.

Lying in bed last night, I stumbled across the above quote and felt that it was more than apt to my current situation. Things may not go to plan, but it is me in the driving seat and I have control of which way I steer.

It’s pretty obvious that I absolutely love my job. I started working in a regional office of a London firm in March of this year as an Admin Assistant. The hope was to work my way up with the firm and, in a perfect world, secure the elusive training contract that every law graduate in the country would also be applying for.

Six months on, I have worked my way up to the position of Mental Health Caseworker with Admin responsibilities. When I tell people my role, a lot of people have absolutely no idea what it means. A few of my family, through no fault of their own, simply lack of knowledge, thought that mental health law meant that someone with mental health issues had committed a crime and mental health lawyers try to ‘get them off’.

The role of a mental health lawyer is to ensure that the rights of those with mental health problems are upheld. For me, it’s about protecting the most vulnerable in society. Now, some people with mental health problems are detained under the Mental Health Act if they are really unwell, but that doesn’t at all mean that the person has done something wrong. There is something called a ‘forensic section’ which deals with those who have committed crimes, but, generally, those detained under the MHA are just like you or I and Doctors simply feel that they ought to be in hospital for assessment (section 2) or treatment (section 3). There are other sections but these are the most common.

Now, on Facebook recently, a fellow Warwick University Graduate who works as a mental health paralegal in London, posted a status saying that he was representing someone detained under the MHA at a Hospital Managers’ Hearing the next day. It’s safe to say that I was incredibly jealous! Then, someone who I don’t know, commented on the status saying that he was a junior doctor in psychiatry and asked why the person was detained. My friend said that the gentleman had schizophrenia with paranoid ideations. To this, the JUNIOR DOCTOR IN PSYCHIATRY replied “then why are you contesting it. Dude needs help”. Well, that got me angry, because help isn’t always a hospital.

The role of the mental health solicitor/paralegal is to advance the rights of the client, so if they say that they would like to be discharged from hospital then this is what we tell the Tribunal or Hospital Managers’ when the person appeals their section, with arguments added that discharge would be appropriate. We’re not ‘getting people out’.

For some people, being in hospital can make them worse. Especially if the ward is particularly disruptive, and where drugs are rife that can make things a lot harder. Assessing/treating those with mental disorder should not be about keeping someone in hospital until a doctor decides that they’re better. It’s about the individual, who may find it helps more to be at home with community psychiatric support, than in the often chaotic surroundings of a ward.

Anyway, I digress. What I’m trying to say, and what I could have said in eight words is, I really love working within mental health law.

And that’s when the rug of contentment was pulled right from underneath my feet…

All employees at my Firm were recently given notice of redundancies. Such an unexpected life-changing shock isn’t the best for someone with anxiety disorder. For the past week, I have had the worst headaches, and I never get headaches. Although, interestingly, there was no headache on Wednesday when I had my University day. It’s difficult because I got to the point where the stress of not knowing what was going on was really starting to become an issue, but I felt that I couldn’t say anything because of that fear of mentioning anything related to my own mental health having a detrimental impact on my future, as if it would show that I “can’t hack it”. Of course, that’s me being ridiculous but it is how the vast majority of those with mental health issues feel.

When I told my Grandma that I was potentially losing my job, she said “well you’ll just have to get another one won’t you”. God, if only it was that simple! Basically, there are no mental health paralegal jobs being advertised for in the whole of the North East, so that isn’t looking great.

All I can hope is that I will be able to continue doing the work that I love, wherever that may be. For now, I need to focus on my own mindfulness and wellbeing. One thing is for sure though, I won’t give up because I’ve worked too hard for that.

Dr Seuss is right, and every time I see my #semicolonproject tattoo, I’m reminded that I can conquer anything.

semicolon project

Deprivation of Liberty Safeguards

The number of people living with Alzheimer’s who are subject to deprivation of liberty safeguards (DoLS) is on the increase. DoLS are intended to ensure that residents in care homes and hospitals are protected in a way that does not deprive them of their liberty (if a person lives in supported living or their own home then it is possible to deprive them of their liberty in their best interests, but this must be done by applying directly to the Court of Protection). Effectively, DoLS authorise a deprivation of liberty when it is necessary to do so for a patient or resident who lacks capacity to consent to care or treatment in order to keep them safe from harm.

It has recently been reported that DoLS are linked to delays in families being able to bury their loved ones when they have died in a care home. This is because regulations require state inquests into such deaths, even when the cause of death is fairly clear – the deceased who was subject to the safeguards is considered to have died ‘in state detention’ thus an inquest is needed and the release of the body is delayed.

The Independent on 28th May 2015 interviewed a relative of someone who had been subject to the safeguards and who was forced to wait for 2 months before being able to bury the deceased. That relative stated “who actually benefits from these safeguards? It’s a box ticking exercise and I’m just so glad it’s finally over”.

There has been a dramatic rise in DoLS applications over the past year – The Independent quotes that 113,000 applications were made and that 36% of these were granted. That same article also includes a quote from George McNamara, Alzheimer’s Society, who states “DoLS are important for people with dementia to make sure they are not wrongly deprived of liberty but the current system is complicated and there is lack of awareness about the process”. I agree entirely with this statement and hope that this post will bolster people’s understanding of DoLS and their beneficial uses.

Deprivation of Liberty Safeguards are part of the Mental Capacity Act 2005. A deprivation of liberty is described as occurring when ‘the person is under continuous supervision and control and is not free to leave, and the person lacks capacity to consent to these arrangements’.

For a person to have capacity, they must be able to : 1) understand information relevant to the decision they want to make 2) retain that information long enough to allow them to make a decision 3) weigh up that information to come to a decision 4) communicate that decision.

The ECtHR has clarified what may amount to a deprivation of liberty. Examples of such deprivation include: restraint so that someone may be admitted to hospital; medication given against the person’s will; staff making all decisions about a person; and staff restricting a person’s access to family and friends. The point is that, whilst doing these things does deprive someone of their liberty, it is done for the person’s own benefit – therefore a DoLS is something that legally authorises the deprivation of liberty. If the examples above took place without a DoLS in place, then the person’s human rights would have been breached. Thus, under the MCA restraints and restrictions are allowed to be used when in a person’s best interests, but DoLS are needed if this restriction and restraint amounts to a deprivation of liberty.

If a relative were in a care home/hospital, and you felt that they were being deprived of their liberty but there is no authorisation for such deprivation in place, then the first port of call would be the care home manager – always attempt to resolve things from the bottom and an agreement could be reached re more freedom for your relative. If the care home manager does not think that an authorisation is needed, then you would approach the local authority and ask them to investigate whether a deprivation of liberty has taken place.

It is against the law to deprive someone of their liberty without there being an authorisation in place.

The recent case of Re AJ [2015] clarified that a local authority, when it knows that a person will be entering a care facility on a permanent basis, should make an application to the court or carry out a DoLS assessment. Effectively, authorisation should be obtained before any deprivation of liberty occurs. If an authorisation has not been made prior to a person’s move into a care setting, then an urgent authorisation could be made by the care home/hospital manager when the person arrives, although Re AJ [2015] confirmed that such an authorisation should last for no more than seven days, save in exceptional circumstances, and that an application for standard authorisation ought to be made at the same time.

The assessment process for a standard authorisation involves at least two independent trained assessors – one mental health assessor and one best interest’s assessor. If the pair do not think that all of the conditions have been met then the deprivation of liberty will not be authorised. This procedure is intended to protect the patient or resident in question. Part of the assessment process is that family, friends and paid carers who know the person well be consulted so that they may give suggestions as to how the person may be supported without depriving them of their liberty.

Should the care home resident or hospital patient concerned have no family or friends, they can utilise the support of an IMCA (Independent Mental Capacity Advocate) during the assessment process.

Following authorisation, a Relevant Person’s Representative (RPR) should be appointed as soon as possible. It will tend to be a family member or friend who will fulfil this role but if no one will take on the role on an unpaid basis then the supervisory body will have to pay someone to be the person’s RPR. In such a case, it is likely that this will be an advocate. If the RPR is unpaid (which would be the case if it were a friend or family member) then both the person and the RPR are entitled to the support of an IMCA.

An authorisation for a deprivation of liberty is intended to last for the shortest time possible, with the maximum authorisation time being 12 months, during which time regular checks must be carried out to determine whether the authorisation is still needed. If the authorisation is no longer necessary, then it must be removed. The patient/resident and their RPR are able to challenge the deprivation of liberty in the Court of Protection at any time, and can also require the authorisation for the deprivation to be reviewed at any time. The review would determine whether the criteria to deprive the person of their liberty is still met and, if so, whether the conditions need to change.  The home or hospital should do all that it reasonably can to explain to a detained person and their family what their rights of appeal are.

Useful info on DoLS can be found at:

http://www.rcpsych.ac.uk/healthadvice/problemsdisorders/deprivationlibertysafeguards.aspx

http://www.scie.org.uk/publications/ataglance/ataglance43.asp