Category Archives: Risk

Physical Restraint: The Story Behind the Stats

As Mind publishes survey data and calls for a ban on face-down restraint, The Stuff of Social Care looks at the issue from the point of view of those doing the restraining

It’s been a long time since I last took part in physical restraint, but for many years I did work in environments where the need to prevent harm was part and parcel of a nurse’s working day.

For the most part we relied on the first resort. Talking, listening, reasoning, observing. Using a rapport that may have been built up over a period of time, and developing skills that were fundamental to working with highly distressed, agitated people. For most of my nursing career I was lucky enough to work in well-staffed forensic units where staff and patients knew each other well, and where the very thought of an agency or locum nurse was unimaginable.

But at times the last resort was unavoidable. Most of the trained, professional staff I worked with would much rather not use physical restraint. Like me, they would loathe the idea of holding down another human being to inject them with powerful drugs. But when all else has failed, or extreme harm was imminent, or where leaving a severely psychotic man or woman unmedicated would almost certainly leave them more terrified, confused and at risk than they already were, then I for one would not lose any sleep restraining that individual.

By the time I had qualified as a nurse, physical restraint had gone from the often chaotic bundle of arms legs and torsos of my student days toward a set of techniques called Control and Restraint (C&R), a Home Office approved means of managing physical aggression. I along with my colleagues attended regular training in C&R. We turned up at sports halls in trackies and trainers spending hours and days learning and practising the management of physical aggression.

A major (and rather unpopular) part of the training involved role-playing ‘the patient’ and being subjected to the procedures oneself. C&R was based on a 3-person team immobilising the patient. It used a certain amount of discomfort and even short bursts of pain to contain violent people, a fact which we as the role player would be only too well aware. Some of the techniques we learnt involved immobilising the patient face-down on a floor or bed. The reasons for this were that a) the person on their back can fight back much more effectively than if they are face down, and b) saliva and teeth make very potent weapons when they belong to a person who really, really doesn’t like being held down on a floor by several nurses. A key part of the 3-person team was the ‘head’ man or woman, whose job was to ensure minimum discomfort for the person on the floor and protect their airway.

But apart from the actual physical techniques, a fundamental of the training was that physical restraint was absolutely a last resort once every other strategy had failed, or where danger was imminent.

There are those who believe that physical restraint of the mentally ill is little more than state-sponsored thuggery, or who wonder whether restraint is necessary at all. Well, physical restraint is a necessary part of mental health care at times. That’s an undeniable fact, but it’s easy to see why and how restraint gets such a bad press, and why bodies such as Mind need to spend time, money and effort surveying it’s use.

We need go little further than Winterbourne View to acknowledge the presence of thugs masquerading as care professionals. From the very first emergence of the lunatic asylum, the opportunity to get paid for wielding power, authority and physical dominance over others has always proved attractive to a certain type of psychopath.

But there are much deeper and wide-ranging reasons why physical restraint may be over-used or abused. Mental health care certainly needs a sensible, contextualised and much broader discussion about physical restraint per se, and the reasons behind it’s use and misuse. The ‘face down’ issue is perhaps something of a narrow lens, and when 22% of staff report not having had face-to-face training in the last 12 months, we need to ask why that is.

I have a few observations. Questions about restraint are far from being a solely modern phenomenon, but for those whose 7.5 hour shift seems incomplete without a dose of adrenalin-pumping action and a ‘good decking’, current conditions have never been better.

Beds are disappearing. Only the very sickest of the sick have access to hospital treatment. The most distressed and disturbed are funnelled into smaller and smaller pockets of in-patient chaos, often provided by companies with shareholders and profit margins to maintain and gladly filling the gaps left by the running down of NHS in-patient psychiatry.

I would hope that such critical care would be delivered by the sort of skilled, well trained staff I described earlier. This all too often isn’t the case. Many of our most severely ill patients are being cared for by agency and locum staff with bare minimum training, a lack of experience and often poor communication skills. Many will barely know the names of the people in their temporary care.

This is where the ‘jump on, grab a limb and for f*** sake make sure they’re still breathing’ model of managing potential and actual aggression is practised today much as it was in the dungeons of Bedlam.

Right at this moment, someone, somewhere is in a psychiatric unit posing potential or actual danger to themselves or others. People with mental disorders can and do become violent, and staff are needed to contain the violence and minimise that risk. Hopefully they are with staff who can reassure, listen and diffuse aggression with empathy and skill. They are trained to use restraint safely and appropriately, and to be able to make decisions as to when and how it is used.

Mind’s survey results suggest this is all too often not the case.

SOME NOTES ON SUICIDE

As I sit down to write this the headline news on BBC 5 Live is the death of a nurse called Jacintha Saldanha. Her death is being widely reported as suicide. Why is it headline news? That’s a good question. I very much wish it wasn’t. Not because her death doesn’t deserve recognition, but because nobody but her family and those that knew and worked with her would give a toss if it weren’t for a connection to ‘THAT’ news story. And of course because she just happened to take a phone call which resulted in ‘THAT OTHER’ news story. A story which took up the media and internet baton once everyone had run out of ways to report that a certain royal was pregnant and had morning sickness.

Lots of people kill themselves. Probably more than you think. Whenever I discuss suicide in training, people often struggle to believe that around 15 suicides are recorded in the UK every day. Of course these are official figures recorded by a Coroner as the deliberate taking of one’s own life.  With moral and religious taboos, financial implications and family feelings to take into account, Coroners set the burden of proof understandably high to record a death as self-inflicted. The actual suicide figures are quite possibly much higher.

There will of course be a brief outpouring of grief, indignation, speculation and utter cobblers written and spoken about the death of Mrs Saldanha. The armchair psychologists will be bashing away at their keyboards, speculating about people and circumstances of which they know little or nothing. Or if they’ve read about the story in the Royal-obsessed tabloids, they’ll be tweeting, blogging and writing column inches about her death based on some hack’s terror of getting a bollocking from the Editor if they haven’t come up with a thousand words on the ‘KATE NURSE SUICIDE SHOCK!’ story by teatime tomorrow.

In a recent and well judged piece by political commentator Owen Jones, a ‘jumper’ chooses to end their their life by throwing themselves in front of the train Jones was travelling on. As a well known scourge of the right-wing Jones is better known for being the poster boy of my (mainly left-leaning/liberal) Twitter timeline, and the piece was not without highlight of the appalling dismantling of mental health services. But most telling for me was his account of people taking to the internet to moan about their journey’s being delayed by the selfishness of the suicide victim. Why, said the keyboards warriors, could the person not have committed a nice, quiet suicide without causing inconvenience to passengers and traumatising the train driver?

Even the most compassionate among us may look at that last example and think “You know what. Maybe, just maybe they have a point.” Suicide is often described as the ultimate act of selfishness. As well as the many professional and personal encounters I’ve had with those now dead by their own hand, I’ve also worked with those bereaved by suicide. The bewildered ones left behind by a family member or lover who has, like Gary Speed just over a year ago, hung themselves in a garage. And I’ve worked with PTSD sufferers traumatised by witnessing the very last moments of a person’s life which, in the case of a train driver, may be an image he or she will never be able to erase despite years of therapy, anti-depressants or, as is often the case, self-medication with a tanker-full of vodka.

But one thing we can never, ever ask of a suicide victim is ‘Why?’ Even the suicide note is no real explanation. The principal witness is dead.

One thing we do know is that suicide is not necessarily the end game of mental illnesses such as Depression or Schizophrenia. An extraordinarily large number of victims have never been anywhere near mental health services, or (like Speed), given an inkling of their desperation to those around them. A significant proportion of suicides happen in the aftermath of life events.

Failing businesses, failing relationships, redundancy, bullying, bereavement. The stuff of life that craps on all of us from time to time but is usually coped with through time and resilience and doesn’t force us to jump from a multi-storey car park. It’s a quick-fix solution to situations or mental states that few of us can begin to contemplate. Selfish? That’s a very big call when we can never, ever know those final thoughts of the person who has decided to bring an end to their own life.

There are many other myths around suicide. Many assume that Christmas and New Year is a sort of suicide ‘rush hour’. A fatal hell for those whose loneliness (whether actual or perceived) is compounded by the tsunami of happy families and festive warmth thrown at them every time they switch on the telly. That and the long nights are often cited as high risk factors, but if there is any seasonal pattern to suicide we are (in this country at least) more likely to see suicides peak in early Spring than in the depth of winter.

Statisticians, mental health professionals and social researchers have been fascinated by suicide since Emile Durkheim’s famous work from the late Nineteenth Century. We could go on and on with stats and explode many more myths, but pending the Coroners report, Mrs Saldanha is (allegedly) yet another statistic to add to the other five or six thousand people who will kill themselves every year.

She isn’t alive to tell us her story, but the Tweeters, Facebookers, broadsheet columnists and tabloid muck rakers probably won’t worry too much about that. The Daily Mail, which true to form managed a whopping twelve pages of preggers-related drivel almost as soon as the royal  foetus was announced will, at this moment, have their hacks chasing anything and everything to do with Mrs Saldanha’s precious but otherwise unremarkable life. But neither they, nor we, nor even those closest to her will ever really know why she chose to end her life, or what thoughts were going through her mind in the hours and minutes beforehand.

Well this isn’t the most cheerful thing I’ve ever written, but if you’ve stuck it out this far, please have a think about three final thoughts:

1) Please don’t assume that everyone about to kill themselves is writing wills and suicide notes, or checking themselves in for an appointment with the GP, or announcing to all and sundry that life isn’t worth living and that their families would be better off without them. Yes, sometimes it works like that. And very often, it doesn’t.

2) Whether it’s Gary Speed, Jacintha Saldanha or the person who jumps in front of a train, please don’t jump onto your keyboard with a handful of assumptions and a degree in cod psychology. Think about those who are left to pick up the pieces. They read the internet too.

3) And finally, please keep these good peoples details to hand. Someday you or someone close to you may need it. It could be a lifesaver.

The Samaritans

Tel: 08457 90 90 90

Email: jo@samaritans.org

Homicide, Suicide and Mental Health: Time for a Rethink?

In the wake of yesterday’s ONS crime statistics revealing a major drop in homicide rates in England and Wales, has the ‘inquiry culture’ made any significant impact on mental health-related tragedies, and is it time for a rethink? 

If you’ve worked in front-line mental health at any time in the last two decades, there’s a small but not insignificant chance an independent inquiry has shone it’s torch at you, your colleagues and your collective role in a homicide.

Yesterday’s announcement suggests a downward trend in homicide rates, but before 2011-2012 there were between five and six hundred and fifty homicides recorded in England each year (National Confidential Inquiry, 2012). On average around ten per cent of these deaths will have been committed by a ‘psychiatric patient’, or to be more precise, by a perpetrator who has been in contact with mental health services within a year prior to the offence.

This relatively small contribution may come as a surprise to the more indignant ends of the media. And it is hardly a damming indictment of community care, especially as only a proportion of ‘psychiatric’ killings will have been committed as a direct result of psychiatric pathology such as command hallucinations or paranoid beliefs.  A mentally ill killer doesn’t necessarily kill for reasons that are different from anyone else.

Nonetheless, this is still fifty or sixty people a year dying at the hands of someone whose name is on the books of a mental health professional, and the question of preventability is one that must be asked.  And it does. Dozens of times a year.

Independent inquiries into mental illness related homicides were made mandatory in the wake of the Ritchie Report of 1994. In the light of criticism about their continued usefulness, not to mention the weighty invoices for an army of psychiatrists , barristers and other senior personnel who make up the panels, the ‘mandatoriness’ was slightly relaxed in 2005, but still we are seeing dozens of publications a year of inquiry reports which were once headline news but are now so common as to be barely noticed.
Homicide is not the only adverse event to trigger independent inquiries. Suicides, sudden unexpected deaths and safeguarding events can all be subject to scrutiny where circumstances dictate, generating what is now a vast library of reports, findings and recommendations. We are all aware of the benefit of hindsight, and there’s certainly no shortage of it here.
 
Lack of communication, inter-agency squabbling, non-adherence to the Care Programme Approach and poor or non-existent discharge procedures are all among the usual suspects to appear within the panel’s cross-hairs. We will also read frequent accounts of agencies such as the police, mental health professionals and social services treating each other as if they had a communicable disease. 

But other themes are also present in abundance. Professional disinterest. A ‘more than my jobs worth, guv’ attitude. Rigid bureaucracy and referral criteria trumping good clinical judgement. Oh, and we nearly forgot a lack of common sense and sheer incompetence.

We should all by now have learnt our lessons. We should have developed evidence-based, multi-agency training in prevention of violence and suicide. We should have developed collaborative approaches to working with crisis and risk involving everyone within a community who works with mental health: Community Mental Health Teams, the Police, Parmamedics and Support Workers. Everyone.

We should have developed collaborative, reflective approaches to analysis of adverse events and ‘near misses’ which involve service users and those so often excluded from deliberations, the families and carers. And we should have developed robust policies and procedures which mean risk work becomes a key clinical skill and not the ticking of a few boxes on a side of A4.
 
But while there is certainly evidence that care providers have followed recommendations at an organisational level, have eighteen years of automatic inquiries really made an impact at the sharp end of care and support? Are inquiry recommendations actually being followed and learnt from in day-to-day practice, or are the reports offering little more than a handsome hourly fee for their very expensive authors?

There is no evidence of any decline in the rate and frequency of homicides, suicides or other adverse events. Suicides are becoming less frequent among in-patients, but is this due to improved care on the wards or to the fact that trusts have followed previous advice from the NCI in removing ligature points such as curtain rails? And why has there been a rise in suicides among patients in ‘home care’? 


The faults highlighted by countless inquiries and repeated here are still happening day in and day out. I don’t need a literature review to know this – I’m a trainer. I see and hear the horror stories from staff all over the UK and from a wide variety of settings. So if these are the problems, where are the solutions?

I have two very simple, affordable suggestions for mental health care which may (if you’ll forgive the drama) save lives.

Firstly I would very strongly support the suggestion that we now abandon the independent inquiry system and hand responsibility for the scrutiny of adverse events to the National Confidential Inquiry. One centrally organised body using standardised methodologies to examine homicides, suicides and sudden unexpected deaths, feeding their work directly into a programme of training and research that directly links evidence with day-to-day reality.

Secondly, I think it’s time for a change in how front-line mental health services work with risk. We’ve seen painful evidence over many years of how the collective will, for a variety of reasons, make mistakes and allow tragedies to occur.

Perhaps it’s time for an individual response. A Risk Practitioner.  Or even, if you prefer the dramatic, a Troubleshooter.

An experienced individual who knows what can happen, has an intimate awareness of the inquiries and evidence base, can coach, micro-teach and work alongside front-line colleagues, and has the ability to link agencies, teams and individuals together  in a way that we seem patently unable to do when left to our own devices.

If this sounds rather fanciful, it’s been done. Unfortunately the very partisan forces that so often plague inter-agency working brought my particular project to a premature close, but as a Forensic CPN I once worked closely with an Assertive Outreach Team fulfilling pretty much the job description outlined above. There was of course a little more to it than that which might have benefitted from formal audit or research, but as proof of concept it worked extremely well.

The tragedy of psychiatric disaster is far more real and important than any number of statistics or findings or recommendations. If even only a few of these events is preventable, then surely we should be sitting up and taking notice of how to do the precenting. Maybe it really is time to try something new. 


This post was written as part of a Risk and Mental Health project currently in preparation by the author