3. INCIDENT PREVENTION AND RESPONSE – Alternative intervention techniques, including pre-emption and de-escalation techniques; – Procedures for authorizing the use of instruments of restraint; – The requirements for documenting the use of restraints; and – Consequences for staff who violate laws or policies on restraints. The role of health-care staff The Mandela Rules are clear that health-care staff shall not have any role in the imposition of disciplinary or other restrictive measures. However, if the prison director orders the use of a restraint to prevent injury or damage to property, the director should immediately alert the physician or other qualified medical professional. This is particularly important, as there may be risk factors associated with physically restraining some prisoners, particularly for those with specific medical conditions. 29 Health-care staff may inform prison staff about particular medical conditions prisoners suffer from on a “need to know basis” to inform them of potential health risks associated with using restraints on certain prisoners. This information is only to be provided to protect the health of the patient and does not constitute health-care staff involvement in prison management. More information on the right to medical confidentiality and the provision of medical information on a “need to know” basis can be found in Chapter 6, paragraphs 108–132 of this guidance document. 30 Health-care staff should report to the director any adverse effects they discover of restrictive measures on the prisoner, and should advise the director if they consider it necessary to stop using such restrictive methods for physical or mental health reasons. Restrictive measures in this context include the use of restraints. 31 Health-care staff should examine prisoners following the use of restraints to check for any injuries caused by the restraints, or any signs that the prisoner has been subjected to other ill‑treatment while restrained. Any signs of injury caused by restraints should be considered as part of ongoing reviews of the appropriateness of particular instruments of restraint. Any injuries that appear to have been inflicted on prisoners through the use of restraints must be reported to the prison director without delay (Rule 46 (2)). 32 The International Dual Loyalty Working Group183 notes that health professionals are often expected to ignore or passively accept the physical restraints imposed on their patients. This group recommends that, in addition to having no role in the use of restraints, health-care professionals should also not perform any medical duties on patients who are shackled or blindfolded unless “some form of restraint is necessary for the safety of the individual, the health professional and/or others, and treatment cannot be delayed until a time when the individual no longer poses a danger. In such circumstances, the health professional may allow the minimum restraint necessary to ensure safety.”184 More information on medical ethics can be found in Chapter 6, paragraphs 102–124 of this guidance document. 3 28 Restraint during transfer 33 The use of restraints during transport should always be based on individual, case-by-case assessments and the principles of legality, necessity and proportionality. Decisions on whether to use a restraint and what restraint to use should involve consideration of the particular risks associated with using restraints during the transportation of prisoners. Their use during transport should also be properly recorded and monitored. 34 While the use of handcuffs may be the norm during transfer, the mere fact of transfer does not necessitate the use of restraints. Decisions to use restraints must be informed by prior assessments of the risk posed by the prisoner, which should be conveyed to the escorting officers. 183. The International Dual Loyalty Working Group is a collaborative initiative of the organization Physicians for Human Rights and the School of Public Health and Primary Health Care at the University of Cape Town, South Africa. 184. Dual Loyalty & Human Rights In Health Professional Practice; Proposed Guidelines & Institutional Mechanisms, International Dual Loyalty Working Group, 2002, para. 1 at s3.amazonaws.com/PHR_Reports/dualloyalties-2002-report.pdf. Guidance document on the Nelson Mandela Rules 85