Issues identified (more than one per case) The broad categories of recommendations made either in discussion or formal reports were: Non-detained hospital patients have restrictions 12 Non-detained hospital patients are restrained 2 Informal community residents have restrictions 3 Service must consider seeking proper legal authorisation 3 Service users with a proxy are restrained 0 Service must assess/reassess capacity of service user 5 Service users with a proxy are restricted 3 Service must consider changing/ reducing level of restriction 6 Practical issue (fluctuating capacity) 1 Service must ensure staff have proper training 7 Practical issue (use of DOL* when MHA** more appropriate) 1 Service must develop clear policy 4 5 22 Service must ensure service users know their rights None recorded 3 Total *DOL = Deprivation of Liberty Safeguards (England and Wales only) **MHA = Mental Health Act Recommendations (more than one per case) Total 33 In most cases, the NPM member took action to bring the matter to the attention of staff and managers. In most cases, this resulted in a formal report to managers of the service. Actions taken (one per issue) Discussed with all parties involved 5 Report to managers of hospital/service 9 Discussed with all parties and report to managers 3 Discussed with staff/managers 3 No action noted 2 Total 22 29