National Preventive Mechanism Sixth Annual Report 2014–15 Good practice in a low secure hospital A patient with a history of violent assault was held in a secluded area of a low secure hospital with a permanently activated alarm on the door, rather than referring him to a medium secure facility, which was considered a more restrictive measure. Agreement of the patient’s family was sought and obtained, and safeguards included continuous review, care planning, independent advocacy, and regular contact with the NPM member regarding any further changes. An independent consultant psychiatrist and consultant nurse from a medium secure hospital elsewhere in the UK were asked to review the treatment plan to ensure it met the patient’s needs and rights, and implemented appropriate safeguards. The patient had access to therapeutic and activity interventions and regular observations. After improvement in the patient’s behaviour, nursing staff facilitated his contact with other patients, under close supervision. Legitimacy of isolation During their visits, NPM members identified concerns about the legitimacy of the use of isolation. For example, patients on a forensic child and adolescent ward claimed that seclusion was used as a punishment, a patient on an acute ward stated that seclusion was not used as a last resort as other options had not been considered, and other patients said that they might be secluded if they refused to take medication. In one case, a resident in a care home in Wales was isolated as she was restricted to using only her bedroom because of being urine incontinent. This case led to a criminal investigation. NPM members are aware that where isolation is not used, alternative means of managing disturbed behaviour might include increased use of medication (chemical restraint), prolonged manual restraint or mechanical restraint (the use of restraining garments). One NPM member noted that in a learning disabilities unit the lack of a seclusion facility led to prolonged manual restraint on many occasions. Positive efforts by some services to look at their restraint practices more broadly, and attempts to move to a ‘no restraint’ position, by focusing on the root causes of behaviour disturbance (boredom, lack of staff contact, lack of quiet or private spaces), are to be welcomed. Reintegration The Mental Health Act Code of Practice 2015 (England) includes the enhanced requirements that debriefing and support should follow all episodes of seclusion, and an acknowledgement that they are likely to cause some degree of distress to patients. Such debriefing, or post-incident review, should provide an opportunity for organisational learning. Where patients are able to and agree to discuss the incident that led to the use of a restrictive intervention, they should have the opportunity, through an empathetic therapeutic relationship, to explore aspects of the intervention that helped, did not help and might be done differently, as well as to record in an advance statement their wishes for future restrictive interventions.83 83 Department of Health (2015), op. cit., paras 26.148, 26.167-171. 38