National Preventive Mechanism Sixth Annual Report 2014–15 In England, two distinct categories are recognised: ‘seclusion’ and ‘long-term segregation’ (LTS).79 Secure hospitals in Scotland use ‘seclusion rooms’, usually monitored via a window. Patients are normally allowed out of the room for personal care, using the toilet, and exercise where appropriate. In some settings, patients are given ‘time out’ in their rooms when their behaviour has escalated. This essentially isolates the patient, and is more common in places where there is no seclusion room, or as a step before formal seclusion. NPM members also come across cases where an area is separated off in a ward as a self-contained area for an individual patient. Voluntary isolation or isolation ‘at own request’ also occurs, as a way to reduce stimuli on wards that could provoke aggressive behaviour. Such isolation must also be subject to frequent review. In care homes, NPM members identified residents who had become isolated as a result of disproportionate measures taken to address perceived risks (for example, falling from their wheelchair). Specific issues identified through monitoring Terminology Isolation and/or solitary confinement were a main feature or defining characteristic of the following practices: seclusion; long‑term segregation; low stimulus; time out; intensive care suite; therapeutic isolation; singleperson wards; enforced segregation. Length and frequency of isolation: formal and informal practices Isolation defined as seclusion can last several hours or even days. Where practices are identified as LTS as defined in the Mental Health Act (MHA) Code of Practice,80 which applies in England, these will usually meet the NPM definition of solitary confinement. One NPM member has expressed concern at the routine isolation of patients in high security hospitals as they are locked in their bedrooms at night. Specific powers to do this have been set out in policy.81 Although the practice would meet the criteria for seclusion under the MHA Code of Practice, the Department of Health has stated that such practices are not to be deemed as such and therefore are not subject to the same review requirements.82 Concerns were raised by the NPM member that this effectively introduced a new category of seclusion. 79 Seclusion refers to the supervised confinement and isolation of a patient, away from other patients, in an area from which the patient is prevented from leaving, where it is of immediate necessity for the purpose of the containment of severe behavioural disturbance which is likely to cause harm to others. Long-term segregation refers to a situation where, in order to reduce a sustained risk of harm posed by the patient to others, which is a constant feature of their presentation, a multidisciplinary review and a representative from the responsible commissioning authority determines that a patient should not be allowed to mix freely with other patients on the ward or unit on a long-term basis. In some instances, LTS may constitute solitary confinement. LTS introduced into Mental Health Act Code of Practice (Department of Health) 2008 and 2015 since 2005 ruling Regina v. Ashworth Hospital Authority (now Mersey Care National Health Service Trust) ex parte Munjaz [2005] UKHL 58. 80 Department of Health (2015), Mental Health Act 1983: Code of Practice. London, The Stationery Office. 81 National Health Service England (2013), The High Security Psychiatric Services (Arrangements for Safety and Security) Directions 2013. 82 See Department of Health (2015), op. cit., para 26.105. 36