Mr VY Mr VY has a diagnosis of schizophrenia and was admitted to hospital in a secure setting following a serious incident. He is subject to a CTO under the Mental Health Act. Mr VY is stated to be impulsive and unpredictable. It can be difficult to identify the drivers for this, some of it being psychotically driven. He develops ‘paranoid’ ideation about individual members of the nursing staff, and, when he assaulted a staff nurse, he had thought that two staff members were implicated in the world ending. The psychologist has been involved and has instigated with staff and Mr VY a formal arrangement whereby he receives two ten minute one to one episodes with nursing staff per day. He has exhibited frequent episodes of self-harm and there have been numerous assaults in the form of lunging and punching at staff and, as a result, Mr VY required to spend numerous periods of time in a seclusion room. Mr VY has made some positive progress but he continues to be nursed in seclusion and separate from other patients. He has been able to spend increasing amounts of time out of the seclusion room and has been able to engage in some activities (such as playing cards) with staff. He was previously nursed in strong (anti-ligature) clothing but in the last month he has been able to return to wearing his own clothes. He continues to be nursed very intensively, with three nursing staff with him at all times when he is out of the seclusion room. Staff progressed from moving him around the ward in full secure holds to using loose holds and eventually to no holds. Mr VY continues to receive medical treatment in the form of antipsychotic and mood stabilising medications with which he fully complies. In addition, he receives regular input from a clinical psychologist and other members of the multidisciplinary team, including occupational therapy. More recently, he commenced a regular anxiolytic medication which may have contributed to the improvement in his behaviour towards others. Mr VY continues to have very limited insight into his illness or need for treatment. This example demonstrates the difficulties involved in longer term management of behaviour likely to cause harm and the additional problems and risks involved when attempting to reduce the restrictions in use. Here, there was a policy on use of seclusion in place, good record keeping and robust systems for evaluation and review. 25