Appendix 1 These case examples relate to people cared for in both hospital and community settings. They have been altered to protect the anonymity of the individuals concerned. They illustrate areas of good practice and areas of poor practice for learning purposes. Ms CG Ms CG is a woman with treatment resistant schizophrenia who lives in a self-contained flat within a locked hospital ward environment, having been a patient in hospitals for many years. She is detained on a Compulsory Treatment Order (CTO) and has 2:1 staffing at all times with additional staff when out of the ward. She also has access to her own garden space. The bedroom is lockable and nursing staff can observe her through a window to both bedroom and bathroom. She has a well-furnished living room with DVD and TV. Ms CG has very little communication, has persistent psychotic delusions and hallucinations and her illness has proven to be fairly resistant to treatment with medication. She is now mainly compliant with her care and treatment. Ms CG can be very assaultive, mainly kicking, spitting and if close enough, biting. She is less inclined to damage her environment. Nursing staff have a management plan, which mainly involves them removing themselves from her proximity as most of the harm is done to those who are in close contact with her. She can be impulsive, unpredictable and aggressive, mainly towards staff and other patients. When Ms CG is distressed to the extent that staff or other patients are felt to be at at risk, the door to her private flat suite is locked in accordance with the locked door policy. When it is felt to be necessary for her to be locked in her bedroom on her own she is observed through the viewing windows. A record of the door being locked is kept with the reason for it being locked recorded. Nursing staff lock the bedroom door when she is distressed for her to have time alone in her bedroom with access to the ensuite bathroom. We consider that this situation amounts to use of level one seclusion and should be managed with reference to this guidance. Managing it in any other way, potentially infringes human rights and obviates the need for scrutiny and proper evaluation and review. Mr AF Mr AF has epilepsy and severe learning disabilities and autistic spectrum disorder. He has no verbal communication. He attended school before having his own accommodation with support provided when he reached adulthood. His family have welfare guardianship. They feel that he did not fully understand that when he left school he was no longer able to attend the placements he previously had and so reacted badly to this. He started absconding, developed repetitive behaviours, severe aggression, disrupted sleep and reduced appetite. He developed behavioural patterns which made it difficult to sustain his placement. Staff were no longer able to support him in his accommodation and he was admitted to hospital for further assessment. Since admission to hospital Mr AF's behaviour has not responded to medication and he recently assaulted another patient leading to him being placed in seclusion for periods when his behaviour became unpredictable. He has assaulted staff leading to serious injuries and 23