Section three The use of force and restraint This increased her agitation and distress, and the hospital responded by sedating her over 100 times with injections or rectal medication. MWCS considered that this could amount to degrading treatment.13 Another investigation highlighted that it can also be inhuman not to use force. A woman with alcohol-related brain damage refused medical interventions despite being suspected of having cervical cancer. When she became terminally ill and had a large bloody vaginal discharge, staff in her care home allowed her to refuse to be cleaned and given pain relief. MWCS considered that this left the woman in considerable indignity and distress – it was content that her decision not to receive medical treatment was respected, but felt that care home staff should have overruled her later refusal of care in order to preserve her dignity.14 To address risks of staff using excessive force, or omitting to use reasonable force, MWCS published a good practice guide on the use of force to provide physical health care.15 In Northern Ireland, RQIA monitors health and social care settings, including those where people are, or may be, detained. During inspections, RQIA found a range of restraints being used, including inappropriate use of rapid tranquilisation, bedrails, lap straps on specialist seating, arm splints and specialist sleepwear. It was evident to RQIA that, in some settings, staff used restraint without adequate training and policies governing the use of physical interventions were inadequate, out of date or simply absent. Several patients interviewed by RQIA said that they had sustained injuries while being restrained. In several non-secure health or social care settings that RQIA visited, it found environmental restrictions that could amount to de facto detention. These included locked internal doors, locked external doors and gates, and the use of seclusion as a method of behaviour management. RQIA was concerned about: • a lack of understanding among service providers that the practices were restrictive • failures to assess the impact of servicewide restrictions on individual service users • few services were able to describe the assessment processes and agreements with service users and/or their representatives in relation to these restrictions • the absence of safeguards to monitor the appropriateness of restrictions. As a result of these inspections, RQIA took enforcement action against several care providers. In each case, this has resulted in improvements in the quality of care. Case study RQIA found a voluntary patient in a long-stay ward for adults with learning disabilities wearing arm splints. The splints were used to minimise the risk that he would harm himself. RQIA was concerned that the patient’s care records did not indicate any consideration of less restrictive measures to prevent self-harm. The patient was found to be wearing the splints at all times, despite an occupational therapist recommending that this should not occur. 13 MWCS, Starved of Care: Investigation into the care and treatment of ‘Mrs V’ (May 2011). 14 MWCS, Ms R Report: Challenges in providing healthcare for an individual who cannot understand or consent (May 2012). 15 MWCS, Right to Treat? ( July 2011). 23