7 – PSYCHIATRIC CLINICS In 2017, the National Agency visited five general psychiatric clinics, four clinics for forensic psychiatry and three child and youth psychiatric clinics in BadenWürttemberg, Bavaria, Berlin, Bremen, Lower Saxony, North Rhine-Westphalia and Saxony. Three of these visits were follow-up visits. During one follow-up visit, the National Agency found that the recommendations from its first visit in 2015 had not been implemented, even though the clinic and the competent supervisory authority had given a statement providing assurances to the contrary. Only one of the recommendations was implemented during the follow-up visit. regular checks on the restraining measure or monitored it via CCTV. Both of these facilities were being visited for the second time. The National Agency had already recommended during its first visit that these facilities ensure the presence of a “Sitzwache” for patients under physical restraint. This recommendation should be implemented as a matter of urgency. Only the personal supervision of a therapist or caregiver in the immediate vicinity of the person being restrained can ensure comprehensive care and assistance while reducing the significant risk of injury. This is also stipulated by section 25 (3) of the BadenWürttemberg Mental Health Act (Psychisch-KrankenHilfe-Gesetz des Landes Baden-Württemberg). The guidelines of the German Society for Psychiatry, Psychotherapy and Nervous Diseases (Deutsche Gesellschaft für Psychiatrie und Psychotherapie, Psychosomatik und Nervenheilkunde e.V., DGPPN) call for one-to-one supervision with personal contact 81 for patients under physical restraint. Furthermore, direct supervision enables staff to identify the earliest point at which the restraint can be ended. 7.1 – POSITIVE EXAMPLES The National Agency highlighted several positive examples during its visits. The visited facilities offer in-house and interdisciplinary training courses, particularly on the subjects of de-escalation, non-violent communication and dealing with aggression. Theoretical preparation, coupled with practical exercises on how to employ patient-friendly flight and defence techniques, are extremely important for all staff working in a psychiatric setting. They provide a methodological tool for the prevention or management of crisis situations, and thereby help to reduce the use of restraints and prevent physical attacks. An inspection of the files in some of the facilities revealed that the forms for ordering and documenting coercive measures included a text box for describing the current situation, the risk of self-harm or harm to others, and the measures taken towards de-escalation. The National Agency welcomes this procedure, as it creates a larger obstacle to the ordering of physical restraints than simply ticking a box with pre-specified reasons, for example. 7.2.2 – Documentation of coercive measures Having examined the forms used for ordering and documenting coercive measures, the National Agency noted in facilities in Bavaria, Berlin, Bremen, North Rhine-Westphalia and Saxony that the use of means of restraint was insufficiently documented in some cases. The use of physical restraints should only be ordered as a last resort. The National Agency takes the view that the reasons for physical restraint must be fully documented for each individual case, and that restraints should not, for example, be ordered by simply ticking the relevant boxes. This includes documenting which less severe measures have already been tried and an explanation of why they failed. 7.2 – FINDINGS AND RECOMMENDATIONS The visited facilities were given recommendations on the following main topics: 7.2.3 – Segregation In forensic psychiatry clinics, patients can be segregated in crisis situations. In one facility, all 7.2.1 – Physical restraint In Baden-Württemberg and Bavaria, persons under 80 physical restraint are not always supervised by a trained member of staff in their immediate vicinity (known as “Sitzwache”). Staff merely carried out 80 81 DGPPN, S2-Leitlinie “Therapeutische Maßnahmen bei aggressivem Verhalten in der Psychiatrie und Psychotherapie” (2009), URL: https://www.dgppn.de/_Resources/Persistent/fa128e27b086d 7a72813034b7532cee62c025848/S2LL_Aggres.Verhalten_Kurzversion_21.10.2009.pdf (retrieved on 04/01/2018). See chapter II. 4.4 – “Physical restraint”. 57