15th Greek Australian Legal and Medical Conference
Thessaloniki, Greece 2015

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 ‘A Celebration of Law and Medicine’: Law and Medicine Working Together to Reduce Seclusion and Restraint in Health-Settings

Kay Wilson

I would like to begin by thanking the Conference Committee for awarding me the John Harber Phillips Travelling Fellowship (Legal) and inviting me to share my research with you.  I have called my paper ‘A Celebration of Law and Medicine: Law and Medicine Working Together to Reduce Seclusion and Restraint in Health-Settings.’  While I will go into the definitions later, for those who are not familiar with this field seclusion and restraint are usually used in healthcare to restrict a person’s movement to control their behaviour.

I realise that seclusion and restraint may seem like an unusual, or even a grim topic, for a Conference with the theme of a ‘celebration of law and medicine,’ but my paper will consider what law and medicine can bring to the issue and how both professions can work together to achieve success. I will argue that the safe reduction of seclusion and restraint is achievable and that elimination is desirable.  It would certainly be an achievement that could be celebrated by both law and medicine.

For the purposes of my paper, I will draw on my contribution to a report for the National Mental Health Commission (NMHC) on the Reduction of Seclusion and Restraint as part of an interdisciplinary team in which I reviewed the regulatory frameworks in Australia, New Zealand, England, Scotland, Ireland, Europe and the United States.1  I understand that our report should be published on the Commission’s website, having been launched at the 10th  National Seclusion and Restraint Reduction Forum in Melbourne last week.  Unfortunately, Greece has no national guidelines and doctors are forced to rely on clinical experience, local hospital policies and guidelines from other countries.2   For this reason, my focus will be on Australia, with some discussion of international trends.

1. Road Map for my Presentation

So, where is my presentation going?

  1. Well, first of all it is always good to begin these things with a true story to make it real.  While there are many stories out there, I am going to draw on the Victorian Coronial Inquest into the death of Adam White.3  I will refer back to it as a “case study” throughout my presentation.
  2. Then I will give you some more background about seclusion and restraint - what is it, when and where is it used and why we should try to reduce and eliminate it.
  3. Thirdly, I will provide a brief overview of the international and national regulatory framework.
  4. Fourthly, I will consider the problem from a medical perspective and provide a brief overview of strategies that medical research has shown can reduce seclusion and restraint.
  5. Finally, I will conclude with how law and medicine can work together towards the reduction and elimination of seclusion and restraint.

2. The Death of Adam White

Adam White was a 31 year old man and who had suffered from schizophrenia for 10 years along with intermittent alcohol and substance abuse. At six feet tall and weighing over 140kg, he was by all accounts a big man.  He was also not particularly likable and was rude to staff and other patients.
In 2007 he was admitted to the Maroondah Hospital Emergency Department with psychosis, agitation, impulsivity and delusional beliefs that he was saving the world.  While waiting in the emergency department, he was medicated for over 18 hours, until he was finally admitted as an involuntary psychiatric inpatient at Dandenong hospital.

After his admission, Mr White displayed a number of challenging behaviours.  He was very restless, pacing up and down the ward and was also observed trying to ‘tear down’ the courtyard fence, but he returned inside when requested.  When he came inside he was described as behaving in a ‘passive aggressive’ manner until he went to sleep around midnight.  However, by 4am he was up pacing the ward again and was described by the nursing staff as being ‘agitated, paranoid and delusional.’  There was a misunderstanding between Mr White and the nursing staff about whether Mr White could have a coffee or whether he needed to fast before having a blood test.

Mr White became increasingly confused and frustrated about whether he needed a blood test.  But, by the time security staff arrived, he had calmed himself and had agreed to walk to the seclusion room.  Mr White reacted angrily to being escorted by security staff, and at that point, one staff member told him to go to his bedroom.  Mr White obeyed this instruction and went to get his toothbrush. Staff then tried to redirect him back to the seclusion room and insisted that he did not need his toothbrush.  Mr White lost his temper again and clenched his fists.  At that point, two security staff pushed him to the floor face down in what is called the ‘prone position.’  Mr White was very strong and struggled so much that the police were called.  However, it was clear that something had gone wrong when Mr White grew still and could not be revived.

The Coroner found that Mr White’s death was caused by restraint asphyxia, possibly complicated by his underlying heart problems and that his death was avoidable.  The Coroner identified problems with the seclusion and restraint regulatory framework, how that framework was implemented, management problems, staff shortages, lack of staff training and poor practices on the ward.

I have not found any publicly available explanation of why the Coroner took 5 years to make his findings, but Mr White’s case and the death of Justin Fraser at Frankston hospital following physical restraint also in 2007,4 prompted some reforms in our new Victorian mental health act.  However, as discussed later, further reform may still be required.

I have chosen this story because it illustrates some of the issues surrounding the use of seclusion and restraint.  It always leaves me wondering could law and medicine have done better for Mr White?

3. What are seclusion and restraint?

Seclusion and restraint are the most restrictive behavioural interventions in healthcare and their definitions are by no means settled.  But, for the purposes of this presentation, by the term seclusion, I mean the confinement of a person alone in a room or area where free exit is prevented5 - in a word, isolation. By restraint, I mean the restriction of a person’s movement and liberty.  Typically, there are three types of restraint: physical restraint (being the use of bodily force to immobilise a person), mechanical restraint (being the use of a device to restrict movement) and chemical restraint (being ‘medication given primarily to control a person's behaviour, not to treat a mental illness or physical condition.’)6  It is also arguable whether psychological interventions and emotional intimidation7 may also amount to restraint.

Mr White’s case illustrates three different types of restrictive intervention - chemical restraint when he was medicated in the emergency room, his agreement to go to the seclusion room, and of course, the physical restraint that killed him.

4. When are seclusion and restraint used?

Seclusion and restraint are usually permitted by law to prevent harm to a patient or to others, to prevent persistent property damage, to facilitate treatment and to prevent absconding.8  More recently, the focus of law reform has been on limiting seclusion and restraint to use as the ‘least restrictive alternative’9  or ‘last resort’10 for the purpose of safety.  There is wide international agreement that seclusion and restraint are not therapeutic, should not be used as a threat or for punishment or discipline, should not be used for staff convenience or to compensate for staff shortages or resource constraints.11

It all sounds very reasonable, so what is the problem?  Well, as we know what the law is ‘on the books’ can differ from practice and studies show that seclusion and restraint can often be used for the wrong reasons.12  The picture I have used here in my slide captures the perceptions of consumers who feel that seclusion and restraint are used as a form of discipline for not obeying the rules or disagreeing with their doctors.  It is perhaps also an example of emotional restraint where people feel totally powerless and that they cannot express themselves and be heard.

The story of Mr White demonstrates that seclusion and restraint can occur where there are staff shortages and staff members feel out of control.  It also raises the issue of whether someone who is capable of calming himself to the extent that he can consent to walk to a seclusion room is really a sufficient danger to themselves or others that they need to be put in seclusion at all?  I have often wondered whether it would have been enough for Mr White to have agreed to have had some quiet time in his bedroom, rather than for staff to continue to insist that he go to the seclusion room.  Would it have really mattered if he had brushed his teeth? Perhaps he wanted to go back to bed?  We will never know because no one asked him what his intentions were, or tried any de-escalation techniques.

 5. Where are seclusion and restraint used?

Seclusion and restraint can be conceptualised as being at the extreme end of a continuum of responses to ‘clinically-related challenging behaviour.’13  That is, ‘any non-verbal, verbal or physical behaviour exhibited by a person which makes it difficult to deliver good care safely.’14  Clinically-related challenging behaviour can result from cognitive impairment (eg. dementia, intellectual disability, delirium, head injury or intoxication), mental illness, or other underlying illness or condition.15

While seclusion and restraint are primarily used in psychiatric practice there is growing recognition that seclusion and restraint take place in a variety of general health,16 disability17 and aged-care18 settings.  As clinically related challenging behaviour can occur in all health-settings, this issue is relevant to all health workers.  Disturbingly, there are cases where a failure of medical staff to understand clinically-related challenging behaviour has led to a failure to diagnose life-threatening conditions.19

The Australian Institute for Health and Welfare has reported that the national average rate of seclusion was 8.0 incidents per 1,000 bed days in 2013-2014 and that there has been a declining trend in the use of seclusion over the last 5 years.20  But, there is great volatility in the figures between states and territories and those figures are just for seclusion, the rate of restraint is unknown. 

6. Adverse Effects of Seclusion and Restraint.  Why seek to reduce with a view to eliminating it?

Obviously, the most serious adverse effect is death.  I have found a number of cases in Australia and overseas21 where people have died from physical, 22 chemical23 and mechanical restraint24 and in seclusion after receiving high doses of medication.25 Physical injuries range from cuts to broken limbs and deep vein thrombosis.26  Most people report that seclusion and restraint is a traumatising experience that leaves them feeling angry, anxious, abandoned, powerless and punished as well as reviving memories of past traumatic experiences.27 It may be that Mr White’s experiences of seclusion and restraint on previous admissions contributed to his contempt towards the nursing and security staff.

However, seclusion and restraint are not just dangerous for patients, they are also associated with increased injuries to staff and can be traumatising for staff.28  High rates of seclusion and restraint also tend to be associated with low staff morale, absenteeism and sick days.29 In Mr White’s case, the Coroner noted that there was a nursing culture at Dandenong hospital where patients were often deliberately ‘goaded’ by staff who wanted to make compensation claims if they were hurt.30  That is, high rates of restrictive practices may be an indicator of low quality care, poor management and nursing practices.31

7. The Legal Perspective

At the international level, human rights approaches recognise that seclusion and restraint can be a significant interference with liberty, bodily integrity and can result in a loss of dignity.  Recent comments by the Committee for the Convention on the Rights of Persons with Disabilities (CRPD) that Australia should ‘take immediate steps to end such practices’32 highlight the seriousness of the issue in human rights law.  Similarly, the conceptualisation of restrictive interventions as a form of cruel, inhuman and degrading treatment and the call for an ‘absolute ban’33 on seclusion and restraint by the Special Rapporteur on Torture, Juan E Méndez, creates urgency for change. There was wide acceptance by respondents to the survey we conducted for the National Mental Health Commission that use of seclusion and restraint is a human rights issue.34

At the national level, I have not seen any proposals to immediately abolish seclusion and restraint, but the push at the international level seems to be shaping the field.

In Australia, seclusion and restraint are essentially regulated by a patchwork of state Mental Health and Disability Acts and a plethora of complicated and confusing policies and guidelines.  For example, in 2013 Gaskin analysed 133 documents from 17 Victorian organisations alone.35  There is also considerable variation between different states and settings. Our project36 and the Australian Law Reform Commission37 have both recommended the development of some kind of uniform national regulatory framework for seclusion and restraint across the mental health, disability and aged care sectors.
I believe that in order to reduce seclusion and restraint there needs to be a regulatory framework with an emphasis on both seclusion and restraint prevention and the setting of guaranteed minimum standards and safeguards for when seclusion and restraint cannot be avoided.  There is also a case for banning or at least restricting the use of prone restraint, as recommended by the Coroner in the Fraser/White inquest.38

However, seclusion and restraint reduction is not going to happen by simply drafting another policy, which brings me to the medical perspective.

8.  The Medical Perspective

While there is a vast medical literature on seclusion and restraint reduction, our project only identified 33 relevant peer-reviewed studies and many of those had methodological flaws.39  Not surprisingly, there are no silver bullets. That is, there is no single intervention strategy for seclusion and restraint reduction.  Rather, researchers are now focussing on multi-intervention strategies.  The most well-known of these is still the National Technical Assistance Centre’s Six-Core Strategies. In the United States use of these strategies has resulted in reported reductions of 47 to 92%.40

The strategies are:

No.

Strategy

Explanation

1

Leadership Towards Organisational Change

This is the overall commitment of an organisation to the reduction of seclusion and restraint, including appropriate systemic practices, allocating responsibility at all levels of an organisation, and obtaining additional resources.

2

Use of Data to Inform Practice

Using data in an empirical, ‘non-punitive’ way to examine and monitor patterns of seclusion and restraint use.

3

Workforce Development

This begins with suitable recruitment, limiting the use of casual/agency staff, ensuring that there are enough staff, regular staff training and support for staff if they experience aggression.

4

Use of Seclusion and Restraint Prevention Tools

For example:

  • Assessing risk and history of trauma;
  • De-escalation safety plans;
  • De-escalation techniques;
  • Good communication;
  • Being attentive to needs and distress;
  • Use of alternatives to seclusion and restraint such as, observation and positive engagement, comfort and sensory rooms;
  • Meaningful structured treatment activities designed to teach people self-management skills.

5

Consumer Roles in In-Patient Settings

This means including consumers, carers and advocates in seclusion and restraint reduction initiatives.

6

Post-Event Debriefing Techniques

 

Conducting an analysis of why seclusion and restraint occurred and how to prevent it in the future.

Of these strategies, the first one that of leadership has had the most empirical testing, although they all have had support from the literature.41  However, the fifth strategy, the use of consumer and carers in restraint and seclusion reduction initiatives has been under-utilised and needs further development.42

In addition, there are three other recent research findings that I think are quite interesting. First, the making of environmental changes including repainting walls warm colours, replacing furniture and use of plants, decorative throws and rugs has resulted in a reported 82.3% reduction which was maintained after 10 years.43 Secondly, the use of a sensory room which contains items to promote feelings of safety and relaxation like weighted blankets, audio-visual material, aromatherapy and stress-balls have been a useful non-cognitive approach to helping people to manage their own emotions and arousal and form better relationships with staff.44  Thirdly, the Safewards model which involves understanding the flashpoints for conflict between staff and patients is being currently trialled in Victoria.45 The survey participants in our project (roughly half being carers and consumers and half being nurses, mental health practitioners and hospital managers) perceived that access to counselling, environmental change, staff use of de-escalation techniques and family involvement were the four most effective seclusion and restraint strategies.46

I know that I have stated that seclusion and restraint can be significantly reduced without compromising safety.  The reason I believe this is that when you look at these strategies, most of them are aimed at understanding and tackling the causes of clinically related challenging behaviour, promoting good communication, understanding and de-escalating conflict, arming staff with options and alternatives, and making health-settings more a pleasant, happier and healthier place to work.  What is very exciting is that the first clinical randomised trial in Finland has recently reported that the six core strategies can result in a decrease in the overall violence on the ward and can work even for high security forensic patients.47  That is, less seclusion and restraint can actually make health-settings safer for everyone.

Going back to Mr White, I wonder if his story might have been different if a comprehensive seclusion and restraint reduction program was in place.  How might he have felt if he entered a warm and welcoming environment with empathetic and engaging staff. Perhaps Mr White or his carers could have been able to help staff understand his triggers for aggression, his anxieties, his fears, his preferences if seclusion and restraint is unavoidable and his history of trauma at the time of his admission, long before any crisis.  What if staff, noticing that he was restless and unsettled, were more attentive to his needs and had talked to him about why he was so agitated and what could be done to help him feel calmer.  Perhaps, he could have been offered some medication as a temporary measure, although I say this tentatively as I have some concerns about potentially swapping physical for chemical restraint.  When and how medication should be used to manage behaviour is an issue that I believe requires further exploration and discussion between doctors and lawyers.  Maybe Mr White would have been soothed by spending some time in a sensory room, rather than a seclusion room, or by talking to and getting reassurance from a peer worker.  Perhaps, instead of jumping on him, when staff saw his fist rise, they could have used de-escalation techniques and tried to ‘talk him down’ first.  Maybe, the prone position could have been avoided or implemented for a shorter time and more carefully. Then, even if Mr White still ended up being restrained or secluded, at least there would be a sense that everything that could be done had been done to prevent it and that there would be a subsequent debriefing to prevent the use of further restrictive interventions in the future.

9. Conclusion

Law and medicine have much to contribute to the reduction and eventual elimination of seclusion and restraint.  While it would be naïve to say that the relationship between law and medicine is always a happy one, there is much to be gained by collaboration, looking for common ground and exploring differences. Neither discipline is likely to succeed on its own.

Patricia Recupero and colleagues have observed:

Experience has shown and research has confirmed that attempts to reduce or eliminate R&S…[restraint and seclusion]… by means of regulation alone are unlikely to produce overall beneficial changes in the therapeutic milieu.  Success stories from the literature illustrate the importance of comprehensive treatment-improvement strategies rather than attempting to enforce blind compliance with strict regulations.48

Further, regulatory frameworks need to be supported and actually implemented by medical and security staff.

At the same time, regulation forms the backbone of most seclusion and restraint reduction strategies and is important for providing clear direction, setting standards, creating safeguards, oversight and accountability.  The legal perspective also reminds us that human rights are at stake and should not be transgressed lightly, while international human rights bodies challenge us to be more ambitious and to aim for elimination rather than just reduction.

As the European Committee Against Torture have observed a comprehensive policy is not only a:

major support for staff, but is also helpful in ensuring that patients and their guardians or proxies understand the rationale behind a measure of restraint that may be imposed.49

Therefore, law and medicine are mutually reinforcing and must work together to celebrate a new era in the management of clinically-related challenging behaviour in health settings.

Footnotes

1 Melbourne Social Equity Institute (2014) Seclusion and Restraint Project Report, Melbourne, University of Melbourne, Ch 2.

2 Nick Bilanakis, George Kalampokis, Konstantinos Christou and Vaios Peritogiannis, 'Use of Coercive Physical Measures in a Psychiatric Ward of a General Hospital in Greece' (2010) 56(4) International Journal of Social Psychiatry 402; Nikolaos Bilanakis, Georgios Papamichael, Vaios Peritogiannis, 'Chemical Restraint in Routine Clinical Practice: A Report from a General Hospital Psychiatric Ward in Greece' (2011) 10(4) Annal of General Psychiatry 1.

3 White, Peter, Coroner, ‘Inquest into the Deaths of Justin Fraser and Adam White’ Coroners Court of Victoria, 13 March 2013.

4 White, Peter, Coroner, ‘Inquest into the Deaths of Justin Fraser and Adam White’ Coroners Court of Victoria, 13 March 2013.

5 For example, Mental Health Act 2014 (Vic), s3.

6 For example, Mental Health Act 2013 (Tas), s3.

7 National Mental Health Consumer and Carer Forum, 'Ending Seclusion and Restraint in Australian Mental Health Services' (2009) 4.

8 For example, Mental Health and Related Services Act (NT) ss61(3), 62(3).

9 For example, Mental Health Act 2000 (Qld), ss 9 & 162M.

10 For example, Mental Health Act 2009 (SA), s7(h); Mental Health Act 2014 (Vic), s105.

11 For example, Centers for Medicare and Medicaid Services, 'Appendix a - Survey Protocol, Regulations and Interpretive Guidelines for Hospitals' (2014) 3244F , §482.13(e).

12 B Paterson et al, 'Corrupted Cultures in Mental Health Inpatient Settings.  Is Restraint Reduction the Answer?' (2013) 20 Journal of Psychiatric and Mental Health Nursing 228.

13 National Health Service, 'Meeting Needs and Reducing Distress: Guidance on the Prevention and Management of Clinically Related Challenging Behaviour in NHS Settings' (2014) 10. (accessed 27 June 2010).

14 Ibid.

15 Ibid.

16 For example, Rick van der Zwan, Lynn Davies, Doug Andrews, Anna Brooks, 'Violence in the ED: Issues Associated with the Implementation of Restraint and Seclusion' (2011) 22(2) Health Promotion Journal of Australia 124.

17 For example, Disability Act 2006 (Vic) and  Disability Services (Restrictive Practices) and Other Legislation Amendment Act 2014 (Qld).

18 The Australian Medical Association is currently reviewing its position statement on the use of seclusion and restraint in older persons: Australian Medical Association, ‘Restraint in the Care of Older People’ (4/2/2014) (accessed 27 June 2014).

19 National Health Service, 'Meeting Needs and Reducing Distress: Guidance on the Prevention and Management of Clinically Related Challenging Behaviour in NHS Settings' (2014) (accessed 27 June 2010).

20 https://mhsa.aihw.gov.au/services/admitted-patient/restrictive-practices/

21 For example, Joy Duxbury, Frances Aiken and Colin Dale, 'Death in Custody: The Role of Restraint' (2011) 2(4) Journal of Learning Disabilities and Offending Behaviour 178.

22 For example, Deputy State Coroner  Milovanovich, ‘Inquest into the Death of Mark Ian Hare’ Coroners Court of New South Wales, 29 July 2009; Cavanagh, Greg, Coroner  ‘Inquest into the Deaths of Robert Plasto-Lehner and David Gurralpa aka Moscow’ [2009] NTMC 014; Alastair Hope, Coroner, ‘Inquest into the Death of Warwick Andrew Ashdown’, Coroners Court of Western Australia, 23 November 2011.

23 For example, King, Barry Paul, Coroner ‘ Inquest into the Death of Antoinette Williams’ Coroners Court of Western Australia, 25 February 2014.

24 Johns, Mark Frederick, Coroner ‘Inquest into the Death of Ruth Ann Dicker’ Coroners Court of South Australia, 15 September 2013.

25 Chief Psychiatrist ‘Quality Improvement Themes from Coronial Recommendations Reviewed by the Chief Psychiatrist in 2005’ 2

26 Abraham Taub Maryam Rakhmatullina, Theresa Jacob, 'Morbidity and Mortality Associated with the Utilization of Restraints: A Review of Literature' (2013) 84 Psychiatric Quarterly 499.

27 Ibid; Julie Merineau-Cote and Diane Morin ‘Restraint and Seclusion: The Perspective of Service Users and Staff Members’ (2014) 27 Journal of Applied Research in Intellectual Disabilities 447-457.

28 Ibid.

29 A Putkonen et al, 'Cluster-Randomised Contolled Trial of Reducing Seclusion and Restraint in Secured Care of Men with Schizophrenia' (2013) 64 Psychiatric Services 850.

30 White, Peter, Coroner, ‘Inquest into the Deaths of Justin Fraser and Adam White’ Coroners Court of Victoria, 13 March 2013. para 66.

31 B Paterson et al, 'Corrupted Cultures in Mental Health Inpatient Settings.  Is Restraint Reduction the Answer?' (2013) 20 Journal of Psychiatric and Mental Health Nursing 228.

32 Committee on Rights of Persons with Disabilities, Concluding observations on the initial report of Australia, adopted by the Committee at its tenth session (2-13 September 2013), CRPD/C/AUS/CO/1 (Advance Unedited Version, 4 October 2013) 36.

33 Human Rights Council, Report of the Special Rapporteur on torture and other cruel, inhuman or degrading treatment or punishment, Juan E. Méndez A/HRC/22/53 (1 February 2013) [63].

34 Melbourne Social Equity Institute (2014) Seclusion and Restraint Project Report, Melbourne, University of Melbourne, 122.

35 CJ Gaskin ‘Reducing Restrictive Interventions: Literature Review and Document Analysis’ (Department of Health, Victorian Government, 2013). (accessed 16 April 2015).

36 Melbourne Social Equity Institute (2014) Seclusion and Restraint Project Report, Melbourne, University of Melbourne, 163.

37 Australian Law Reform Commission, 'Equality, Capacity and Disability in Commonwealth Laws' (2014) Discussion Paper 81, recommendation 8-1 & 8-2.

38 White, Peter, Coroner, ‘Inquest into the Deaths of Justin Fraser and Adam White’ Coroners Court of Victoria, 13 March 2013. 46

39 Melbourne Social Equity Institute (2014) Seclusion and Restraint Project Report, Melbourne, University of Melbourne, 44, Appendix 3.

40 Ibid, 45.

41 Ibid, 45-7.

42 Ibid, 54.

43 JJ Borckardt et al, 'Systematic Investigation of Initiatives to Reduce Seclusion and Restraint in a State Psychiatric Hospital' (2011) 62 Psychiatric Services 477.; Alok Madan et al, 'Efforts to Reduce Seclusion and Restraint Use in a State Psychiatric Hospital: A Ten-Year Perspective' (2014) 65(10) ibid.1273.

44 Daniel Sutton et al, 'Optimizing Arousal to Manage Aggression: A Pilot Study of Sensory Modulation' (2013) 22 International Journal of Mental Health Nursing 500; Tina Champagne and Nan Stromberg, 'Sensory Approaches in Inpatient Psychiatric Settings: Innovative Alternatives to Seclusion and Restraint' (2004) 42(9) Journal of Psychosocial Nursing and Mental Health Services 34.

45 Len Bowers, 'Safewards: A New Model of Conflict Containment on Psychiatric Wards' (2014) 21 Journal of Psychiatric and Mental Health Nursing 499; Len Bowers et al, 'Safewards: The Empirical Basis of the Model and a Critical Appraisal' ibid. 354.

46 Melbourne Social Equity Institute (2014) Seclusion and Restraint Project Report, Melbourne, University of Melbourne, 44, 98.

47 A Putkonen et al, 'Cluster-Randomised Contolled Trial of Reducing Seclusion and Restraint in Secured Care of Men with Schizophrenia' (2013) 64 Psychiatric Services 850.

48 Patricia R. Recupero, et al, 'Restraint and Seclusion in Psychiatric Treatment Settings: Regulation, Case Law, and Risk Management' (2011) 39(4) Journal of the American Academy of Psychiatry and the Law 465.

49 European Committee for the Prevention of Torture and Inhuman or Degrading Treatment and Punishment (CPT), 'CPT Standards' (2013) 62.