Restraint and isolation: what lessons have been learned since Winterbourne View?

The Care Quality Commission is reviewing the treatment of people with learning disabilities and autism in inpatient settings to ‘eliminate inappropriate restrictive practices’

The Care Quality Commission is reviewing the treatment of people with learning disabilities and autism in inpatient settings to ‘eliminate inappropriate restrictive practices’

Picture: iStock

It is more than six years since the government published its response to the Winterbourne View Hospital scandal.

Among the many findings of the report was a warning about the misuse of restraint, which it said was a problem in assessment and treatment units. But despite countless promises things would change, the issues remain.

Last year, the health and social care secretary Matt Hancock ordered the Care Quality Commission (CQC) to review the treatment people who have learning disabilities and autism receive in inpatient settings.


episodes of restraint in England between 2016 and 2017

Source: NHS Digital 

‘Increasingly concerned’

Mr Hancock acted after hearing from families whose loved ones had spent months in isolation or experienced restraint. In a letter to the CQC, he said he had become ‘increasingly concerned’ and wanted the review completed as quickly as possible to ‘eliminate inappropriate restrictive practices’.

The Joint Committee on Human Rights, which includes MPs and peers, is also looking at the units as part of a wider inquiry on detention.

After sitting through hearings, committee chair Harriet Harman says she is worried about the ‘steady stream of claims’, adding that: ‘These units are supposed to care for some of the most vulnerable people and yet it seems some are failing this task.’

So what do we know?

Figures from NHS Digital show the number of incidents in England involving restraint and people who have learning disabilities and autism rose by 50% between 2016 and 2017 to just over 22,600. Projected figures for 2018 suggest it will rise again.

Guidance on proportion

The crucial unanswered question is what proportion of these incidents are unnecessary or incorrectly carried out? The guidance says the use of restraint should be for the shortest time possible – and should only be used as a last resort.

The CQC plans to talk to all people with learning disabilities and autism who have spent time in confinement and been subject to restraint.


rise in number of incidents in England involving restraint and people with learning disabilities and autism between 2016 and 2017

Source: NHS Digital 

CQC deputy chief inspector of hospitals Paul Lelliott says this process will take some time – the final report is not due until March 2020. It is taking so long because he wants to delve into the ‘individual circumstances’ of why each patient has ended up in that situation.

‘I’m sorry we cannot do it any sooner,’ he adds.

But Dr Lelliott is promising to share lessons as the review progresses – an interim report is expected this summer – and escalate concerns about individual cases if they arise.

Flawed system

RCN learning disability nurses’ forum chair Simon Jones is convinced the system is ‘flawed’.

Simon Jones: ‘We need people to have
their own space where they can be
cared for.’ Picture: David Gee

‘Putting people in these communal settings when they are stressed, agitated and have difficult behaviours is the worst place for them to be.

‘They’re surrounded by others in a similar situation and that makes things worse. When they get even more stressed, then staff often have no other option than to isolate or restrain, or both, to keep them and others safe. It’s depressingly obvious.’

He is also concerned about training – the guidance recommends preventive approaches and de-escalation techniques are used – saying restraint often becomes the ‘first resort’ rather than last.

‘What we need is people to have their own space – where they can be cared for and one which provides a calming environment. There are examples of this but they are few and far between.’

He says the system also needs to address the ‘logjam’ that causes so many people to be placed in hospitals rather than the community.

Debra Moore: ‘High use of agency
and inexperienced staff may affect
safety.’ Picture: Neil O’Connor

Independent learning disability nurse consultant Debra Moore adds: ‘The high use of agency and inexperienced staff may affect safety. If you don’t know the person well you may use restraint to contain a situation you could have de-escalated.’

She also says there needs to be a close look at services which have very low seclusion and restraint figures ‘to find out what needs to be in place to achieve this everywhere’.

'I’ve had to speak to my daughter through a hatch'

One of the cases behind the review is that of Bethany. She is 17 and has autism. She has spent the past two years in a secure hospital.

Her father, Jeremy, says most of that time she has been in seclusion, locked in a cell with ‘no treatment and no therapy’ because she has struggled with the unit’s environment, and the staff have found her behaviour too challenging.

‘It is full of distressed people. With Bethany’s condition, she has massive sensory issues. She cannot cope,’ says Jeremy.

No privacy

He adds that she has no privacy, is watched in the shower and when she goes to the toilet.

‘I cannot imagine how my daughter copes with that situation,’ he says.

On occasions when Jeremy visited he had to kneel down at a hatch in the door to speak to her.

‘If the right people were doing the right things you would not know that Bethany has autism. She is the most wonderful, engaging and funny child you could meet.’

In a statement St Andrew’s Healthcare says it could not comment on the care being provided to a patient without their consent, but that it is a priority is to provide the ‘best possible care’.

The statement added: ‘Where patients find interaction with other patients unsettling every effort is made to mitigate this by the use of bespoke environments with permanent staff.’


Restraint sometimes necessary

NHS England national learning disability director Ray James agrees that more progress needs to be made.

He says the figures on restraint are concerning, particularly the use of ‘prone’ whereby patients are held face down – more than 13% of cases in 2017 involved prone restraint.


of restraint cases in England involved prone restraint in 2017

Source: NHS Digital

However, he believes some of the rise may be down to ‘better reporting’ and has defended the use of restraint, saying it is sometimes needed to assess, identify treatment or because the individual has a mental health condition.

He says staff need good training and more people need to be treated in the community.

‘The aspiration should always be to help the individual live the life they want and to live it as independently as possible.’

How one trust reduced the use of restraint

Mersey Care NHS Foundation Trust has introduced a programme called No Force First to reduce the use of restraint.

Piloted in 2013 it is being rolled out to all inpatient wards providing care to people with mental health problems and learning disabilities.

Staff have been encouraged to take several steps. These include carrying out debriefs with staff and patients when restraint is used, scrapping blanket rules that cause conflict, seeking to run activities tailored to individual needs and having ‘positive handovers’ between staff.

Some wards have also introduced their own measures, including allowing families to visit outside visiting hours to assist with meals.

In the space of a year the use of restraint had dropped by more than one third and assaults on staff by one fifth.


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