1,880 people were restrained or secluded across mental health services last year
We published a report - The Use of Restrictive Practices in Approved Centres; Seclusion, Mechanical Restraint and Physical Restraint, Activity Report 2020 - that documents the use of these restrictive practices across 66 inpatient mental health centres in Ireland in 2020. The report is the eleventh such publication by the MHC and forms part of its remit to report independently on the quality and safety of mental health services in Ireland.
As had been indicated last year, the MHC in recent months commenced a public consultation process and full review of the rules and code of practice governing the use of restrictive practices in approved mental health centres with the current review process expected to be completed and revised documents issued by mid-2022. The current rules and code of practice came into effect on 1 January 2010 and are currently applicable to all inpatient mental health services in the public, voluntary and independent sectors.
The report shows that there were 5,830 episodes of restrictive practices reported to the MHC in 2020, with 1,880 people being secluded and/or restrained during that time. This represented a decrease from 6,741 combined episodes of seclusion and physical restraint, involving 1,796 residents, in 2019.
In terms of intervention types, the report revealed a significant 21% decrease in episodes of physical restraint over a 12-month period, with 3,990 episodes recorded in 2020, compared to 5,029 in 2019. Physical restraint was used in 73% of centres in 2020, as opposed to 89% in 2019, while 1,211 people were physically restrained in 2020 - 232 fewer people than in 2019 (1,443).
Physical restraint was the most frequently used restrictive intervention. It was used in most centres and accounted for 68% of all interventions in 2020, compared to 75% in 2019. In 2020, 48 centres (73%) reported episodes of physical restraint, while 58 centres reported episodes in 2019.
There were 1,840 episodes of seclusion involving 699 people in 2020, an increase from 1,719 episodes in 2019. The report also noted that seclusion was used in 41% of centres in 2020 - similar to the previous year - and that there were 243 episodes in 2020 where a person was secluded for more than 24 hours (an increase on 225 episodes in 2019), and 74 episodes where a person was secluded for over 72 hours (an increase from 61 episodes in 2019). The average seclusion duration across all approved centres (excluding the Central Mental Hospital) was 14 hours and 12 minutes, while 38% of residents who were secluded were secluded for eight hours or less.
While the use of mechanical restraint was higher in 2020 than in 2019, this practice continues to be relatively uncommon. Two centres – consisting of the Central Mental Hospital and one child and adolescent centre - reported the use of mechanical restraint. All of the reported 150 episodes (which combined lasted just over 3,452 hours, compared to 18 episodes lasting 34 hours in 2019) involved the use of both hand and leg cuffs. In response to the increase in mechanical restraint in a child and adolescent service, the MHC took follow-up steps and required the service to provide specific assurances about the circumstances and manner in which it was being used.
The report also examines some of the published activity data from 2008 to 2020 in order to identify trends. While demonstrating a welcome decrease in physical restraint in 2020, the data shows that the use of physical restraint remains relatively high and the overall figure in 2020 was higher than the figure for 2008. The number of residents experiencing physical restraint has also tended to increase year on year. Seclusion episodes have generally decreased since 2008, with the number of residents undergoing seclusion remaining relatively static. The reduction in episodes of seclusion may be as a result of the Restraint Reduction Strategy (MHC, 2014) which aims to ensure restrictive practices are only used as a last resort.
“It is encouraging once again to see a reduction in the overall use of restrictive practices in 2020,” said the Director of Regulation for the Mental Health Commission, Gary Kiernan. “We know that there is no evidence of a therapeutic benefit associated with the use of seclusion, mechanical restraint or physical restraint, and they should never be regarded as a therapeutic practice.
“Overall, the MHC is concerned that there continues to be an upward trend in the use of physical restraint across approved services in Ireland since 2008. Although the number of recorded episodes of mechanical restraint remains low, there was a significant increase in episodes involving a small number of residents in 2020. The MHC is hopeful that in 2021 and beyond, the frequency of mechanical restraint returns to the low numbers observed in previous years. It is positive to note that 2020 continued the general trend of a decrease in the number of episodes of seclusion since 2008, and that the number of residents who underwent seclusion has not increased in the past 12 years.”
Mr Kiernan continued: “The MHC strongly advocates for the use of de-escalation measures over restrictive practices. For such measures to be successful, it is essential that staff are appropriately trained in de-escalation and in clinical risk management. In 2017, the MHC set mandatory training for all healthcare professionals in approved centres in the prevention, de-escalation and management of violence and aggression. We are hopeful that increased training levels will contribute to the reduction of restrictive practices and we will continue to monitor the situation closely.”
As part of their review of the rules and codes of practice governing restrictive practices, the MHC has undertaken significant public and stakeholder engagement. Details of this consultation process and a comprehensive evidence review will be published in 2022, along with the revised rules and code of practice in 2022. It is hoped that the review - and the launch of a new online restrictive practice notification function for approved centres in the coming months - will allow for improved analysis, increased scrutiny and overall awareness of the use of restrictive practices nationally.
You can read our full statement here.
