Over the last few years, there have been many assumptions around prone restraint and what we are allowed or not allowed to do.
These assumptions have ranged from ‘total ban’ to time limits and only certain persons can be restrained.
Because of this ambiguity, there are training providers who refuse to cover prone restraint in their syllabus. The major problem with this approach is that staff, when confronted with challenges that exceed the limited training they received, do their own thing without the appropriate training to fall back on. This leads to risky situations where the person being restrained is subject to holds that might be harmful and unlawful, not only putting the person at risk of harm but the service provider at risk from litigation, fines, inspections and improvement notices.
Another outcome from uncertainty surrounding prone restraint is misreporting or inaccurate terminology. Whilst this appears to improve statistics and reports, it really only amounts to false reporting, with service user still in the same position of risk. Not calling it prone restraint doesn’t change what it is!
So what does the law actually say about prone restraint?
To answer this let’s look at what law and guidance exist in this field.
Firstly, and perhaps most importantly, there is the Mental Health Act 1983 (amended 2007) and the accompanying Code of Practice. Chapter 26 of the code of practice is actually very specific on the use of prone.
Unless there are cogent reasons for doing so, there must be no planned or intentional restraint of a person in a prone position (whereby they are forcibly laid on their front) on any surface, not just the floor.
What does this mean? The code is suggesting that prone restraint must be avoided in the context of planned interventions, such as the likes of care plans stating to use prone restraint in the first instance, or premeditated prone restraints by staff.
And although the guidance here is that they must be avoided, it does stipulate, ‘cogent reasons’, in recognition of times when planning a prone restraint is the safest, least restrictive or most person-centric option. In these situations, responsibility for evidencing why the decision to plan a prone restraint was taken sits with the service provider.
It is also important to discuss unplanned prone restraint. Typically there are 3 main occasions when an unplanned prone restraint is likely to be used.
Firstly, there are occasions when the service user ‘drops’ themselves to the floor. Whilst not directly instigated by the staff, we should record it as a service user-directed action, after all- if the person is still held in a prone manner, it is still a prone restraint.
This ideology is supported by BILD, the British Institute of Learning Disabilities and their forthcoming restraint guidance which states any time a person is held face down is and must be accurately recorded as, prone restraint, irrespective of the reason for which that position was adopted. The reason for the position must be fully detailed in the relevant reports and documentation.
The second main reason for unplanned prone restraint commonly falls under the category of risk. This is pertaining to when a person behaviour is so extreme and dangerous, it is impossible to contain safely without the use of prone restraint, and to not use it would incur a greater element of harm, either to the person under restraint or to other people affected by the aggression.
Lastly, prone restraint is often required for various clinical reasons, such as administering intramuscular injections (commonly called IM medication) as part of a rapid tranquillisation restrictive intervention. Other reasons may include blood testing and medical care.
In the last few years, it has become commonplace for services to record these as ‘Clinical Holds’ to avoid documenting prone restraints, and it is this that BILD wants to bring to an end. Any time a person is held face down, prone restraint should be documented, and the reason for the prone restraint may be explained under a clinical purpose.
National Institute of Clinical Excellence Guideline NG10
Replacing NICE Guideline 25 in 2015, NG10 sets our the principals for safer management of violent behaviour in mental health, health and within community settings.
Paragraph 1.4.24 under manual restraint provides the following guidance:
When using manual restraint, avoid taking the service user to the floor, but if this becomes necessary:
- use the supine (face up) position if possible or
- if the prone (face down) position is necessary, use it for as short a time as possible.
This guidance sits very well under the GSA model of physical intervention as we adopt a hierarchical approach to restraint, always starting at the lowest possible level and only ever advancing to more restrictive interventions when the risk has escalated beyond what the current intervention can safely contain. It also very clearly permits the use of prone restraint, but only at times when facing up (supine) has either been tried, or cannot be used for whatever reason.
To a lesser extent, there are other laws which, when prone restraint is used appropriately may support staff in its use.
The main focus here is the Criminal Law Act 1967.
Section 3(1) of the Criminal Law Act states:
A person may use such force as is reasonable in the circumstances in the prevention of crime, or in effecting or assisting in the lawful arrest of offenders or suspected offenders or of persons unlawfully at large.
This significance in law for the purpose of this discussion is where a person is subject to criminal assault, they have the right to use force to protect themselves, or aid others subjected to unlawful force. Whilst the law here does not actually directly reference restraint at all, the use of prone restraint may well fall under the terms of ‘reasonable’ in the ‘circumstances’.
Reasonable being an approved, taught and well-implemented skill, which will inevitably be a lower level of force compared to other types of self-defence such as physically fight back against an aggressor.
The ‘circumstances’ would ultimately be the reasons why the staff had to use prone restraint to stop the unlawful aggression over other types of restraint.
An example of this could be illustrated in the scenario of a supine restraint occurring, without a person being available to contain the aggressor’s legs, giving them free rein to kick the staff. This type of assault could lead to serious injury and harm, and thus it could be considered reasonable in these circumstances to use prone restraint to protect the staff from this assault.
In summary, the use of prone is both legal and can be carried out ethically, for the right reason and in a wide variety of scenarios. However, what is important to remember are the limitations and requirements for its use.
Firstly, it must always be truthfully and fully reported and documented.
It must always be used where there are no other safer and less restrictive alternatives.
All other alternatives must be duly considered and where not possible, the reasons clearly explained.
The safety of the person and others affected by their actions remains of paramount importance at all times.
Staff should be well trained with a wide scope of skills, that relate the risks they work with.
For more information, or arrange a consultation on how we may be able to support your service and this sensitive subject, please feel free to call us on:
01508 218017 or email firstname.lastname@example.org