Confinement, restraint, seclusion and forcible giving of medication

It is important to have a clear understanding of the terms used in association with confinement, restraint, seclusion and forcible giving of medication.

There is a commitment to reducing and where possible, eliminating interventions that are considered restrictive and you should regard these interventions as a last resort option to prevent imminent harm to the person, others or to property.

Considerations

Under the Mental Health Act 2015, only a person on a mental health order can be confined, restrained, secluded or forcible given medication.

There may be occasions where you deem it appropriate to restrict the liberty of a person who is at immediate risk of harm to themselves or someone else under ‘duty of care’. This is beyond the scope of the information provided on this page.

Restraint or seclusion of a person who is not on a mental health order, and doesn’t meet criterial under ‘duty of care’, may be deemed as illegal detention by the courts, with the person involved in the illegal detention being open to possible legal and/or professional sanctions.

For an explanation of all technical definitions and terms used, refer to the definitions of terms in the Act.

Key Terms

Confinement

Confinement is defined as any restriction of movement or liberty of a person that does not include seclusion.

Restraint

The restriction of an individual’s freedom of movement, including mechanical restraint, physical restraint, and the forcible giving of medication.

The time in restraint is kept to the absolute minimum necessary.

Clinicians and staff who use therapeutic holds must be trained and approved through approved courses such as predict, assess and respond (PART), to violence prevention and management (VPM) or similar de-escalation and aggression management training programs.

Mechanical restraint is the application of devices, including belts, harnesses, manacles, sheets and straps to a person’s body to restrict their movement. This is to prevent the person from harming themselves or endangering others, or to ensure that essential medical treatment can be provided.

It does not include the use of furniture, including beds with cot sides and chairs with tables fitted on their arms, that restricts the person’s capacity to get off the furniture, except when the devices are only used to restrain a person’s freedom of movement.

The use of a medical or surgical appliance for the proper treatment of physical disorder or injury is not considered mechanical restraint under the National Quality and Safety Health Care Standards.

Seclusion

Under the Australian Institute of Health and Welfare data dictionary, seclusion is defined as the confinement of a patient at any time of the day or night alone in a room or area from which free exit is prevented.

A person who is secluded is usually placed alone in a room or area, with the door closed and advised that they cannot leave.

You should ensure people in seclusion are kept under close observation and the time in seclusion is kept to the absolute minimum necessary.

Forcible giving of medication

Forcible giving of medication is defined as the therapeutic use of medication, against a person’s will, to prevent any immediate and substantial risk of the person causing harm to themselves or someone else. The treatment provided at this time can only be to minimise immediate risk, rather than for longer-term improvement, under the Mental Health Act 2015.

This is limited to treatment, care or support that will not impact the person’s function for longer than 3 days. The Act provides an exception if a person has a mental illness for which, in the opinion of a psychiatrist, the most appropriate treatment is long acting medication.

Where a person presents who is well known to the service and has been well-maintained in the community on a long acting antipsychotics, is unwell and needs to be provided with involuntary care, you can use the long-acting medication that has previously kept them well.

The Senior Practitioners Act (2018) refers to the use of medication or a chemical substance for the primary purpose of influencing a person’s behaviour or movement as chemical restraint. This excludes the use of a chemical substance that is prescribed by a medical practitioner or nurse practitioner for the treatment, or to enable the treatment, of a mental or physical illness or condition in a person and used in accordance with the prescription.

Any provider exercising a function under the Mental Health Act 2015 or the Mental Health (Secure Facilities) Act 2016 is also excluded from this definition.

Clinical practice tips

Medical examination

Any person who is restrained or secluded must be examined by a doctor immediately following the restraint and, if the person secluded, at least once every 4 hours.

Authorisation of seclusion

A period of seclusion must always be authorised by a consultant psychiatrist. Ideally, the psychiatrist will have assessed the person immediately prior to authorising the seclusion. If a consultant psychiatrist is not immediately available and a person is in immediate danger of harming themselves, nursing staff may authorise restraint or seclusion. The person in charge must then seek authorisation for the seclusion from the consultant psychiatrist via telephone, confirming the period for which seclusion is authorised.

If authorisation is not provided by the consultant psychiatrist, the person must be released from seclusion immediately.

In the ACT, every person who is secluded is placed on an at-risk category (ARC) score of 5 and must:

be under constant visual observation and if they are still or asleep the nursing observations must note respirations
undergo a physical and mental health assessment every 4 hours by a psychiatric registrar or medical officer
have a new authorisation requested and approved if ongoing seclusion is required after 4 hours.

Debriefing

Anyone who directly experiences or participates in an intervention that is considered restrictive must be offered debriefing as soon as practicable.

Reporting and documentation

The following documentation must be completed in relation to above interventions:

A record in the person’s clinical record indicating the fact of and the reasons for the use of intervention.
The relevant registers held in the unit or ward such as seclusion, restraint or forcible giving of medication registers.
A Riskman event.
Public Advocate must be notified in writing.

If more than one of the above interventions is used, both the restraint and forcible giving of medication registers must be completed.

Responsibilities of key people

Under the Act, these people have responsibilities if a person is confined, restrained, involuntarily secluded or forcible given medication.

Chief Psychiatrist

The Chief Psychiatrist or their delegate may authorise the restraint, seclusion, or forcible giving of medication of a person.

Facility lead

The person in charge of the facility must:

ensure that the reasons for and the details of the confinement, restraint, involuntary seclusion or forcible giving of medication are documented in the person’s clinical record
ensure that the person is examined by a doctor, in person, at least once in every four-hour period during which the person is involuntarily secluded and after any restraint
advise the Public Advocate in writing of the restraint, involuntary seclusion or forcible giving of medication
keep a register of the restraint, involuntary seclusion or forcible giving of medication
ensure that the person has adequate opportunity to contact the Public Advocate or their lawyer.

Clinicians

All clinicians involved in the use of confinement, restraint, involuntary seclusion or forcible giving of medication should ensure that:

the use of these interventions is kept to an absolute minimum
any force used must be the absolute minimum needed. This means the minimum number of people necessary are involved and the least force required to ensure the safety of the person, staff and others are used
their involvement in such an intervention is documented in the person’s clinical record and all relevant registers.

Reduction of restrictive practices

Reducing and, where possible, eliminating practices considered restrictive in mental health services is a key national mental health safety and quality priority.

A reduction and elimination plan is a written plan developed by an authorised doctor that provides for the reduction and elimination of the use of mechanical restraint or seclusion on a relevant patient. While some mental health legislation in Australia mandates the use of these, there is no such reference in the ACT’s Act.

The Chief Psychiatrist recommends that a person whose behaviour is repeatedly considered to be threatening to themselves or others and whose symptoms fail to respond to a full range of clinical interventions should be reviewed including:

the person’s history, treatments attempted and their duration, medications administered and responses, as well as the impact of contextual factors such as organisational factors, the environment and team functioning
an exploration of the static and dynamic factors associated with the repeated behaviour
the development of a management plan, detailing strategies to be used to reduce and where possible eliminate the need for further restrictive practices.