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Supporting the challenging behaviour foundation's statement on RPI

The Challenging Behaviour Foundation have produced a position statement regarding Restrictive Physical Interventions for Children and Young People that Team Teach almost fully agrees with as accurate and helpful. We have written to them offering our support, with regards to the information they are distributing concerning “face down” positions.

Dear Vivien Cooper,

I have just finished speaking to Jessie, who suggested that l email you concerning my anxieties about some of the misleading and outdated information provided on your web site and sent to services and employers regarding restrictive physical interventions and children.

I would like to make it quite clear, that l am fully supportive of the great majority of the information provided and believed that if we could agree a joint approach, then we would be more likely to secure better outcomes for all involved. I am keen to help you make a positive difference to the lives of children and adults across the UK.

Maintaining a position that face down restraint should never happen is idealistic and unhelpful. With regard to face down restraint, l believe our energies should be put into making sure that the techniques that people use, are used rarely, but when so, are carried out in a highly personalised and documented risk assessed approach, with a record, report and review process built in, with an aim to eliminate their use as soon as possible. We should also focus on making sure that those who use such a technique have the knowledge, skill and understanding required to reduce risk to the foreseeable minimum.

The serious case review into abuse at Winterbourne View recommended that supine restraint should be banned, not prone. This has not stopped training organisations who use supine holds campaigning for a ban on prone restraints, which they do not use. Prone has never been banned.

“Guidance provides information and good practice but is not statutory guidance or legally binding. Providers can choose to depart from the Guidance but may be asked (e.g. by court or CQC) to justify their reasons for doing so.”

(NHS Protect consulted DH and HSE; DH provided following clarification “It is accepted that there may be exceptional circumstances where the use of prone restraint will happen…On rare occasions, face down restraint may be the safest option for staff and service users, with few, if any, viable alternatives.” (NHS Protect, March 2015)

Guidance from the Department of Health, in the form of a revised Code of Practice for the Mental Health Act 1983, was published in January 2015. This contains some useful clarifications.

The new wording is more careful than that used in the April 2014 document. “Positive and Proactive Care”, avoiding the ‘absolute’ terminology that has created problems so many times in the past. For example, instead of a blanket ban on prone restraint in all circumstances, the wording is now that prone restraint should be avoided unless there is a “cogent reason”. for using it. That phrase should really be applied to all forms of restraint and restriction. Nobody should be using any form of restraint or restriction unless there is a cogent reason for doing so. (Why do anything unless there is a cogent reason?)

Employers, leaders and managers are legally obliged to make and evidence decisions that they believe to be in the best interests of the people they educate and care for, including adopting appropriate risk reduction and positive behaviour strategies as identified in individual positive handling plans and risk assessments.

We have received no evidence or data, (we monitor ground recovery reports every 6-8 weeks returned from services) in the last 10 years, to suggest that there are any significant injury patterns arising from the use of such specific Team Teach responses.

“The Welsh Assembly Government is of the view that no restrictive physical intervention technique is 100% safe and should therefore be avoided wherever possible. Best practice suggests prevention to avoid restraint, through positive risk management and finding alternative ways of dealing with the situation. Providers should undertake a full risk assessment before any technique is employed and staff should be properly trained or practised in using restraint.

The ‘Framework’ is not statutory guidance, but sets out general principles that should inform practice on the use of restrictive physical intervention. Practitioners should continue to use their professional judgement to determine whether use of a particular restraint technique is an appropriate response to a given situation. It does not have the power to prohibit the use of a particular physical intervention technique but should be regarded as a “best practice” guidance. (Graham Davies Pupil Engagement Team WAG 20/1/09)

The Smallridge and Williamson review (June 2008) of restraint in juvenile settings provides a balanced and informed view in this area.

“Our conclusion is that some, but not all, prone restraint positions have a significant effect on breathing. It is clear that recommendations given previously, either to consider all prone restraint as dangerous or to consider prone restraint as presenting no additional risk, are not supported by empirical results.”)

And “We are aware that the secure estate is looking to us for guidance on prone restraint. But there are no simple answers. We are wary of over-simplification over prone restraint and are cautious on the issue. Where a young person is held face down with pressure only on the limbs the evidence is that there is likely to be only a small effect on lung function, and in these cases prone may be quite safe for most young people, for most of the time. However, more ‘forced’ prone restraint, when body weight is applied to the back or hips may be unsafe for almost everyone ( 6.34).

In the light of the competing evidence we feel that we cannot make any recommendation to ban prone restraint, but we consider it prudent that when prone restraint is used there should be a re-assessment of the risks after control has been obtained in the initial restraint. There should be procedures in place to ensure that a senior member of staff responds to the incident, assesses the situation, evaluates the competing risks and implements an alternative to prone if safety demands.” (6.35)

In 2003 and 2011, Coventry University carried out 2 studies into blood oxygenation levels in individuals during periods of being held in accepted restraint positions. The early study compared blood oxygenation levels from standing to prone and standing to supine to attempt to establish if one position was more of a risk then the other. They found that there is less than a 5% decrease in these levels in either position. This means that the actual reduction is not statistically significant in either the prone or supine position. It also established that there is no difference in oxygenation levels when comparing prone to supine providing no pressure was applied to the torso. The second study examined blood oxygenation levels from standing to the seated position. This study found that there was a statistically significant decrease in blood oxygenation levels when an individual is placed in the seated position, when leaning forward and being held. This is compounded when an individual has a BMI of more than 25. This would suggest that external factors such as the health of the individual, pressure applied to the abdomen and relative body position (i.e. leaning forward) have a much greater impact on blood oxygenation levels than first thought. Therefore the prone position itself is unlikely to be the cause of death. It is far more likely that pressure applied to the torso or a separate health risk is in fact the compounding factor. It is important that all physical risks are identified in robust personalised planning and review. Equally, it is essential that de-escalation strategies that affectively reduce the risk of restraint are employed rather than relying on “safe” restraint techniques. It is far more effective to address the risks involved in restraint by not applying restraint.

Health and Safety legislation (1974 & 1996) and The Children Act (1989) should drive decision makes in this area. Employers and employees are required to comply and be able to demonstrate, how they have complied with health and safety legislation and how they have acted (steps taken) in the best interests of children.

As a training provider, Team Teach (following a pre visit audit of need) will deliver core knowledge and understanding, plus where risk appropriate, a limited range of agreed physical techniques, selected from a hierarchy of responses: from a possible range involving standing, seated and ground techniques: the latter from a range of supine, prone and side shield ground position.

A blanket ban prohibits such a safeguarding approach and potentially places the child and staff in more danger. Without the use of the Ground Recovery Response, it is likely that there will be an increase in the use of mechanical restraints, possible use of pain compliance techniques and seclusion. Also, it is foreseeable that some children’s services may well decide that certain individuals are beyond the level of their safe care. It may result in staff still using a prone hold, but with no training or knowledge to safeguard and reduce risk.

This is why we provide staff with the flexibility to select the ground technique that best reduces the risk for all concerned allowing staff to work with and include the child within their service setting.

Employers are legally responsible for providing their staff with the knowledge, understanding and skills that are required to reduce risk in their workplace. These personalised responses to reducing risks should be documented in the individual risk assessments and positive handling plans. It is employers who are legally accountable for maintaining a safe workplace; where an employee feels unsafe, or feels that the children and young people they look after are unsafe, they should bring this matter to the immediate written attention of their employer. Both the employer and employee have recourse to the Health and Safety Executive, as well as the Local Safeguarding Children Board and their MP, should the matters not be resolved in a reasonable and responsible way.

Essentially, if services can do without ground holds, in particular Front Ground Recovery and still maintain a safe workplace, then you would hope that such a “last robust resort” response would not be used. We strongly support and encourage services and individuals to continually look at how they can reduce all aspects of risk and restraint. (See Risk and Restraint Reduction template “Gold Award” provided on the Home Page of the Team Teach web site).

If however, the Front Ground Recovery response has proved, via documented risk assessments, to be a tool that reduces risk, then what viable alternative or placement strategy is going to be used, should this no longer be the case?

Should Front Ground Recovery be no longer used and children or staff get injured as a result, then this could be a costly (physical, emotional and financial) consequence for all involved, especially the employer.

Children, young people and vulnerable adults need staff who feel safe and secure around them. Without the necessary tools to provide a safe working environment, the anxieties of all individuals and as a result, incidents of challenging behaviour will increase. It is very difficult to provide a quality teaching, caring and learning environment when we all feel anxious.

Two U.K high profile restraint related fatalities (Gareth Myatt & Jimmy Mebenga) occurred whilst the individuals were being held in a seated position. Yet there has been no outcry to ban the seated position, just quite rightly the techniques that were used whilst held in the seated position. Rather than a “Two legs good and four legs bad” mentality and a blunt: “Let’s ban the use of the ‘face down’ position”, we should concentrate our energies and discussions, on what went wrong and what can be learned from the applications of the holds in those positions?

As researchers in the U.S.A (“Learning from tragedy: A survey of child and adolescent restraint fatalities” M.A. Nunno et al. Child Abuse & Neglect 30 (2006) 1333 /1342 / 1341) are keen to point out:

“Our caution to policy makers concerned about lowering the risk of serious injury and deaths due to these restraints and building safer therapeutic environments for children is that they may legislate or regulate solutions that give a false sense of safety while actually producing greater risk. Safety might be better served if risk reduction efforts focused on eliminating adverse environmental causes for aggression and violence, eliminating dangerous staff practices (sitting on children, choking or lying on them, placing weight on the their upper torso, and ignoring their distress signals), and strictly enforcing the restraint application standard of self-harm or harm to others. All restraint positions were represented in this sample and all positions can be lethal, especially when misapplied or misused.”

Our techniques have been in use for nearly 20 years, all serious incidents involving any injury to staff and individuals is reported to us and we look to see if there are ways to improve what we do and to reduce risk for all involved. No techniques are risk free, but the evidence, and l welcome those that differ, including the individuals calling for a ban on prone restraint, to attend our advanced course, visit our offices and go through the summary returns we have received during the last decade. Equally, if these individuals have other viable alternatives that would maintain safety levels, l am open to be convinced.

I am keen to offer and share our experiences, our research and evidence base – see case study and research area on our web site, in the hope we can achieve together a more balanced, risk – assessed, health and safety position; rather than take polar positions with the CBF supporting a view that all “face down” positions should be banned.

20 Jan 2016
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