What this is
Trust and Respect is the report of the Independent Inquiry into Mental Health Services in Tayside, commissioned by NHS Tayside and chaired by David Strang CBE, who was appointed in July 2018. It reported in February 2020.
It examined the accessibility, safety, quality and standards of care across all of the board’s mental health services. It took evidence from patients, families and staff about acute inpatient wards, including the Carseview Centre in Dundee, and about community services. Chapter 5, on inpatient services, contains a section on control and restraint.
What it records
The inquiry recorded that restraint causes “anxiety, fear and feelings of humiliation”, and that it can traumatise the patients restrained and the people who witness it.
Patients described being handled by up to six staff, held face down with staff kneeling on their back, and given intramuscular injections.
An internal review found that not all instances of control and restraint were accurately recorded, which the inquiry said made managerial monitoring impossible.
Staff told the inquiry that restraint was overused, that they were expected to restrain without training, and that practice varied between wards.
The report said patients should not be placed prone “whenever possible”, and made 51 recommendations under five cross-cutting themes.
How to read it
This is a finding about a system, not about an incident. It tells you nothing about what happened to any one patient, and it should not be cited as though it did.
The finding worth carrying is the one about records. If the only account of a restraint is written by the staff who carried it out, and the patient’s account is not in it, then nobody can see how often restraint happens, on whom, or whether the technique used was the one taught. Overuse and technique both disappear into the same gap.
The recommendation on prone is phrased as a preference, “whenever possible”, not a prohibition. A reader looking for a rule to quote will not find one there, and should not turn a preference into a ban.
Where it stops
One health board, one set of services, and evidence gathered before February 2020. It is a statement about Tayside’s mental health services in the late 2010s, and about no other board.
It was commissioned by the board, not by a court, so it makes recommendations rather than findings of liability. No proceedings followed. NHS Tayside accepted the report, an Independent Oversight and Assurance Group reported progress to the Scottish Government, and the inquiry team published its own progress review in July 2021. This page does not assess whether the 51 recommendations were implemented.
The report prints February 2020. The inquiry website gives 5 February 2020. No single day is asserted here.
Sources
- Independent Inquiry into Mental Health Services in Tayside, Trust and Respect: Final Report of the Independent Inquiry into Mental Health Services in Tayside, February 2020
- Independent Inquiry into Mental Health Services in Tayside, inquiry website, final report and July 2021 progress report
If you are reviewing how restraint is recorded in your own service, and whose account has to be in the record, our physical interventions training covers the write-up and the review that follows it.
Reviewed 20 October 2026.