Coroners, courts, regulators and inspectors have recorded what restraint does to the people it is used on. This casebook publishes those records as short, sourced case pages: what happened, what went wrong, and what it means for the people running the service.
Every entry states its confidence, what could not be verified, and where the source runs out. Where a case is still live, we hold it. Where a name cannot be justified, we do not print it. Publications are labelled as publications, because a national count is not an incident.
147 case entries and 47 publications.
A leg across a toddler’s back, then two hours unchecked
A 14-month-old was held face down at his nursery until staff believed he was asleep, and nobody physically checked him for about two hours.
PublicationAn inquiry that found the ward could not count its own restraint
NHS Tayside's own inquiry heard that patients were held face down by up to six staff, that restraint was not reliably recorded, and that some staff were expected…
Face down under seventeen officers, after a calm walk
Footage shows a remand prisoner walking calmly to a shower room minutes before a restraint that ended in a cardiac arrest. He died four days later.
Fifty-eight minutes on the floor, then carried face down
A restraint the jury called appropriate ended with a man carried and driven face down, and a death the positioning may have contributed to.
Four entrapments in four weeks, then a second fall
A nursing home was prosecuted after a 98-year-old man was caught in his bed rail four times and then died following a fall.
He said he could not breathe, and CCTV showed staff doing nothing
A man with a learning disability died in a private hospital that a safeguarding review later found used excessive restraint and seclusion by unqualified staff.
Held down for eleven hours, then arrested
An autistic man was restrained by up to nine staff at a private hospital, then handcuffed by police the hospital had called.
Held on the ground in a parking dispute, then a seizure
A man restrained on the street over a badly parked car appeared to have a seizure while officers doubted it.
Six times trapped in the bed rails, then an amputation
An 88-year-old woman with dementia was put behind bed rails without a risk assessment, trapped six times, and lost her leg.
Swaddled face down on a bean bag and left for ninety minutes
Nine months old, harnessed face down on a bean bag for over ninety minutes at her nursery. The worker caring for her was convicted of manslaughter.
PublicationThe school where restraint became the first response
A Scottish inquiry into abuse at a residential school and secure unit found that a de-escalation model had been read by staff as a restraint system, and that…
PublicationThirteen deaths within seven days of control or restraint
The CQC counted 13 detained patients for 2023/24 who had experienced control or restraint within seven days of death. The next year's figure was 14, on a slightly…
Three restraints in twenty minutes, and a death
Prison officers used unlawful force on a remand prisoner who died on arrival at hospital. One of them was later convicted of perjury.
Tied to chairs with belts, in a home closed by court order
Residents at a 35-bed Aberdeenshire care home were restrained with belts, and the regulator's answer was to close the building.
A home rated good, then inadequate in six months
Ofsted found restraint rising at a council children's home, prone holds in the high-level mix, and injuries that nobody followed up.
A lap belt outside the door, and nothing inside
A nursing home resident at high risk of falling was held in her wheelchair with a belt outdoors and with nothing indoors.
A welfare check that became thirty minutes of restraint
A man agreed to go to hospital, changed his mind, was restrained by numerous officers, and died hours later.
Eleven minutes face down, then handcuffed while unresponsive
Security officers held a man by the neck and then prone for eleven minutes. The jury found a recovery position would have saved him.
Handcuffed face down on the ground, and left unchecked
A 38-year-old man died of a hypoxic brain injury after door staff and police restrained him face down outside a Devon pub.
Held face down hours before he was found dead in his room
A 14-year-old was restrained face down at a secure training centre and found dead six hours later. An inquest found the force unlawful.
PublicationNine in ten restrained children were injured
A parent survey in Scotland found more than 600 children restrained or secluded in school over two years, per the charity's returns, with injuries in more than nine…
PublicationOver 10,000 restrictive interventions in three months, a third against children
Between April and June 2019, inpatient units in England recorded more than 10,000 uses of restrictive practice against people with a learning disability or autism, almost a third…
Restrained in handcuffs and carried to a van as he left hospital
A man was restrained at a hospital as he was being discharged, carried to a police van, and died in the same hospital six days later.
Restraint “common and standard” at Northern Ireland’s secure unit
A regulator found that restrictive practice at Northern Ireland's only secure care centre had become routine, for the fourth inspection running, and the report was never published.
PublicationRestraint was part of the culture, and seclusion ran for years
The CQC's 2020 review of restraint, seclusion and segregation in learning disability and autism services found 81% of 313 wards for children and young people had restrained someone…
PublicationSeven deaths near seclusion, fourteen near restraint
The CQC return that recorded fourteen deaths of detained patients within seven days of restraint recorded seven during or within seven days of seclusion or time out.
She fell from her chair because the strap had no buckle
An 84-year-old resident died after a fall from her wheelchair, and the coroner recorded that neglect contributed to her death.
Sprayed and restrained in hospital, then a medically-induced coma
A man already detained under the Mental Health Act was restrained by police at a north London hospital, lost consciousness and spent six weeks in hospital.
Strapped into a chair at school, and told it was a one-off
Twin boys with severe autism were strapped into mechanical restraint chairs at a Kent special school for four years. The council admitted the failings and paid £80,000.
PublicationThe detention count with no restraint count beside it
According to NHS England Digital, 52,458 new detentions were recorded under the Mental Health Act in England in 2023-24. That is the population restraint happens in, and it…