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.
Three straps and no shoulder harness
A 76-year-old stroke patient died in the back of an ambulance after the crew left off the harness their own training required.
A school wrote its own policy to authorise a spit hood
An autistic boy with cerebral palsy was spit-hooded, restrained and placed alone in a cupboard-sized room. His claim settled without an admission of liability.
PublicationIf it restricts a person’s movement, it is restraint, whatever it is called
The Equality and Human Rights Commission's framework defines restraint by its effect rather than its name, and sets out the conditions that have to be met before any…
PublicationThe law that defines restraint in mental health units, and stops at recording
The Mental Health Units (Use of Force) Act 2018 puts a statutory definition of restraint into English law and requires providers to name a responsible person, publish a…
Two hours without a check, and nobody started CPR
A woman detained in a private hospital went two hours without the half-hourly observation her care plan required, and six first-aid-trained staff did not attempt resuscitation.
A knee in the back of the neck of a man already in handcuffs
He was handcuffed and leg-strapped, then moved by the neck and pinned with a knee in his neck; he survived, and the officer was found to have committed…
Restraint used to force-feed a care home resident
A care worker bound a woman's arms in a nightie so she could be fed, then went to prison for it.
PublicationThe review that said all restraint can kill
A Home Office review of 1,000-plus police custody deaths concluded that every restraint carries the potential to cause death, and that training was inconsistent across all 43 forces.
Tied into a chair with his own neck tie
An 86-year-old man with dementia was restrained in a care home chair with a neck tie. The conviction that followed was quashed on appeal.
A boy was held in a padded room whose door staff held shut from outside
A court found a residential special school was secluding a severely autistic pupil and using transport holds without a legal footing, and set conditions for both.
Left face down in a locked room for 28 minutes
A student detained under the Mental Health Act was restrained twice in four days, then left face down and unobserved until his heart stopped.
Pinned in a seat before take-off
An Angolan man restrained face down in his aircraft seat said he could not breathe for at least ten minutes before he lost consciousness.
A hold that was banned after he died
A 15-year-old died in a seated restraint at a secure training centre. The technique was suspended afterwards, and two-thirds of the centre's restraints that year were judged potentially…
Held face down for ninety minutes by untrained staff
A care home resident was restrained face down for an hour and a half, released, and found dead in his room.