What counts as restrictive practice?
Restrictive practices are actions that restrict a person's movement, liberty or freedom to act independently. On mental health wards they include physical restraint, mechanical restraint, chemical restraint such as rapid tranquillisation, seclusion and long-term segregation. They also include less obvious restrictions: locked doors, blanket bans on phones or outside space, and enhanced observation that limits privacy.
Sometimes an intervention is the only way to prevent serious harm. But every one carries risk. Restraint can cause injury and, rarely, death, especially face-down holds or pressure on the chest or back. Rapid tranquillisation can cause breathing and heart rhythm problems. Seclusion can be frightening and isolating. Many patients describe these experiences as traumatic, and some groups, including Black patients, autistic people and people with a learning disability, have been shown to experience restrictive interventions more often.
Which laws and guidance apply?
| Source | What it covers |
|---|---|
| Mental Health Units (Use of Force) Act 2018 (Seni's Law) | Duties on mental health units in England: a responsible person, a published use of force policy, information for patients, staff training, and recording of every use of force |
| Mental Health Act 1983 Code of Practice (2015) | Statutory guidance on preventing and managing behavioural disturbance, including restraint, rapid tranquillisation, seclusion and long-term segregation |
| Mental Capacity Act 2005 | For people lacking capacity, restraint only if reasonably believed necessary to prevent harm and proportionate to it |
| Human Rights Act 1998 | Prohibition of inhuman or degrading treatment, right to liberty and right to private and family life |
| NICE NG10 | Prevention, de-escalation, restrictive interventions, rapid tranquillisation and post-incident review |
| Positive and Proactive Care (2014) | National guidance to reduce restrictive interventions, including no planned or intentional prone restraint |
| Restraint Reduction Network Training Standards | Standards that NHS-commissioned training in restrictive practices is expected to be certified against |
The Use of Force Act is named after Olaseni Lewis, who died in 2010 after being restrained by police in a mental health unit. Its main provisions came into force in 2022 with statutory guidance from the Department of Health and Social Care. Every unit must have a named responsible person and a use of force policy you should be able to find.
The Code is statutory guidance. You should follow it unless there is a cogent reason to depart from it in a particular case, and record that reason. Unjustified departures can be challenged by the courts and the CQC.
How do you prevent restraint? De-escalation first
Most aggression on mental health wards can be predicted and prevented. Common triggers include refused leave or phone calls, feeling ignored or disrespected, noise, boredom, pain or physical illness, medicine side effects such as akathisia, intoxication or withdrawal, fear and psychotic experiences. Ward rules and staff behaviour can be triggers too.
Each patient at risk should have an individual plan, ideally written with them, covering triggers, early warning signs, what helps, what does not, and their preferences if an intervention becomes necessary.
- Notice early signs: Pacing, raised voice, clenched fists, staring, withdrawal. Early action works far better than responding to a crisis.
- Approach calmly: One person leads, at a safe distance, with an open posture and calm voice. Do not crowd the person or block exits, theirs or yours.
- Listen and acknowledge: Ask what is wrong and acknowledge feelings without arguing.
- Offer real choices: A quieter room, a drink, a preferred staff member, or oral medication they have chosen.
- Reduce stimulation and fix the cause: Move others away and lower noise. Solve the problem if you can; if not, explain honestly what can be done instead.
- Plan quietly in case it fails: Agree who will lead and who will monitor physical health if an intervention becomes necessary.
Blanket restrictions, such as locked kitchens or fixed bedtimes for everyone, should be avoided unless justified as necessary and proportionate and reviewed regularly. Unnecessary rules increase frustration and incidents.
What are the rules on physical restraint?
Physical restraint should only be carried out by staff trained in approved techniques, when de-escalation has failed or is not possible and there is a real risk of harm.
- Use the least restrictive technique for the shortest time, and stop as soon as it is no longer needed.
- One person leads and talks to the patient throughout.
- One person monitors airway, breathing and physical condition, with no other task.
- Avoid taking the person to the floor. If necessary, use a face-up (supine) position in preference to face-down (prone). If prone is unavoidable, keep it as short as possible.
- Never apply pressure to the neck, chest, back, abdomen or pelvis in a way that could restrict breathing or circulation.
- NICE advises not routinely using manual restraint for more than 10 minutes; consider alternatives if it continues.
- Do not use pain-based techniques except, in line with training, to rescue someone in immediate danger.
Risk is higher in people with obesity, heart or lung disease, sickle cell disease, intoxication or withdrawal, recent rapid tranquillisation, or acute behavioural disturbance with high temperature and exhaustion, as well as children, older adults and pregnant women. Resuscitation equipment should be immediately available wherever restraint may be used, and a doctor should review the patient after significant restraint.
What do you need to know about rapid tranquillisation?
NICE defines rapid tranquillisation as medication given by injection (usually intramuscular, exceptionally intravenous) when oral medication is not possible or appropriate and urgent sedation is needed. Offering oral medication to an agitated patient is not rapid tranquillisation, but often avoids the need for it. The aim is calm, not unconsciousness.
Choice of medicine depends on the patient's preferences or advance statement, physical health, current medicines and previous response. Follow your local rapid tranquillisation policy and the BNF, and always add up what the patient has already had in the last 24 hours, including oral as-required doses, before prescribing more.
Monitoring is where reviews most often find failings. NICE recommends checking side effects, pulse, blood pressure, respiratory rate, temperature, hydration and level of consciousness at least hourly until there are no further concerns, and every 15 minutes in higher-risk situations, such as when the patient appears asleep or sedated, has taken alcohol or illicit substances, has a physical health problem, or the BNF maximum was exceeded. A patient who seems asleep is at higher risk, not lower. If full observations are not possible, record at least breathing, consciousness and colour, and why.
What are the seclusion rules and review times?
The Code defines seclusion as the supervised confinement and isolation of a patient, away from other patients, in an area they cannot leave, where immediately necessary to contain severe behavioural disturbance likely to cause harm to others. It must not be used as punishment or threat, as part of a treatment programme, because of staff shortages, or solely to manage self-harm.
| Safeguard | What the Code expects (summary) |
|---|---|
| Who can start it | A doctor, an approved clinician or the professional in charge of the ward |
| Doctor attendance | If not started by a doctor, a doctor is told at once and attends within one hour |
| Observation | A skilled professional within sight and sound at all times, with a documented report at least every 15 minutes |
| Nursing reviews | At least every two hours, by two trained people, one a registered nurse |
| Medical reviews | Every four hours until the first internal MDT review, then at least twice in 24 hours (one by the responsible clinician) |
| MDT review | At least once every 24 hours |
| Independent MDT review | If seclusion lasts more than 8 hours continuously, or 12 hours intermittently over 48 hours |
| Ending | As soon as it is no longer warranted |
The room must be safe, heated, lit and ventilated, allow observation at all times and give access to toilet and washing facilities. Offer food and drink, keep the patient informed and treat them with dignity. Long-term segregation is a separate, MDT-authorised arrangement with commissioner involvement, external review and a plan to end it. Your trust's policy will set out the local forms and roles.
Recording, debrief and learning
Every use of force must be recorded promptly. The record should show what happened before, de-escalation tried, why the intervention was necessary, techniques and positions used and for how long, staff roles, medication and monitoring, injuries, the patient's views and the incident report.
Pt became aggressive. Restrained and given IM. Settled. Obs stable.
14:20 Shouting and threatening another patient after a phone call. Named nurse de-escalated for 10 min (quiet room, oral medication of choice, later phone call offered), declined. 14:32 Punched wall, moved towards another patient. Guided to floor supine by three trained staff; nurse A led, nurse B monitored airway and breathing throughout. No prone position. Held 6 min. 14:36 IM medication given per rapid tranquillisation protocol. Hold released 14:38. Obs every 15 min while sedated, then hourly until no concerns. Graze left elbow, reviewed by duty doctor 15:10. Patient's views sought 16:00: felt frightened, prefers female staff if held again; added to care plan. Incident reported. Debriefs offered and held.
Joseph, detained under section 3, is restrained prone four times in a week, each time after being refused a cigarette break because of staffing. At the weekly use of force review, the team spots the pattern and meets him with his advocate. He explains that being held face down reminds him of a past assault. The new plan protects daily fresh air breaks, adds nicotine replacement and a daily check-in, and records his wish to be held standing or seated and offered oral medication first. There are no further restraints over the next month, and the team reviews whether the cigarette rule is a blanket restriction.
After any intervention, hold an immediate debrief for safety and wellbeing, then a fuller review within a few days. Offer the patient a chance to talk to someone not involved, or an advocate. Units should review use of force data regularly, including by ethnicity.
What if you see force used wrongly?
If force is unnecessary, excessive, punitive or unsafe, you have a professional duty to act. In the moment, say it plainly: "He's saying he can't breathe, release the hold now." Afterwards, report it through the incident system and to a senior colleague or Freedom to Speak Up Guardian, and raise safeguarding concerns where abuse is suspected.
If an incident leads to an investigation, inquest, complaint or regulator referral, seek early advice from your defence organisation, trade union or professional body before giving formal statements.
Learning more about restrictive practice
Our course Restrictive Practice and Use of Force in Mental Health covers the legal framework, de-escalation, safe restraint, rapid tranquillisation monitoring, seclusion safeguards and recording, with a reflection and action plan. It is educational and does not replace accredited, hands-on restraint training certified to national standards. Readers in related settings may also find Maternity Care and Fetal Monitoring Concerns or Paramedic Practice: Assessment and Non-Conveyance Decisions useful. No course decides the outcome of any process.
Frequently asked questions
What is Seni's Law?
Seni's Law is the common name for the Mental Health Units (Use of Force) Act 2018, named after Olaseni Lewis, who died after being restrained in a mental health unit in 2010. It requires units in England to have a responsible person, a use of force policy, patient information, staff training and recording of every use of force.
Is prone restraint banned in mental health units?
Not completely, but national guidance says there should be no planned or intentional prone restraint. NICE advises avoiding taking people to the floor and, if necessary, using a face-up position in preference to face-down. If prone is unavoidable, it should be for the shortest possible time with no pressure that could restrict breathing.
How long can someone be restrained for?
There is no fixed legal maximum, but restraint must stop as soon as it is no longer needed. NICE advises that manual restraint should not routinely last more than 10 minutes, and that alternatives such as rapid tranquillisation or seclusion should be considered if it continues. Follow your trust's policy and training.
How often should a patient in seclusion be reviewed?
Under the Mental Health Act Code of Practice, a skilled professional should be within sight and sound at all times with a record at least every 15 minutes, nursing reviews every two hours, medical reviews every four hours until the first MDT review, MDT reviews daily, and an independent review if seclusion is prolonged.
Can seclusion be used for an informal patient?
The Code says that if an informal patient needs to be secluded, this indicates an immediate need to assess whether they should be detained. Seclusion should only be used to contain severe behavioural disturbance likely to harm others, and the legal basis must be clear. Follow your trust policy and seek senior advice.
Is enhanced observation a restrictive practice?
Yes, it can be. Close or one-to-one observation limits privacy and freedom, so it should be individually justified, proportionate, reviewed regularly and carried out in a way that respects dignity. Good observation is therapeutic engagement, not just watching, and the patient should understand why it is in place.
Has the Mental Health Act 2025 changed the rules on restraint?
The Mental Health Act 2025 received Royal Assent in December 2025 and is being commenced in phases. At the time of writing, the Use of Force Act, the 2015 Code of Practice and NICE NG10 still set day-to-day expectations, and a new Code is expected. Check the current commencement position and your local policy.
Related courses
Restrictive Practice and Use of Force in Mental Health
This course explains the legal and professional framework for restrictive practices in mental health settings in England, including physical…
Maternity Care and Fetal Monitoring Concerns
This course teaches safe fetal monitoring in labour, including intermittent auscultation, structured CTG review and escalation, using UK guidance and…
Paramedic Practice: Assessment and Non-Conveyance Decisions
This course teaches a structured approach to assessment and safe decision-making when a paramedic considers discharging a patient on scene or…
Sources and further reading
- Mental Health Units (Use of Force) Act 2018: statutory guidance. Department of Health and Social Care.
- Mental Health Act 1983: Code of Practice (2015). Department of Health.
- Violence and aggression: short-term management in mental health, health and community settings (NG10). National Institute for Health and Care Excellence.
- Positive and Proactive Care: reducing the need for restrictive interventions. Department of Health.
- Out of sight: who cares? (2020). Care Quality Commission.
- Mental Health Act 2025. legislation.gov.uk.
Practitioner Insight is an independent education provider. It is not affiliated with or endorsed by the GMC, MPTS, NMC, HCPC, GPhC or any NHS organisation, and this information is not legal advice. If you have been referred to a regulator, speak to your defence organisation, trade union or legal representative.
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