Intended for healthcare professionals

Rapid response to:


Report accuses NHS of institutional racism

BMJ 2004; 328 doi: (Published 12 February 2004) Cite this as: BMJ 2004;328:367

Rapid Response:

The Blofeld report and the dangers of restraint

The news report by Mark Gould1 on the inquiry into the death of David Bennett focuses on the charge of institutional racism in the NHS. Although racial issues are of course important in this inquiry, we should not be deflected from considering the other main issue about the dangers of the use of restraint in mental health services.

In October 1998, an investigative report by the Hartford Courant in the US produced a database of 142 deaths which occurred during or shortly after psychiatric or developmentally disabled patients were restrained or secluded.2 Subsequent reviews of the literature highlighted the lack of evidence to guide clinical practice about the benefits and risks of methods to control aggression.3

Training and other therapeutic efforts can reduce the amount of use of seclusion and restraint in clinical practice, at times dramatically. At the time of the death of David Bennett, the principal system of physical restraint training in the UK was known as "Control and Restraint" (C&R). Evidence concerning the effectiveness of C&R training is contradictory and inadequate.4 Restraint position may be a factor in death during restraint, but apparently only when other factors contribute to the overall situation.5 The balance of non-aversive and no touch techniques with the use of physical intervention as a last resort is crucial.

The issue of restraint also needs to be set in context. Control of psychiatric patients has been highlighted over recent years by the obligation on health authorities since 1994 to hold an independent inquiry in cases of homicide by those who have been in contact with psychiatric services. The recent debate about reform of the Mental Health Act has stressed the potential for increasing coercion in the treatment of the mentally ill. More generally a risk-averse approach has encouraged practice to err on the side of caution and as a consequence to become increasingly defensive and bureaucratic, ostensibly to avoid litigation. Death of a patient under restraint should help us to refocus on the need for a therapeutic approach rather than just custodial practice in mental health services. This cultural perspective applies to all patients, not just black people.


  1. Gould M. Report accuses NHS of institutional racism. BMJ 2004; 328: 367 (14 February) [Full text]
  2. Articles reprinted at The Council of Parent Attorneys and Advocates website.
  3. Sailas E, Fenton M. Seclusion and restraint for people with serious mental illnesses (Cochrane Review). In: The Cochrane Library. Issue 1. John Wiley: Chichester, 2004
  4. Wright S. Control and restraint techniques in the management of violence in inpatient psychiatry: A critical review. Med Sci Law 2003; 43: 31-38
  5. Parkes J. Sudden death during restraint: a study to measure the effect of restraint positions on the rate of recovery from exercise. Med Sci Law. 2000; 40 :39-44.

Competing interests:
None declared

Competing interests: No competing interests

24 February 2004
D B Double
Consultant Psychiatrist
Norfolk Mental Health Care NHS Trust