An unusual death of a patient in seclusion

Physical Harm and Death in the Context of Coercive Measures in Psychiatric Patients: A Systematic Review

Background: For centuries coercive measures in psychiatry have been means of averting acute danger. It has been known for almost as long that these measures can lead to harm or even death to those affected. Over the past two decades the topic has increasingly been the subject of scientific discussion and research. While the legal and ethical preconditions for coercive measures in psychiatry as well as epidemiological studies on their incidence and patients' subjective experiences have increasingly come into focus, research on possible adverse events has lagged behind. To our knowledge there is no systematic review on the harmful or even fatal physical adverse effects of coercive interventions in psychiatry. Methods: We searched the databases PubMed and CINAHL for primary literature with a search string based on the PICO framework including key words describing different psychiatric diagnoses, coercive measures, and harms. Results: In total, 67 eligible studies (mainly case reports and case series) of very heterogeneous quality were included. Two RCTs were found reporting position-dependent cardiac deterioration, but were, however, carried out with healthy people and were characterized by a small number of cases. Death was the most frequently reported harm: cardiac arrest by chest compression in 14 studies, cardiac arrest by strangulation in 9, and pulmonary embolism in 8 studies. Further harms were, among others, venous thromboembolism and injuries. Injuries during physical restraint were reported in 0.8-4% of cases. For other kinds of coercive interventions, there are no sufficient data. Venous thromboembolism occurred in a considerable percentage of cases during mechanical restraint, also under prophylaxis. The most commonly reported coercive measure was restraint, distinguishing in mechanical restraint (43 studies), physical restraint (22 studies), bedrails (eight studies), vest restraint (7 studies), and chair restraint (6 studies). Forced medication was explicitly mentioned only in two, but seems to have occurred in nine studies. Six studies included seclusion. Conclusion: Coercive measures can lead to physical harm or even death. However, there is a significant lack of data on the incidence of such adverse events related to coercive interventions. Though reported anecdotally, physical adverse events during seclusion appear to be highly underresearched.

Physical control of patients on an inpatient setting: forensic vs. civil populations

The current study examines the use of physical control (seclusion and restraint) in a sample of patients hospitalized in a public mental hospital during 1989. A total of 243 patient records involving physical control were examined; of these, 124 had been civilly committed and the remaining 119 were forensic (Incompetent to Stand Trial or Not Guilty by Reason of Insanity). Some 870 physical control events occurred in the sample, a rate that is intermediate when compared with other facilities described in the literature. Seclusion was employed most often (46% of events), with the combination of seclusion and restraint used in 32% of events and the remaining 22% of physical control events being restraint. Seclusion tended to be used more often with civilly committed patients, with restraint more frequently employed with forensic patients. Forensic patients differed from civil subjects in their greater frequency of threats, agitation, and verbal hostility. However, civil patients were more frequently aggressive toward others and destructive of property. These findings are discussed in the context of previous evidence also describing forensic patients as being perceived as more dangerous, but behaving in a fashion no more physically aggressive than civil patients.