Consultation on Updates to the Code of Practice for the Mental Health (Care and Treatment) (Scotland) Act 2003

Draft Code of Practice updates

Restraint and Seclusion

Purpose of this new chapter

This section provides guidance on the safe and rights‑based use of restraint and seclusion in hospital for practitioners discharging functions under the Act.

The use of restraint and seclusion must comply with the principles set out in Part 1 of the Act, including using the least restrictive option, respect for autonomy, participation in decision‑making, maximising the benefit to the patient and the principles relating to the welfare of the child.

This guidance applies to all practitioners discharging functions under the Act, including clinical staff, Mental Health Officers (MHOs), and other professionals.

Introduction

This chapter of the Code of Practice provides guidance to support practitioners and service providers to perform their functions under the Act and strengthen the protection of the rights of children and of others with mental disorders, in relation to the use of restraint and seclusion. It is applicable to both voluntary and involuntary patients.

A restrictive intervention refers to any intervention that limits a patient’s movement, liberty, or freedom of action. In mental health settings, this includes forms of restraint such as physical restraint, mechanical restraint, or medication as restraint, and seclusion.

Although this section is aimed at practitioners carrying out functions under the Act, it will also be of interest to patients receiving care under the Act.

General principles

The Act establishes a framework within which all functions must be exercised in a manner that promotes the welfare, rights, and dignity of patients receiving care and treatment. The principles set out in Part 1 of the Act require that those discharging functions under the Act do so in a person-centred way, taking account of the past and present preferences of the patient, the views of carers and named persons, any advance statement made by the patient and the patient’s particular circumstances.

Where the patient is under the age of 18, persons discharging functions under the Act must have regard to the welfare of the child. Practitioners should consider how any intervention will affect the child’s safety, wellbeing and development. Practitioners should act in a manner that involves the minimum restriction on the freedom of the child necessary in the circumstances, ensuring that any restriction is proportionate, justified and consistent with the child’s best interests.

Practitioners must ensure that any intervention – particularly one that restricts liberty or movement, is the minimum necessary to prevent harm to the patient or others and is consistent with the least restrictive principle in the Act. The emphasis must always be on preventing or minimising the use of restrictive interventions, including early identification of distress, de‑escalation, and anticipatory planning, so that restraint and seclusion are avoided wherever possible. Restraint should occur only where it is necessary and proportionate in the circumstances and no less restrictive measure is appropriate.

All decisions to use restrictive interventions must be trauma‑informed, recognising that many patients subject to mental health interventions may have experienced trauma and that further harm can result from inappropriate use of restraint or seclusion. Practitioners must be aware of the potential for such interventions to cause significant physical injury, emotional distress and lasting psychological harm, including re‑traumatisation and erosion of trust in services. Restraint and seclusion should be approached with caution and used only where strictly necessary to prevent harm, and for the shortest duration required to achieve that purpose.

Any use must be proportionate, properly authorised, recorded and subject to review. Where restraint or seclusion is used, it should be followed by appropriate review, reflection and support for the patient, with a focus on learning and reducing the likelihood of future use. Trauma‑informed practice requires a focus on prevention, early intervention and de‑escalation, alongside therapeutic, relational and rights‑respecting approaches that uphold the dignity, safety and wellbeing of the patient and support a reduction in the use of restrictive interventions.

Practitioners must also conduct their duties in accordance with Scotland’s wider human rights obligations. This includes compliance with the European Convention on Human Rights (ECHR), particularly in relation to liberty, dignity, respect for private and family life and freedom from inhuman or degrading treatment. Where the patient being treated is under 18, the United Nations Convention on the Rights of the Child (UNCRC) requires that the best interests of the child be treated as a primary consideration. The United Nations Convention on the Rights of Persons with Disabilities (UNCRPD) also requires that disabled people are supported to exercise their rights on an equal basis with others, including through respect for autonomy, supported decision making, and protection from discriminatory or disproportionate restrictions.

Where the patient being treated is under 18, practitioners must also have regard to the rights and protections contained within the United Nations Convention on the Rights of the Child (UNCRC). The application of the UNCRC in the context of the Act is considered in more detail below.

United Nations Convention on the Rights of the Child

In Scotland, the United Nations Convention on the Rights of the Child (Incorporation) (Scotland) Act 2024 places duties on public authorities (when acting within devolved competence) to act compatibly with the requirements of the United Nations Convention on the Rights of the Child (UNCRC).

The UNCRC is an international treaty which sets out the civil, political, economic, social and cultural rights of all children (defined as persons under 18 years of age). Practitioners exercising functions under the Act in relation to children must have regard to the rights set out in the UNCRC. Its provisions are relevant to the assessment, care and treatment of children under the 2003 Act and should inform all decision-making and practice.

In particular, practitioners should have regard to the following principles and rights within the UNCRC:

• Article 3 (Best interests of the child): In all actions concerning children, the best interests of the child must be a primary consideration.
• Article 12 (Respect for the views of the child): Children and young people have the right to express their views freely in all matters affecting them, and to have those views given due weight in accordance with their age and maturity.
• Article 5 (Parental guidance and evolving capacities): Practitioners should recognise the responsibilities of parents and carers, while taking account of the child’s evolving capacity to make decisions.
• Article 9 (Separation from parents): Children should not be separated from their parents except where necessary in their best interests. Where separation occurs, children have the right to maintain personal relations and direct contact with their parents on a regular basis, unless contrary to their best interests.
• Article 10 (Family reunification): Children and their families have the right to have applications for family reunification considered in a positive, humane and expeditious manner, and to maintain contact across borders where family members live in different countries.
• Article 16 (Right to privacy): Children have the right to protection from arbitrary or unlawful interference with their privacy, family, home or correspondence.
• Article 19 (Protection from harm): Children must be protected from all forms of physical or mental violence, injury, abuse, neglect or negligent treatment.
• Article 23 (Children with disabilities): Children with disabilities have the right to special care and support to ensure they can enjoy a full and decent life.
• Article 24 (Right to health): Children have the right to the highest attainable standard of health and to facilities for the treatment and rehabilitation of health.
• Article 37 (Deprivation of liberty): The detention of a child must be lawful, necessary and used only as a measure of last resort and for the shortest appropriate period of time.
• Article 39 (Recovery and reintegration): Children who have experienced trauma or harm are entitled to support for recovery and reintegration in a manner that promotes their dignity and self-respect.

In carrying out their functions under the 2003 Act, practitioners should ensure that: 

• the best interests of the child are a primary consideration in all assessment, care and treatment decisions;
• children and young people are supported and enabled to participate effectively in decisions affecting them;
• their rights to dignity, respect, privacy and family life are upheld; and 
• any intervention, including compulsory measures, is necessary, proportionate and consistent with the child’s rights.

Having regard to the UNCRC requires practitioners not only to be aware of these rights, but to actively consider how they apply in the particular circumstances of each child. This includes taking a child-centred, rights-based approach to assessment, care planning, treatment and review. These considerations should inform all decisions relating to the use of restraint, seclusion and other restrictive interventions involving children and young people.
 
Taken together, this means that restraint and seclusion must be used in a manner that is rights respecting, person-centred, preventive, and proportionate, ensuring that any restriction on a patient is lawful, justified, and consistent with Scotland’s human rights obligations.

Practitioners should actively support patients to understand and access advocacy services. Patients should be given clear, age‑appropriate information about the role of advocacy, how an advocate can support them to express their views, and how to make contact, with assistance offered where communication, distress or capacity may be affected.

Patients should also be supported to understand how to raise concerns or make a complaint. This includes explaining complaints processes in a clear and accessible way, providing written information where appropriate, and offering practical support to navigate the process.

Purpose of restraint and seclusion

The purpose of restraint when it is necessary and proportionate is to manage immediate risk and to prevent imminent harm to the patient or others. It can ensure safety in circumstances where no less restrictive measure is sufficient. The use of restraint to administer treatment should be avoided where possible, but may sometimes be necessary. in an emergency situation.

The purpose of seclusion is to manage acute behavioural disturbance, reduce immediate risk of harm to others and create a safe environment in which care and treatment can be delivered.

Practitioners are expected to ensure that restraint or seclusion occurs only where no less restrictive measure is appropriate, and that interventions respect the dignity and rights of the patient.

Restraint and seclusion should only be used for the minimum necessary duration and only where required to prevent immediate and significant harm to the patient or to others. These interventions must never be used as a means of punishment, coercion, or as a routine response to distress.

Restraint and seclusion must always be considered within the wider context of person-centred, trauma-informed, and preventive care. Practitioners must actively seek to anticipate and de-escalate distress wherever possible so that restrictive interventions are avoided. In all cases, the use of restrictive interventions must be lawful, proportionate, time limited, and consistent with the principles in Part 1 of the Act.

Definitions of restraint and seclusion

There is no statutory definition of restraint or seclusion within the Act. These definitions are intended to support consistent understanding and should be read alongside relevant guidance issued by the Mental Welfare Commission for Scotland.

Restraint refers to any intentional restriction of a patient’s movement, liberty, or decision making. This includes physical restraint, mechanical restraint, and medication as restraint (also known as chemical restraint).

Physical restraint

Physical restraint means the use of physical contact to prevent, restrict or subdue movement of all or part of a person’s body. It is used where there is a risk of harm to the person or others, or to enable necessary care or treatment to be provided. It may also include threatened physical intervention where this is used to secure compliance or prevent movement.

Mechanical restraint

Mechanical restraint means the use of any device, equipment or environmental adaptation intended to prevent, restrict or subdue movement of all or part of a person’s body, where the primary purpose is to manage risk, behaviour or safety by limiting freedom of movement. This may include, but is not limited to, restraining chairs, belts, limb restrictions, cot sides or other equipment used for that purpose.

Medication as restraint

Medication as restraint means the use of sedative, tranquillising or psychotropic medication where the immediate purpose, or one of the immediate purposes, is to control behaviour, reduce agitation, prevent harm, and restrict a person’s movement or action. This includes rapid tranquillisation and may include as needed or other medication where it is used in response to acute behavioural disturbance. Its use should be clearly distinguished from routine or planned medication.

Seclusion

Seclusion means the supervised confinement and isolation of a patient away from other patients in a room, area or other space from which the patient is prevented from leaving, where this is immediately necessary to contain severe behavioural disturbance likely to cause harm to others. It may occur whether the door is open or closed, locked or unlocked, and whether the patient is prevented from leaving by a locked door, staff presence, physical obstruction or other means. It should only be used where it is immediately necessary to contain severe behavioural disturbance that is likely to cause harm to others.

Not every restriction on movement is seclusion. Locked ward doors, general observation, a patient choosing to spend time in their bedroom, or restrictions on access to part of a ward may be restrictive interventions but will not amount to seclusion unless the person is isolated away from others and prevented from leaving the relevant space.

Lawful limits of restraint and seclusion

Practitioners authorising and using restraint must be able to justify both the decision to use restraint or seclusion, and the way in which it was used. Use of restraint and seclusion should be undertaken with a clear legal basis, be supported by appropriate documentation and authorisation and with consideration of the patient’s wishes and feelings consistent with principles in Part 1 of the Act.

Restraint and seclusion must only be used where it is strictly necessary, proportionate, and for the minimum time required to prevent immediate and significant harm. Routine, punitive, coercive, excessive, or convenience based use is incompatible with the Act’s principles and with the rights to dignity and bodily integrity protected by the ECHR.

Restrictive interventions that individually or cumulatively, deprive a person of their liberty without lawful authority will breach article 5 of the ECHR (right to liberty). Where restrictive interventions amount to a deprivation of liberty, they must be lawful, that is, grounded in a clear legal basis and accompanied by procedural safeguards such as authorisation routes under mental health frameworks and access to review/appeal.

For voluntary patients, before a physical restraint is used consideration should be given to whether formal detention under the Act is appropriate. As seclusion is more likely to amount to a deprivation of liberty, it should only be used in relation to patients detained under the Act. If an emergency situation arises involving a voluntary patient where, as a last resort, seclusion is necessary to prevent harm to others, then an assessment to consider whether detention under the Act is necessary and appropriate should be undertaken immediately.

The following (alone or in combination), without lawful authority, may indicate a deprivation of liberty when sustained beyond transient, immediately necessary periods and absent valid consent:

• seclusion in a locked or supervised room/space where the person cannot freely exit
• recurrent or prolonged physical/mechanical restraint such that the person is, in effect, confined
• locked doors, key‑pad or escort requirements that the person cannot refuse, coupled with close supervision.

This list provides examples and is not exhaustive. The precise scope of “deprivation of liberty” develops over time in accordance with European Court of Human Rights and UK case law. Health Boards should hold clear guidance and policies to help practitioners using restraint or seclusion to do so in accordance with the principles of the Act, and the rights protected by ECHR.

Restraint

Article 3 of the ECHR grants all patients freedom from inhuman or degrading treatment. Restraint that is not necessary to prevent imminent harm may amount to inhuman or degrading treatment, which is prohibited by Article 3. Where restraint is used, it is a serious measure requiring compelling justification.

Even where restraint is shown to be necessary and proportionate, certain procedural safeguards require to be followed, for example:

• real-time monitoring, health checks, and documented rationale
• recording and review of the incident
• informing the patient (and, where appropriate, the named person/carer) and to learn from incidents
• clear service policy
• trained staff.

This list provides examples and is not exhaustive. Health Boards should hold clear guidance and policies to help practitioners using restraint to do so in accordance with the principles of the Act and the rights protected by ECHR.

Where doubt arises about the necessity or proportionality of a proposed use of restraint or whether this may amount to a deprivation of liberty, practitioners should seek senior clinical advice at the earliest opportunity and legal advice where necessary.

Seclusion

As with restraint, practitioners authorising and using seclusion must be able to justify both the decision to use seclusion and the manner in which it is applied. Seclusion must have a clear legal basis, be supported by appropriate documentation, and be authorised and reviewed in accordance with the principles set out in Part 1 of the Act.

Seclusion should only be used in relation to patients detained under the Act, as it is more likely to amount to a deprivation of liberty. If an emergency situation arises involving a voluntary patient where, as a last resort, seclusion is necessary to prevent harm to others, then an assessment to consider whether detention under the Act is necessary and appropriate should be undertaken immediately.

Seclusion should only be used where it is strictly necessary, proportionate, and for the minimum period required to manage an immediate and significant risk of harm to the patient or others. It must not be used as a response to disturbed behaviour alone, non‑compliance, staff shortages, or environmental factors. Routine, punitive, coercive, indefinite or convenience‑based use of seclusion is incompatible with the principles of the Act and with the rights to dignity, autonomy and freedom protected by the ECHR.

Lawfulness depends not only on the initial decision to use seclusion, but on the conditions in which it is maintained. The following procedural safeguards should be observed:

• ensure continuous observation and regular physical and mental health checks
• maintain therapeutic engagement and communication while the patient is secluded
• timely senior clinical review and clear criteria for ending seclusion
• adequate recording of the rationale, duration, reviews and outcomes
• informing the patient (and, where appropriate, the named person or carer) and to support post‑incident review and learning
• clear service policy governing authorisation, review and maximum duration
• staff who are appropriately trained and supported.

This list provides examples and is not exhaustive. Health Boards should hold clear guidance and policies to help practitioners using seclusion to do so in accordance with the principles of the Act and rights protected by ECHR.

Where doubt arises about the necessity or proportionality of a proposed use of seclusion, practitioners should seek senior clinical advice at the earliest opportunity and legal advice where necessary.

Future care planning

Practitioners should ensure that future care planning is considered for anyone who may be at risk of distress or behaviours that could lead to restraint or seclusion. Future care planning supports the Act’s principles by promoting person‑centred, preventive and least‑restrictive approaches.

Plans should be developed with the patient, and, where appropriate, their family, carers or named person. They should take account of the patient’s preferences, communication needs, trauma history, sensory needs and known triggers in relation to restraint and seclusion.

Advance statements should be considered as part of this process, ensuring that the patient’s wishes about care and treatment are clearly recorded and influence decision‑making wherever possible. Advance statements play an important role in supporting lawful, person‑centred and least restrictive care where restraint or seclusion may be considered in an inpatient mental health setting. Practitioners must have regard to any valid advance statement when assessing risk, planning care and authorising interventions, including preferences about approaches to de‑escalation, restraint or seclusion, and measures the patient has indicated should be avoided. While an advance statement does not prevent the use of restraint or seclusion where this is necessary to prevent serious harm, it should inform decision‑making wherever practicable and guide how any intervention is carried out in a manner that respects the patient’s dignity, autonomy and welfare. Where it is necessary to depart from an advance statement, the reasons for doing so must be clearly recorded, communicated to the patient, and considered through post‑incident review, with a view to supporting learning and reducing future use of restraint or seclusion.

Future care plans should identify early‑warning signs of behaviours that may lead to distress, outline preferred de‑escalation and support strategies, and set out adjustments that help reduce distress and avoid restrictive interventions. They should be easily accessible to practitioners, reviewed regularly, and updated after any incident.

Children and young people

Children and young people admitted to mental health in‑patient services are entitled to care that promotes their safety, dignity, and wellbeing, and which respects their rights under the UN Convention on the Rights of the Child (UNCRC), which requires the best interests of the child to be the primary consideration. The UNCRC (Incorporation) (Scotland) Act 2024 places duties on public authorities in Scotland not to act incompatibly with UNCRC requirements.

Any use of restraint or seclusion on children should be based on the UNCRC principles, being in the best interest of the child, the child’s right to be heard, age appropriate care. The UNCRC secures the rights of children to protection from violence, injury or abuse and cruel, inhumane or degrading treatment and safeguards their right to liberty. Restraint and seclusion can have significant and lasting impacts on a child and must therefore be approached with particular caution, clear justification, and strong safeguards. Practitioners must also comply with the principles in section 2 of the Act to safeguard the welfare of the child and to recognise the importance of minimum restriction on the freedom of the child.

Restraint and seclusion must only be used when all other de‑escalation and supportive measures have been attempted and have failed, and only to prevent immediate and significant harm to the child or others. Behaviour arising from distress does not justify the use of restraint on a child, and practitioners must always consider alternative methods first.

Under Article 3 UNCRC, the child’s best interests must be a primary consideration in all actions concerning the child. This means that any potential use of restraint or seclusion must be assessed against the child’s physical safety, emotional wellbeing, rights, and long-term development.

In practice:

• Restraint and seclusion should only be used by staff with appropriate child specific training.
• Decisions must weigh not only immediate risk but the short and long-term impact of restraint or seclusion on the child’s sense of safety, trust, and recovery.
• Practitioners should consider the child’s developmental stage, communication needs, disability related requirements, cultural background, trauma history, and attachment needs.
• Where a child is subject to restraint or seclusion, services must ensure continuous monitoring, immediate cessation once risk reduces, and compassionate aftercare.

In relation to restraint, practitioners should consider the proportionality, necessity and physical safety of any intervention. Restraint must only be used where there is an immediate risk of harm that cannot be managed through less restrictive, de‑escalatory approaches. Particular attention should be given to the child’s age, size, health conditions, disability, past experiences of restraint, and any increased risk of injury or re‑traumatisation. The method used should minimise pain, fear and humiliation, avoid positions that impair breathing or circulation, and be applied for the shortest possible duration, with continuous observation and clear accountability.

In relation to seclusion, practitioners must carefully assess the psychological and emotional impact of isolating a child from others. Seclusion can significantly affect a child’s sense of safety, abandonment, and emotional regulation, particularly for those with trauma histories, attachment difficulties, neurodivergence, or communication needs. Any use must be time‑limited, actively monitored, and clearly linked to risk reduction rather than behaviour control or punishment. Practitioners should ensure the environment is safe, dignified and culturally appropriate, and that the child is supported to re‑engage as soon as possible, with reflective follow‑up and opportunities for the child to express their experience.

Children have the right, under Article 12 UNCRC, to express their views freely in all matters affecting them, with due weight being given to those views according to the age and maturity of the child. This applies before, during and after any restrictive intervention.

Practitioners should:

• Seek and document the child’s views proactively, for example through an advance statement, including preferences about what helps them feel safe and strategies that reduce distress.
• Use trauma-informed communication, ensuring explanations are age appropriate and sensitive.
• After any restrictive intervention, conduct a child-centred debrief, giving the child an opportunity to explain what happened from their perspective, how they felt, and what could help avoid recurrence.
• Ensure the child’s views meaningfully inform updates to care plans, environmental adjustments, and service learning. Where decisions are taken that differ from the child’s views, clear records should be maintained to evidence why these decisions were taken.
• Take into account the patient’s age, developmental stage, needs and vulnerabilities.

Children require a higher level of protection when restraint and seclusion are being considered as interventions. Children should be kept close to familiar carers or advocates wherever possible, and efforts must be made to maintain nurturing relational support before, during, and after any incident.

Autistic people and people with a learning disability

Autistic people and people with learning disabilities are entitled to care that promotes their safety, dignity and wellbeing. The principles in part 1 of the Act require that all functions be exercised in a way that does not discriminate on the basis of diagnosis or disability and that promotes equality, participation, and the least restrictive alternative. The presence of autism or learning disability should not be treated as an indicator for the need for restraint.

Medical practitioners and Health Board guidance should recognise greater risk of experiencing trauma and increased risk of the use of restraint and seclusion amongst people with a learning disability or autism. Their care should be person-centred and trauma informed, to prevent escalation to the use of restraint or seclusion where possible.

For autistic people and people with learning disabilities, behaviours often reflect distress, communication differences, or environmental overload, not intent to harm. Behaviours associated with sensory overload, communication frustration, or unmet needs should not be misinterpreted as aggression justifying restraint. Practitioners should use positive behaviour support, provide environmental adjustments and trauma-informed approaches to reduce escalation.

Given the heightened vulnerability of autistic people and people with learning disabilities, practitioners must take particular care to avoid prolonged or painful holds, techniques that impair communication or sensory regulation, and situations where restraint becomes routine or normalised.

It would be best practice for practitioners to be trained to understand sensory processing differences, communication profiles, and predictable triggers. It would be best practice that where the patient has a learning disability, either the Responsible Medical Officer (RMO) or the Designated Medical Practitioner (DMP) is a specialist in learning disability treatment and care.

Under both the principles in Part 1 of the Act and UNCRPD, people with disabilities must be supported to express their will and preferences. Practitioners should ensure that the patient’s communication style is understood and supported (e.g. augmentative communication, visuals, simplified language). It is important that the patient is involved, as far as possible, in planning interventions and identifying early warning signs. Post-incident reviews should include the patient’s perspective and used to adjust support plans.

Nasogastric Tube Feeding

This section applies where the giving of nutrition by artificial means without consent is authorised under the Act (section 241) or the urgent medical treatment provisions under the Act (section 243) apply. It provides a high level summary for practitioners on the use of restraint when delivering Nasogastric (NG) tube feeding.

For the majority of patients, NG tube feeding will be delivered without the use of restraint, however for a minority of patients it may be required under restraint. Forcible feeding (which is different from NG tube feeding) should never be used and is not allowed under the Act and force should not be used to insert a nasogastric tube. Practitioners should recognise that NG tube feeding, particularly when carried out under restraint, can be highly distressing, invasive, and potentially traumatic, and therefore requires the strongest safeguards rooted in human rights principles.

Any interventions should be delivered in a way that is person-centred, trauma-informed and compassionate and by practitioners that are appropriately trained.

Communication and information should be simple, clear and honest so that the patient can understand what is happening and have the chance to ask questions and express their views. Communication and information should be adapted based on each patient’s needs, competence, ability, preferences and experiences. Practitioners should actively consider any relevant advance statement when making decisions, and take it into account alongside clinical judgment and the patient’s best interests. Where an advance statement cannot be followed, the reasons should be clearly explained, recorded, and sensitively communicated to the patient and those supporting them.

Practitioners should use best practice guidance that offers opportunities for alternative treatment or for the patient to engage voluntarily, without use of restraint.

If NG tube feeding cannot be achieved voluntarily, restraint should only be used when:

• There is an immediate and serious risk to the patient’s life or health without nutritional supplementation; and
• all reasonable de‑escalation and supportive measures have been exhausted; and
• the intervention is the least restrictive and safest means of achieving the necessary clinical outcome, with the minimum necessary duration and level of force.

The threshold for intervening without consent is not fixed and must be considered in light of the specific clinical context. Factors such as the immediacy and severity of risk, physical health, decision‑making ability, level of resistance, and the purpose of the intervention will all influence whether action is justified. In some situations, intervention may be necessary to prevent serious deterioration or save life; in others, the same intervention may be disproportionate if risk is lower or can be managed through less restrictive means.

Similarly, the procedural safeguards required under the Act, and those recognised as good practice, will differ depending on the circumstances. Urgent situations may allow for immediate action within narrow limits, while planned or ongoing interventions require formal authorisation, multi‑disciplinary discussion, and careful documentation of reasoning. Across all scenarios, practitioners should demonstrate that they have applied the principles in Part 1 of the Act, and that the chosen process reflects both the level of risk and the degree of intrusion involved in the intervention.

After any NG tube feeding involving restraint the patient should be offered a supportive debrief to assess their physical and psychological state. The debrief should be adapted to their communication needs, describing what happened and inviting their perspective. For children and young people, the debrief should support the child’s right to be heard and ensure decisions reflect their best interests.

Following any episode of NG tube feeding involving restraint, a structured review should be conducted. This should consider the clinical justification for restraint, whether less restrictive alternatives were explored, and whether the intervention remained proportionate and necessary throughout. The patient’s experience, views and emotional impact should be central to the review, alongside input from carers and the multi‑disciplinary team. Learning from the review should inform care planning, risk reduction strategies, and efforts to prevent further use of restraint wherever possible.

Practitioners should take into account detailed guidance on paediatric nasogastric feeding issued by Healthcare Improvement Scotland and good practice guidance from the Mental Welfare Commission on Nutrition by Artificial Means. Practitioners should notify the Mental Welfare Commission if urgent medical treatment is carried out, without the patient’s consent.

Monitoring and recording the use of restraint and seclusion

Health Boards and service providers must ensure that the use of restraint and seclusion is appropriately recorded, monitored and reviewed within local clinical governance arrangements, in order to safeguard the rights, dignity and wellbeing of patients. The primary responsibility for monitoring and reviewing practice lies with Health Boards and delivery services, with national monitoring supporting and enhancing delivery.

Monitoring arrangements should support both local review and national oversight. Health Boards should ensure that data on restraint and seclusion is collected and used within local governance structures to inform reflective practice, quality improvement and risk management.

Health Boards and practitioners should comply with national monitoring and reporting requirements, as set out by the Mental Welfare Commission, allowing for consistent data collection across Health Boards. This system will enable practitioners to understand patterns of use, identify areas of concern, and ensure local practice aligns with national standards and human rights obligations.

All episodes of restraint or seclusion must be recorded in the patient’s clinical record. Records should include sufficient detail to demonstrate the legality, necessity and proportionality of the intervention, including:

• the circumstances leading to the intervention
• alternatives attempted
• the type and duration of restraint or seclusion
• monitoring undertaken
• the outcome for the patient.

Where an injury or adverse physical effects occurs as a result of restraint or seclusion, a local critical incident review must take place. This review should consider whether the intervention was necessary, whether alternative approaches could have been used, and what learning can be applied to reduce future risk.

Serious incidents, including those involving significant harm or concerns regarding the appropriateness of the intervention, should be reported in accordance with existing procedures, including notification to the Mental Welfare Commission where appropriate. Patients should be provided with information to help them access advocacy services, and complaints procedures.

The outcome of monitoring and review processes should inform service improvement, staff training, and patient care planning. Health Boards should ensure that learning from incidents contributes to a culture that promotes restraint reduction, respect for rights, and continual improvement in care and safety.

Staff planning, training and welfare

Health Boards should ensure that they have policies in place governing the use of restraint and seclusion. These policies should provide detail in relation to techniques and practices and should comply with human rights requirements.

Health Boards should ensure that practitioners involved in the use of restrictive interventions have access to comprehensive training and work within clear organisational policies governing all forms of restraint and seclusion. Restraint and seclusion should only be conducted by staff that are appropriately trained in the specific techniques they are using. Training should support practitioners to carry out their duties safely, lawfully and in accordance with human rights principles.

Training should support:

• the safe and proportionate use of restraint and seclusion
• de-escalation and consideration of alternative interventions
• trauma-informed and person-centred approaches
• awareness of the needs of specific groups, including children and young people, autistic people and people with learning disabilities
• human rights based practice.

Practitioners should also be trained in preventive frameworks to reduce the likelihood of restrictive interventions.

Health Boards should ensure that training is maintained and refreshed as required, and that practitioners work within clearly defined organisational policies and governance arrangements.

Health Boards should ensure that services are appropriately and sustainably resourced. This may include maintaining sufficient staffing levels with the necessary skills so patients receive high quality, person centred care, in line with the principles of the Act. Adequate resourcing should ensure that patients are not subject to restraint and seclusion unless it is the least restrictive option.

Restrictive interventions can have a significant emotional impact on the practitioners delivering them. Health Boards should ensure that appropriate support is available following incidents, including opportunities for debrief, supervision and reflective practice. Organisations should promote a culture in which practitioners are supported to reflect on their practice and to identify opportunities to reduce the use of restraint and seclusion.