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Restraint techniques have long been used on psychiatric patients when they become uncontrollably violent, but last year's inquiry into the death of David "Rocky" Bennett raised serious questions about their safety.
Bennett, a schizophrenic, suffocated while being restrained for 25 minutes by four to five nurses at the Norvic Clinic, Norwich, in 1998. They held him down after he had hit a nurse in the face.

A key recommendation of the inquiry was that a patient should not be restrained in the "prone" position on the floor for longer than three minutes at a time. The Prison Service already limits physical restraint to five minutes.

The case caused an outcry as much for its racial dimensions - Bennett was African-Caribbean - as for the question of whether the nurses used excessive force.

But it is not unique. The Mental Health Act Commission says that between 1997 and 2000 two mental health patients died while under restraint, four died within 24 hours of being held down and 22 died within a week.
It is likely that these figures are underestimates, says pressure group Inquest, as hospitals are not obliged to summon the police or order a postmortem examination.

When Kurt Howard died while under restraint at a Swansea psychiatric hospital in 2002, the on-duty doctor recorded death as "natural causes". Only when a hospital pathologist questioned this did the police investigate.

The Department of Health, however, rejected the inquiry's calls for an interim three-minute limit on restraint. Draft guidelines from the National Institute for Clinical Excellence (Nice), which are due to be finalised in February, emphasise that restraint should be used for the "minimum possible" period only.

Dr Richard Stone, a former GP who sat on the Bennett inquiry, argues that the three-minute time limit was its most important recommendation.

"There's no doubt in my mind that restraining someone on the floor is an incredibly dangerous procedure - you feel you are being suffocated and killed," he says.

"If someone is pinned for a limit of three minutes face down on the floor, then at least he has time to catch his breath for a minute, even if you have to put him down again."

The draft guidance sets national standards for training in restraint and alternative techniques for managing violence. It also emphasises that restraint and other physical techniques for managing violence, such as seclusion and sedation, should be used only after all other attempts to defuse the situation have failed.
However, the current code of practice, written in 1983, already says the technique should be one of "last resort".

Stone says: "The reality is that when people are given a power as a last resort it quickly becomes the power of first resort. Our view was that, as soon as you say it can be used in exceptional circumstances, you have no limit on restraint. There's no definition of what exceptional circumstances are. The result is that more people are going to die."

Neither the Mental Health Nurses Association nor the Royal College of Nursing explicitly backs the idea of a time limit. Both organisations are more concerned to ensure that nurses are better trained in de-escalation techniques and safety in the use of restraint.

The RCN's mental health adviser, Ian Hulatt, says: "We need an agreed national standard for a safe way to use the last resort and a better understanding of the first resorts. Issues like maintaining a good airway are essential."

Errol Francis, of the Sainsbury Centre for Mental Health, says: "A time limit would be difficult to enforce."
A more profound question is whether mental health nursing can abandon restraint techniques altogether. "Control and restraint is not part of the technique in other specialties. Why is it part of the range of interventions that are taught?" asks Francis.

"In mental health it's institutionalised. Scenarios are rehearsed, and that's the problem. If someone becomes violent it should be an issue for law enforcement, not for nurses."

This would entail a massive cultural shift. Francis says: "It's such a tradition, and has been part of the regime since the birth of psychiatry. People are not ready to abandon it."

One issue is to consider why the nurse-patient relationship can deteriorate so far that restraint is deemed necessary, says Francis.

The inquiry report is clear that Bennett had suffered "cumulatively" from 18 years of racial abuse by fellow patients that in most cases went unchallenged by staff. He became involved in a fight with a patient who had racially abused him in the past, but it was Bennett who was transferred to another ward, not the white patient. So a feeling of injustice triggered his attack on the nurse.

Stone says the nursing staff, who were not racist, cited patients' vulnerability as the reason for not challenging their racism. Yet the inquiry team had noticed that smoking rules were strictly enforced.

It is a question of priorities. Because restraint techniques are used disproportionately on black patients, tackling racism in in-patient care may hold one answer to reducing reliance on a dangerous technique.

Advance directives, in which patients specify how they would prefer to be dealt with should they lose control, could be another solution. They are included in the draft guidelines, but are omitted from the draft Mental Health Bill.

Another client group with experience of restraint techniques in institutional care prefers this option.

A report by England's children's rights director, Dr Roger Morgan, gives the views of children in residential care homes. The children say the method should only be used as a last resort to prevent injuries or serious damage. It should not be a punishment - as it was for one child who merely threw a newspaper.

Staff also need to be mindful - and here there are parallels to sensitivities over race in mental health - that children who have been abused do not like being touched, says the report.

Morgan wants the government to produce guidelines and improve training in using restraint in children's homes. Each child's placement plan should also describe how to deal with them if they lose control.

Everyone agrees there is a dearth of evidence on how effective restraint techniques are compared with non-physical alternatives. Nor has their safety been studied, although a large body of evidence points to the risks.

Figures on deaths under restraint in secure hospitals are not routinely collected, nor is the number of times that restraint is used, although a voluntary reporting system is being established.

In the meantime, restraint remains the nuclear option in mental health services. For now, nobody is prepared to give up the deterrent.

DRAFT GUIDELINES

• When using restraint the level of force applied must be justifiable, appropriate, reasonable and proportionate and should be applied for the minimum possible time.
• Rapid tranquillisation, physical interventions and seclusion should only be considered once de-escalation and other strategies have failed to calm the service user. They should never be used as punishment. 
• During physical restraint one team member must be responsible for protecting and supporting the head and neck at all times, for ensuring that the airway and breathing are not compromised and that vital signs are monitored.
• Where possible (in the form of an advance directive) intervention strategies for the management of disturbed or violent behaviour should be negotiated with all service users, and be documented in the care plan and records.
• All those involved with rapid tranquillisation, physical interventions or seclusion must receive training to a minimum of intermediate life support.
• The crash bag must be available within three minutes in health care settings where rapid tranquillisation, physical interventions and seclusion might be used.
• Staff must receive training to recognise anger, potential aggression, antecedents and risk factors of violence and to monitor their own verbal and non-verbal behaviour. It should include methods of anticipating, de-escalating or coping with violent behaviour. 
• Techniques that rely on the deliberate application of pain are permitted in exceptional circumstances only, when other techniques have been tried and proved unsuccessful.