Department of Health

The Chief Psychiatrist has statutory functions under the Mental Health Act 1986. A primary responsibility of the Chief Psychiatrist is for the medical care and welfare of persons receiving treatment or care for a mental illness. This includes monitoring mental health treatment and care provided to individuals and implicit is the improvement of clinical practice. This includes the development of clinical guidelines and providing education and advice to ensure best practice.

This Clinical Practice Advice Notice is to support clinical services in the development of procedures to ensure the appropriate care and treatment of people being physically restrained in mental health services.

Of particular concern is the practice of prone restraint. The use of prone restraint is to be avoided. If in the course of a restraint a person is put in a prone position then this must cease as soon as practical and is not to exceed 3 minutes.


The physiology of restraint related deaths is difficult to determine as the actual numbers are small and classifications of deaths vary from place to place. Factors include:

  • the position a person is held in and in particular use of the prone position
  • acute behavioural disturbance and excited delirium
  • stress related cardiomyopathy
  • alcohol and drug use.

A recent review by Duxbury et al (2011) found that out of 38 restraint related deaths, 26 deaths were associated with positional asphyxia. Positional asphyxia occurs when a person being restrained is placed in a position that compromises their breathing and as a result does not get enough oxygen. When there is a lack of oxygen, this can lead to disturbance in cardiac rhythm and death may result.


  1. All restraints are high risk to the people involved. Restraint (particularly prone restraint) has been identified as a significant risk and so health services are recommended to have strategies to minimise the use of all restraints and the risks associated with restraint.
  2. Health services should ensure executive oversight is present over all restraint practice and policy development.
  3. Prone restraint should not be used. If in the course of a restraint a person is put in a prone position then this must cease as soon as practical and is not to exceed 3 minutes.
  4. In clinical health settings, it is recommended that a registered nurse is required to be responsible for monitoring of the vital signs and ensure the chest area of a person is not compressed. If prone restraint is used, the registered nurse will ensure the person is not in a prone position for longer than 3 minutes.
  5. All staff should be educated in the use of restraint and the risks associated with restraints.
  6. A suitably qualified health professional should be in charge of the restraint process.
  7. All restraints should be treated as an incident, reviewed and documented accordingly.


Tasmanian Government, (May 2012) Safer Practice Notice : No: 02 / 20120514 -- Prone Restraint & the Risk of Positional Asphyxia

New South Wales, (June 2012) Policy Directive: Aggression, Seclusion & Restraint in Mental Health Facilities in NSW Caring Solutions

United Kingdom: University of Central Lancashire, (2011), Review of the medical theories and research relating to restraint related deaths

Reviewed 26 October 2022


Contact details

Office of the Chief Psychiatrist

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