Recommendation 54

What the Royal Commission said

The Royal Commission recommended:

• The Victorian Government act immediately to end the use of seclusion and restraint in mental health and wellbeing services within 10 years.
• The use of chemical restraint be regulated by Victoria's new Mental Health and Wellbeing Act.
• The Chief Officer for Mental Health and Wellbeing develop and lead a strategy to reduce the use of seclusion and restraint.
• The Mental Health Improvement Unit within Safer Care Victoria develop a range of programs and supports aligned with this strategy. These programs and supports are to be co-designed with mental health and wellbeing services and people with lived experience.

What are the opportunities?

The Royal Commission identified opportunities to improve the quality and safety of mental health and wellbeing services.

A key focus of this work is to reduce the use of seclusion and restraint.

What we've achieved

• We have established the Mental Health Improvement Program in Safer Care Victoria to improve care in publicly funded mental health and wellbeing services.

Towards Elimination of Restrictive Practices

• Safer Care Victoria's Mental Health Improvement Program has supported services to make measurable progress toward the Royal Commission's goal of eliminating restrictive interventions. As an initial phase, participating services set and exceeded an early improvement target of a 20 per cent reduction in restrictive interventions since 2022.
• Building on this progress, the initiative has expanded to work with 27 mental health units across 16 health services, broadening its reach and supporting greater consistency across Victoria's mental health system.
• Now at the midpoint of phase two, interim results show the positive trend is continuing, with further reductions in restrictive practices on track.

Monitoring and Oversight

• The Office of the Chief Psychiatrist now has expanded oversight on the use of restrictive interventions in Designated Mental Health Services, including emergency departments and urgent care centres, ensuring compliance with the Mental Health and Wellbeing Act 2022 and that restrictive interventions are used only as a last resort.
• We have commenced the regulation of chemical restraint for the first time in Victoria.
• The Office of the Chief Psychiatrist Seclusion and Restraint Report 2020-24 was published in November 2025 to provide a comprehensive account of restrictive intervention use in Victoria, promoting transparency and providing a basis for clinical accountability from health services. The report provides a broad overview of seclusion and restraint data, documenting a steady reduction in seclusion and restraint in Victoria from 2020-21 to 2024-25.

What's next?

The Victorian Government is progressing a range of actions towards the elimination of seclusion and restraint, including:

• The Towards Elimination of Restrictive Practices initiative will focus on statewide scale and spread, continuing to improve consumer experience through safer and less restrictive models of care.
• Embedding the Safewards model within mental health, emergency and general health units in public hospitals.
• Supporting services to reduce restrictive practices through workforce education and training, communities of practice and forums, Chief Psychiatrist site visits, sector-wide forums, clinical guidelines, factsheets, regular bulletins and targeted support to individual health services.
• Shifting performance targets to further reduce the use of seclusion.
• Developing a strategy in partnership with people with lived experience, service providers and workforce to guide action towards the elimination of seclusion and restraint. This will build on the significant work underway to reduce restrictive practices and improve the quality and safety of mental health and wellbeing service delivery across Victoria.