1. SECLUSION
My opinion is that seclusion is the last medieval practice that
continues to exist today within psychiatry.
I believe the practice to be degrading, anti-therapeutic and
unnecessary.
To my knowledge the definition of seclusion from the 1950’ onwards
was placing a person alone in a locked padded seclusion room
between the hours of 7pm until 7am. The room contained only a
waterproof mattress on the floor. There was no other furniture. The
toilet was a gutter running around the perimeter of the floor and
there was no internal means of calling for staff assistance. The door
was always locked as the padded door had locks that automatically
sprung into place when the door was closed. If this form of isolation
took place during the day it was not classified as seclusion.
Another way then of isolating very disturbed or aggressive people
was to put them in a strong room. There were usually a number of
these rooms. The rooms were fitted with heavy wooden lockable doors
with a narrow re-enforced glass strip for observation; the windows
were fitted with heavy lockable wooden shutters. Furniture only
consisted of an iron framed bed with a heavy chamber pot
underneath. Difficult or potentially aggressive people were locked in
these rooms at night dressed only in their shirts with the rest of their
clothes bundled up and left on the floor outside the door. Staff did
not enter these rooms during the night. The rooms although locked
were not classified as seclusion.
In 1970 at St James Hospital, Portsmouth seclusion and all types of
manual restraint were banned in every ward including the intensive
care ward. When I started work there in 1972 I was pleased to find
that all of the seclusion rooms (padded cells) and strong rooms had
been removed. I therefore presumed wrongly that seclusion had been

2. disposed of into the dustbin of history. However I was surprised in
the 1980’s when I joined the English Heath Advisory Service to see
that seclusion was still being practiced at Nethern Hospital even in
the acute admission ward where there were 4 or five of these rooms
in constant use. Later I found that the practice was still alive and
well in many other hospitals.
In my HAS reports in the 80’s I advised that alternative ways of
caring for disturbed people should be implemented. This advice
resulted in the Department of Health contacting Dr Dick the
Director of the HAS asking him to stop putting this advice in the
HAS reports as the DH were just issuing guidelines for its continued
use. Dr Dick’s response was to refuse on the grounds that his teams
were drawn from experienced front line practitioners and he
therefore stood by his team member’s recommendations. It should be
understood that the HAS was totally independent and not
responsible to the Department of Health. An arrangement that today
could be of great benefit to the Mental Health Act Commission.
If we now look now at the Mental Health Act Commissions
definitions of seclusion you will see that it has progressively moved
away from a strong, positive and clear definition to one that is
vague, and more open to interpretation and on occasion inconsistent.
In 1987 the Commissions definition was” The supervised denial of
the company of other people by constraint within a closed
environment at any time of the day or night. The patient is confined
alone in a room, the room door cannot be unlocked from the inside
and from which there is no other means of exit open to the patient.”
The rule regarding between 7am to 7pm had been removed.
In the MHAC 9th
Biennial Report 1999 to 2001 it states “If a
patient is kept in a room devoid of entertainment or diversion he
(They) may suffer sensory deprivation. Detention in a small
featureless room is oppressive for anyone but is more likely to be
objectionable and damaging in the case of a person whose mental

3. health is at best vulnerable. It may lead to feelings of increased
despair and isolation, anger and worsening of delusions and
hallucinations. Its effect may be aggravated by uncertainty as to
whether or when seclusion may come to an end. Seclusion may bring
about violent behaviour that it is intended to prevent. If there are
no washing or toilet facilities conditions may at best become
unpleasant and at worst difficult or impossible to bear.”
In 2003 the Munjas vAshworth Hospital provided a definition of
seclusion that used rather unusual language. It appears that in
general the definition is in accord with 1950’s practice and the
Commissions 1987 definition. In the Munjas case seclusion is defined
as “Keeping a patient under regular frequent observation while they
are prevented from having contact with anyone else in the world
outside the room where they are confined.” The stipulation of
between 7pm and 7pm was reintroduced. The other finding of
interest is that seclusion under UK and Human Rights Law did not
constitute inhuman or degrading treatment.
I find this last finding inconsistent with the Commissions 1999
biennial comment on seclusion and my own personal experience. First
seclusion can have a strong undercurrent of punishment, and getting
a disturbed person passed other patients to the seclusion room is
often degrading and hurtful. Once in the room some clothing, ties,
belts shoes and socks are remove and I know of patients who have
been left naked. For women it can be particularly degrading as their
bras are also removed and I have personally seen instances where
woman have been left naked under the close supervision of CCTV.
I also know of a case in a Special Hospitals where a young patient
(with a low index offence) had been secluded over a period of several
years despite the fact that the hospital was visited regularly during
that period by members of the Mental Health Act Commission.

4. Are these situations inhuman and degrading treatment or not? I
leave that for you to judge.
In 2002/2003 the Commission undertook a survey of hospitals using
seclusion. These were their findings.
40% failed to report any monitoring or audit process,
52% failed to provide privacy from other patients
46% failed to enable staff to observe patients at all times.
68% failed to be safe and secure
68% failed to provide a room that did not contain anything that
might harm the
patient or others.
77% failed to be adequately furnished, heated or ventilated
39% failed to provide a quiet but not soundproof room with some
means of calling
for assistance.
Added to these failures I have also seen many instances of creative
recording where the MHAC Code of Practice observation periods have
been missed or retrospectively completed.
Today I am very pleased that there are many alternatives to seclusion
practiced. None involve putting a disturbed person alone in a locked
room. All involve the continuous presence of one or more staff. These
alternatives come with a variety of names. De-escalation. Time Out.
Low Stimulus. High Care, Rumpus rooms and Snoozlums etc. None
come close to the original definitions or practices of seclusion but
despite this the Commissioners continue to classify them as seclusion
and contrary to all logic still requires that all of the seclusion rules
are carried out. Despite the fact that staff are present at all times.
What is required now is an objective evaluation of each of these
alternative practices, involving the views of people who have been
subject to these forms of care. It needs to be established if these
methods are (1) demonstrably humane. (2) assists in the maintenance

5. of good relationships between staff and patients.(3) minimises
disturbed behaviour and (4) is safe and effective. Once this is
established then clear protocols for each method should be drawn up
to enable each member of staff to understand a particular methods
intentions and be able to accepted and follow its rules. The
definition of Seclusion and its now irrelevant rules should then be
dropped.
It is an undisputable fact the seclusion is the easy option, It requires
only very basic skills to seclude. I could get anyone off the street,
regardless of their attitude, to seclude someone. However to practice
some of the alternatives to seclusion requires the right attitude, good
training and skill, good medical support and of course sufficient
staff.
The Commissions latest definition in its 2014 Code of practice is
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Our society is credited as being civilised and you as nurses and
doctors are judged to be the most caring arm within society.
Therefore we need to demonstrate that our caring is genuine by
acting in a positive and humane way by removing this last vestige of
this medieval practice,
Derek McCarthy 6th
November 2015.

6. I believe that if the DH and the Commission had devoted their
energy to getting rid of seclusion instead of writing guidelines
seclusion and seclusion books may have disappeared years ago.
THE CURRENT COMMISSIONS DEFINITION STATES THE
DOOR MAY BE LOCKED. THIS I BELIEVE CLOUDS, THE
ISSUE AND LEADS TO THE CURRENT CONFUSION.
IT EVEN SUGGESTS THAT MANY OF THE PRESENT
ALTERNATIVES TO SECLUSION ARE INFACT STILL
SECLUSION AND THEREFORE COME UNDER THE
SECLUSION GUIDANCE IN THE MHAC CODE OF PRACTICE.
THEY COULD HAVE JUST BEEN ADMITTED.
THEY MAY BE VERY ILL AND DISTURBED.
THEY MAY HAVE NEVER PREVIOUSLY BEEN
SECLUDED.
THEY MAY ALSO SUFFER FROM A DEGREE OF
CLAUSTROPHOBIA.

7. THEY MAY HAVE HAD TO BE RESTAINED AND
MANHANDLED INTO THE SECLUSION ROOM.
THEY WOULD HAVE HAD THEIR SHOES
REMOVED, THEIR BELT AND TIE REMOVED, IF
THE ARE WOMEN THE MAY HAVE HAD A SCARF
AND THEIR BRA REMOVED.
AND THEY MAY BE SUBJECT TO CONSTANT CCTV
OBSERVATION.
WHEN A PATIENT HAS BEEN THROUGH THIS
PROCESS HOW MUCH DIGNITY OR PERSONAL
POWER DO YOU THINK THEY HAVE LEFT?
IMPORTANTLY WOULD THE PATIENT VIEW THE
PERPETRATORS OF THIS ENFORCED
ISLOLATION AS FRIENDS OR AS CAREING STAFF
TRYING TO HELP THEM?
NOW YOU MAY REPOND BY SAYING MY POINT
OF VIEW IS TOO EMOTIVE AND AN
EXAGGERATION OF REALITY.
WELL LETS SEE WHAT THE COMMISSION SAYS
ABOUT SECLUSION IN ITS 9th
BIENNIEL REPORT
OF 1999 to 2001.
THE COMMISSION SAYS

8. IF A PATIENT IS KEPT IN A ROOM DEVIOD OF
ENTERTAINMENT OR DIVERSION HE MAY
SUFFER SENSORY DEPRIVATION.
DETENTION IN A SMALL FEATURLESS ROOM IS
OPPRESSIVE FOR ANYONE BUT IS MORE LIKELY
TO BE OBJECTIONABLE AND DAMAGING.
IN THE CASE OF A PERSON WHOSE MENTAL
HEALTH IS AT BEST VULNERABLE IT MAY LEAD
TO FEELINGS OF INCREASED DISPAIR AND
ISOLATION, ANGER AND WORSENING OF
DELUSIONS AND HALLUCINATIONS.
ITS EFFECT MAY BE AGGRIVATED BY
UNCERTAINTY AS TO WETHER OR WHEN
SECLUSION MAY COME TO AN END.
SECLUSION MAY BRING ABOUT THE VIOLENT
BEHAVIOUR THAT IT IS INTENDED TO
PREVENT.
IF THERE ARE NO WASHING OR TOILET
FACILITIES CONDITIONS MAY BECOME AT BEST
UNPLEASENT AND AT WORST DIFFICULT OR
IMPOSSIBLE TO BEAR.
IF THIS IS REALLY WHAT SECLUSION IS LIKE
WOULD YOU CONSIDER IT THERAPEUTIC?

9. WOULD YOU WRITE GUIDLINES FOR IT?
OR WOULD YOU DEVELOP MORE SUITABLE
AND HUMANE ALTERNATIVES?
FINALLY I WOULD LIKE TO GIVE A QUICK
OVERVIEW OF SECLUSION OVER THE LAST 3
DECADES.
IN 1972 WHEN I STARTED AT ST JAMES
HOSPITAL IN PORTSMOUTH I WAS INFORMED
THAT THEY HAD DISCONTINUED SECLUSION
FOUR YEARS BEFORE I ARRIVED, BOTH IN
THEIR ADMISSION AND INTENSIVE CARE
WARDS.
THIS FIRMLY CONVINCED ME THAT SECLUSION
HAD BEEN CONFINED TO THE DUSTBIN OF
HISTORY WHERE IT TRULY BELONGS
SOME YEARS LATER IN 1980 WHEN I JOINED
THE HEALTH ADVISORY SERVICE I WAS
AMAZED TO SEE THAT SECLUSION WAS STILL
ALIVE AND FLORISHING.
AFTER A VISIT TO NETHERN HOSPITAL I
ADVISED THEM IN MY REPORT TO FIND
ALTERNATIVES TO THE USE OF SECLUSION

10. ROOMS IN BOTH THEIR ADMISSION AND
INTENSIVE CARE WARDS.
THE DEPARTMENT OF HEALTH SOME HOW
CAUGHT WIND OF THE ADVICE I WAS GIVING
AND CONTACTED THE THEN DIRECTOR DR
DONALD DICK
THEY ASKED HIM TO STOP ME GIVING THIS
ADVICE AND BEING PUT IN H.A.S. REPORTS AS
THEY WERE JUST WRITING GUIDELINES. HE
DECLIND THEIR REQUEST AND MY ADVICE
STOOD.
SOME TIME AFTERWARDS IN 1983 THE
COMMISSION WROTE THEIR GUIDANCE INTO
THE CODE OF PRACTICE.
I BELIEVE THAT BOTH OF THESE
ORGANISATIONS GUIDINES HAVE GIVEN
SECLUSION A LEGITAMACY THAT IT WOULD
HAVE NOT OTHERWISE HAVE HAD AND HAVE
PERPETUATED A PRACTICE THAT IF
DISAPROVED BY THEM WOULD HAVE ENDED
LONG AGO.
OVER THE LAST TEN YEARS WITH THE
COMMISSION I HAVE VISITED EVERY MENTAL
HEALTH HOSPITAL FROM EAST TO WEST FROM

11. THE SUSSEX BORDER TO THE TIP OF
CORNWALL. AND FROM THE NORTHERN
BOUNDRIES OF CHELTERNHAM TO SWINDON.
I HAVE SEEN SERVICES WITH THE SAME
CATAGORIES OF PATIENT WHO DO NOT
PRACTICE SECLUSION SOME FOR MANY YEARS
AND THOSE THAT ARE STILL USING IT AND
HAVE EVEN RECENTLY BUILT NEW SECLUSION
ROOMS.
HOW CAN THIS BE?
GENERALLY IN THE SOUTHWEST,
PARTICULARLY IN HAMPSHIRE MOST OF THE
ACUTE AND INTENSIVE WARDS HAVE
DISCONTINUED SECLUSION IN FAVOUR OF
MORE SUITABLE ALTERNATIVES.
HOWEVER IT REMAINS TRUE SECLUSION IS
STILL THE EASY OPTION.
IT REQUIRES LESS NURSING TIME, LESS SKILL,
LESS THOUGHT AND A MINIMUM OF
FACILITIES.
ALTERNATIVES TO SECLUSION REQUIRE
HIGHLY SKILLED NURSING STAFF WITH
INOVATIVE THINKING, THE RIGHT ATTITUDE

12. AND PROMPT AND GOOD MEDICAL SUPPORT
AND GOOD COMPREHENSIVE FACILITIES.
BUT WHAT ABOUT THOSE FEW SERVICES THAT
CONTINUE TO USE SECLUSION.
THE COMMISSION CONDUCTED A SURVEY OF
SECLUSION IN 2002/3
THIS IS WHAT WAS FOUND.
40% FAILED TO REPORT ANY MONITORING OR
AUDIT PROCESS.
52% FAILED TO PROVIDE PRIVACY FROM OTHER
PATIENTS
46% FAILED TO ENABLE STAFF TO OBSERVE
PATIENTS AT ALL TIMES
68% FAILED TO BE SAFE AND SECURE
68% FAILED TO PROVIDE A ROOM THAT DID NOT
CONTAIN ANYTHING THAT MIGHT HARM THE
PATIENT OR OTHERS
77% FAILED TO BE ADEQUETLY FURNISHED,
HEATED OR LIT AND VENTILATED.

13. 39% FAILED TO PROVIDE A QUITE BUT NOT
SOUNDPROOF ROOM WITH SOME MEANS OF
CALLING ATTENTION.
WE ARE SUPPOSED TO BE AN ENLIGHTENED
AND CARING SOCIETY AND WE ARE REPUTED
TO BE ONE OF THE CARING ARMS OF OUR
SOCIETY.
IF YOU TRULY BELIEVE THIS THEN DON’T JUST
THINK IT OR JUST SAY IT. DEMONSTRATE IT
IMPLIMENT ALTERNATIVES TO SECLUSION.
I REST MY CASE.
Derek McCarthy October 05
THERE IS PROFESSOR OF PSYCHIATRY FROM A
NURSING BACKGROUND THAT IS PUBLICALLY

14. SAYING THAT WE SHOULD RE_EXAMINE THE
USE OF MECHANICAL RETRAINT, HAND CUFFS
AND STRAIGHT JACKETS SO IF YOU ARE
SUPPORTING THE CONTINUATION OF
SECLUSION HE IS WAY AHEAD OF YOU.
IT’S NOW 40 YEARS SINCE PROGRESSIVE
HOSPITALS STOPPED PRACTICING SECLUSION.
IT’S TIME TO START TREATING ALL PATIENTS
NO MATTER HOW ILL WITH REAL HUMAN
DIGNITY. FOR I AM SURE IF YOU OR YOU
FAMILY WERE IN THEIR POSSITION THAT IS
HOW YOU WOULD WISH TO BE TREATED.
FIND ALTERNATIVES TO