Three recent Victorian coronial findings1 have concerned the deaths of psychiatric patients who were being physically restrained as a consequence of exhibiting aggressive or threatening behaviour toward staff. Two deaths occurred on acute psychiatric inpatient wards, and the third in an emergency department.

Some common themes emerging from the findings include:

  • Patients who are physically large and strong require restraint by multiple staff members, which may in itself increase the risk of injury to the patient.
  • Overweight or obese patients may be at greater physiological risk of positional asphyxia.
  • Psychiatric patients may also be at increased risk of cardiac arrest in restraint scenarios, given that they are more likely than other patients to be affected by:
  1. a state of agitation brought on by psychosis or other psychiatric disorders; and
  2. the use of sedative medication.
  • Restraint scenarios often involve security staff and/or police, who are called in to assist clinical staff. Security staff in particular may have limited experience in the care and management of psychiatric patients. Furthermore, the influx of diverse team members into a fraught and fast moving situation can create an environment where otherwise clearly delineated responsibilities and chains of command become blurred. The coronial findings emphasised the importance of clinical staff maintaining leadership and control of such situations so as to protect the wellbeing of the patient.
  • One of the findings2 concerned the death of a patient who was being managed overnight in an emergency department because there were no psychiatric beds available. The finding highlighted the difficulties faced by hospital staff where they are forced to care for psychiatric patients in emergency departments. The Coroner made clear that busy emergency departments provide an inherently sub-optimal environment for patients who are often agitated and at risk of over-stimulation, and require specialist management.
  • It was recommended that hospitals be provided with better guidance on the issue of restraint, either in the form of guidelines from the Chief Psychiatrist or by way of reform to the Mental Health Act 1986 (Vic).


These findings serve as a timely reminder of the challenges that face clinicians who care for psychiatric patients. Hospitals can take a proactive approach by ensuring that:

  • They have clear, consistent policies and procedure in place to manage restraint scenarios, with the roles and responsibilities of relevant team members well defined.
  • Staff, including clinical and security staff, are thoroughly trained in the policies and procedures surrounding restraint, particularly in the context of psychiatric patients.