How far have we really come from the nightmare of ‘One flew over the cuckoo’s nest’? By Dina Poursanidou

Musings on prone (face-down) restraint in inpatient mental health care in England: The image depicts a scene from ‘One flew over the cuckoo’s nest’. In this image*, McMurphy is being subjected to prone (face-down) physical restraint. Throughout the film, face-down physical restraint is normally used on McMurphy to control and punish him after he has broken a rule of the regime.

one flew over

Yesterday (Friday 6th July 2018) Seni’s Law was debated at Third Reading (the final opportunity for the Commons or the Lords to decide whether to pass or reject a Bill in its entirety) at the House of Commons in London. Seni’s Law is Steve Reed’s (MP) bill calling for the end of the use of inappropriate force against people using mental health services. The bill is named after Seni Lewis who died in Bethlem Royal Hospital in London back in 2010 after he was restrained face-down for longer than 30 minutes by 11 police officers until he stopped breathing.


The following account is from ‘a nursing daily record’ (dated 7 February 2009) that comes from my own Care Notes covering the period 28 January-24 April 2009; during that time I was detained under the Mental Health Act 1983/2007 in an acute inpatient psychiatric ward in Manchester. I requested my Care Notes from the time of my sectioning in 2011 and I read them with the help of an NHS clinical psychologist. The highlighting and underlining on the scanned record are mine, and I am referred to in it as ‘Konstantina’ (my full name):


dina notes entry


According to this nursing record, I was restrained for approximately 20 minutes. Although I do not remember much from the first month of my detention (February 2009), I do remember the restraint described in the record quite vividly. I remember being held face-down on my bed by 4 or 5 members of staff…I remember shouting (screaming?) ‘Let go!’ over and over again…Long after I was discharged from the ward, my boyfriend at the time mentioned to me that a couple of the other patients on the ward had told him ‘It took 6 people to hold Dina down the other day…she was fighting for her life…’.

Sadly, I was restrained face-down and for about 20 minutes that day to be given intra-muscular medication merely because I was ‘very agitated’, ‘resistive’ (i.e. not conforming to staff’s orders to stay in my room and constantly knocking on the nurses’ office door to tell staff over and over again that I wanted to go home), and desperate to leave the ward-an environment that I experienced as acutely unsafe and far from caring and therapeutic. Unnecessary (in my view) use of prolonged (and hence rather dangerous) prone (face-down) physical restraint as a means of controlling acute agitation and distress, as well as possibly punishing resistance/recalcitrance in my case…   

One wonders how far had inpatient mental health services in England really come from the nightmare of ‘One flew over the cuckoo’s nest’ back in 2009/2010, i.e. 35 years since the film was released (the film came out in 1975) and 50 years (half a century) since the book upon which the film was based was written (the book was written in the early 1960s)?

In 2015, a joint publication by Mind and NSUN (National Survivor User Network) UK (Restraint in mental health services: What the guidance says) outlined key points from national guidance on restraint in inpatient mental health care – issued, among others, by the Department of Health and the Care Quality Commission – as follows:

‘Physical restraint and other restrictive interventions must only be used as a last resort when there is a real possibility of harm if no action is taken. The action must be proportionate to the risk of harm and its seriousness, and the least restrictive thing staff can do. It must be imposed for no longer than is absolutely necessary. It must never be used to punish, hurt or humiliate’.

‘Physical (manual) restraint

Staff should avoid, if at all possible, holding you down on the floor or any other surface. Most importantly, you must not be held in any way that makes it hard for you to see, hear, speak or breathe, or that affects your blood circulation. This means that the person holding you shouldn’t press on your rib cage, neck or abdomen, or cover your eyes, ears, nose or mouth. You should be held for as short a time as possible; NICE says this should not usually be for more than 10 minutes. But any restraint must always be ended as soon as possible. One of the staff members involved in the restraint should keep communicating with you from before the restraint and during it, continually trying to de-escalate the situation’ (p.18)

In a similar vein, the NICE Guideline entitled ‘Violence and aggression: short-term management in mental health, health and community settings’, issued in May 2015, instructed:

‘When using manual restraint, avoid taking the service user to the floor, but if this becomes necessary: use the supine (face up) position if possible or if the prone (face-down) position is necessary, use it for as short a time as possible’ (p.216)


In 2015-16, 18.5 % of recorded incidents of restraints in England were face-down (Alison Holt & Callum May, ‘Face-down restraint continuing in NHS mental health wards’, 21 September 2016). Characteristically, in 2016, in one of London’s largest Mental Health Trusts, the reporting of prone (face-down) restraint was above the national average and within the upper range of reported incidents nationally.

An article in the Guardian on 10th June 2018 pointed to an ‘alarming’ rise in patient injuries due to restraint at mental health units in England:

‘A total of 3,652 patients suffered an injury through being restrained during 2016-17 – the highest number ever – according to data from 48 of England’s 56 mental health trusts. The figures raise serious questions about the effectiveness of the government’s drive to reduce use of techniques which critics say can be traumatic for patients and even endanger their lives’. “Whilst this dramatic increase may be partly explained by improved reporting, the scale of injuries is horrifying. This is also, no doubt, in part due to the stress that many trusts are under, with bed occupancy close to 100% and often relying on agency staff,” said Liberal Democrat MP Norman Lamb’.

(Denis Campbell, ‘Figures reveal ‘alarming’ rise in injuries at mental health units’, 10 June 2018).


So, the question remains – how far have inpatient mental health services in England really come from the nightmare of ‘One flew over the cuckoo’s nest’?

And how meaningful is it to talk about ‘recovery-focused inpatient mental health care’ in this country when the violent practice of face-down physical restraint is still being used on mental health wards – a practice that is acutely disempowering and even life-threatening for service users on these wards, serving to totally quash the service users’ sense of control, agency and self-worth?

Yesterday (6th July) MPs at the House of Commons in London voted in favour of Steve Reed’s Bill (Seni’s Law) to restrict use of force against people using mental health services. The Bill will now pass to the House of Lords for further scrutiny before it becomes law (Benjamin Kentish, ‘MPs approve ‘Seni’s law’ to restrict use of force against mental health patients’, 6 July 2018).

One hopes that the passing of Steve Reed’s Bill represents a chance to end the use of face-down physical restraint on mental health wards…a chance to make inpatient mental health services in this country safer….


*The image was taken from and is an image made available for public use

7 July 2018


  • Cassie Quinlan ,

    The restraint is not the issue, the forced medication is, and the medicine led world that thinks it is necessary, instead of reconfiguring communities with time, feedback, gentleness in care.


      Hi, Cassie Quinlan…a 20 minute face down unnecessary and dangerous restraint IS very much the issue here, together with the forced medication…

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