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Chief Psychiatrist Standard: 
Compliance is mandatory 
Restraint and Seclusion Recording and Reporting Chief 
Psychiatrist Standard 
Objective file number: 2013-01674 
Document classification:  PUBLIC: I1-A1 
Document developed by: Office of the Chief Psychiatrist  
Approved by the Minister for Mental Health and Substance Abuse: 30 July 2015 
Next review due: 30 July 2017 
 
Compliance with this Chief Psychiatrist Standard is mandated under section 90 of the 
Mental Health Act 2009.  
 

 

Version control and change history 
Version Date from Date to Amendment  
1.0 30/07/15 current Original version  

  Department for Health and Ageing, Government of South Australia. All rights reserved. 

Summary The Restraint and Seclusion Recording and Reporting Chief 
Psychiatrist Standard outlines the requirements of health 
services to record information and make notifications to the 
Office of the Chief Psychiatrist, to enable the monitoring of 
the use of restraint and seclusion. 
 

Keywords Restraint, Seclusion, Reporting, Recording, Notification, Chief 
Psychiatrist Standard, Incident, SLS, EPAS, Physical Restraint, 
Chemical Restraint 
 

Policy history Is this a new policy?  Y 
Does this policy amend or update an existing policy?  N 
Does this policy replace an existing policy?  N 
If so, which policies? 
 

Applies to All Health Networks  
 

Staff impacted All Clinical, Medical, Nursing, Allied Health, Emergency, Dental, 
Mental Health, Pathology  
 

EPAS compatible Yes 
 

Registered with Divisional Policy 
Contact Officer 

No 

Policy doc reference no. S0003 

 



 
 
 
 
 
 

Restraint and Seclusion 
Recording and Reporting  

Chief Psychiatrist Standard   

 

 



 
Document control information 
 

Document owner Chief Psychiatrist, Office of the Chief Psychiatrist 

Contributors Chief Psychiatrist, Office of the Chief Psychiatrist 

Document Classification PUBLIC: I1-A1 

Document location 
SA Health internet    policies page ,  mental health policies    
 
SA Health intranet    policies page  

Reference  

Valid from   30/07/2015  Approval by Minister 

Anticipated Date of Review   30/07/2017 
 

Document history 
 

Date Version Who approved New/Revised Version Reason for Change 

30/07/2015  V.1 Minister for Mental Health and Substance Abuse Minister Approved Version 
 

  

 
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Contents Page 
 
1. Objective .............................................................................................................................. 4 
2. Scope ................................................................................................................................... 4 
3. Principles .............................................................................................................................. 4 
4. Detail .................................................................................................................................... 4 
5. Roles and Responsibilities ................................................................................................... 5 

5.1 Health services staff .................................................................................................. 5 
5.2 Service Managers ...................................................................................................... 5 
5.3 Office of the Chief Psychiatrist staff ........................................................................... 5 

6. Reporting .............................................................................................................................. 5 
7. EPAS .................................................................................................................................... 6 
8. Exemption ............................................................................................................................ 6 
9. National Safety and Quality Health Service Standards ....................................................... 6 
10. Risk Management ................................................................................................................ 6 
11. Evaluation ............................................................................................................................ 6 
12. Definitions ............................................................................................................................ 7 
13. Associated Policy Directives / Policy Guidelines ................................................................. 7 
14. References, Resources and Related Documents................................................................ 8 
  

 
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Restraint and Seclusion Recording and 
Reporting Chief Psychiatrist Standard 

 
1. Objective 
 
Sections 90(1)(b) and 98(2)(c) of the Mental Health Act 2009 (the Act) require the Chief 
Psychiatrist to monitor the use of mechanical body restraints and seclusion in relation to 
voluntary and involuntary patients and for health services to keep records of the use of 
mechanical body restraints and seclusion. 
 
The purpose of this Standard is to outline the requirements of health services to record 
information and make notifications to the Office of the Chief Psychiatrist and Mental 
Health Policy (OCPP), to enable the monitoring of the use of restraint and seclusion. 
 

2. Scope 
 
This Standard applies to all SA Health, Mental Health Service settings and is relevant to 
all SA Health staff providing services to people with an experience of mental illness and 
their support person/s across the age spectrum. 
 

3. Principles 
 
The Act contains a set of Guiding Principles which are designed to provide guidance to 
everyone involved in the administration of the Act. These principles should assist health 
professionals in decision-making and undertaking actions. 
 
The observation of consumers being restrained or secluded is guided by sections 7(1)(b), 
(h) and (g) of the Act which require that services should be provided on a voluntary basis 
as far as possible and in the least restrictive way and environment; mechanical body 
restraints and seclusion must only be used as a last resort; and medication should not be 
used as punishment or for the convenience of others. 
 

4. Detail 
 
All incidents of restraint or seclusion are to be entered on the Safety Learning System and 
any other relevant electronic database system.  
 
Incidents of restraint and seclusion considered a  critical incident  (see Part 12 
Definitions), these incidents will be automatically notified to the OCP via the SLS system. 
An additional report is required by the OCP within one business day and is located on 
the OCP website as part of the Restraint and Seclusion Policy Guidelines Toolkit entitled  
 Restraint and Seclusion Reporting  on Page 8.  
 
 
 
 
 
 

 
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5. Roles and Responsibilities 
 
5.1 Health services staff 
 
It is the responsibility of health service staff involved in the care of people with a mental 
illness to: 
 

&gt; Comply with the requirements of this Standard. 
&gt; Reduce and where possible eliminate the use of restraint and seclusion. 
&gt; Ensure a record of restraint and seclusion incidents, including the name, age, 

gender, ethnicity, diagnosis, type of restraint used, time applied and removed, 
attempted preventative interventions, medical review, direct visual observations, 
post incident follow up and all relevant documentation is completed. 

&gt; Enter incidents of restraint and seclusion on the Safety Learning System, ensuring 
less than 1 hour is a SAC 4 event, less than or equal to 4 hours is a SAC 3, more 
than 4 hours, is a SAC 2 and an incident over 8 hours or resulting in harm to any 
person, is a SAC 1 event. 

&gt; Critical Incidents are any incident of restraint or seclusion where the consumer or 
staff were injured, the incident lasted more than 12 hours or intubation was utilised 
in the process of sedation for the management of challenging behaviours. 
 

5.2 Service Managers 
 

It is the responsibility of Service Managers to: 
 

&gt; Ensure procedures outline what staff can do to prevent or minimise the use of 
restraint and seclusion, ensuring it is used only as an option of last resort. 

&gt; Establish local review processes to monitor and review incidents with a focus on 
reduction and elimination of restraint and seclusion. 

&gt; Ensure staff have access to required systems to report incidents.  
&gt; Ensure local procedures include how to escalate the reporting process. 
&gt; Ensure compliance with this standard across the LHN. 

 
5.3 Office of the Chief Psychiatrist staff 
 
It is the responsibility of the OCPP to: 
 

&gt; Report quarterly to the Local Health Networks and private hospitals on the use of 
restraint and seclusion across all networks. 

&gt; Include data on the use of restraint and seclusion in the annual report to the 
Minister for Health and Aging for tabling in Parliament. 

&gt; Provide information annually to the Estimates Committee Hearing. 
&gt; Nominate a system for state-wide data collection. 
&gt; Provide data for national reporting requirements.  

 

6. Reporting 
 
See Part 4.  
 
 

 
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7. EPAS 
 
Restraint and Seclusion is recorded as part of the electronic record which is built in to 
EPAS. 
 
Any incidents of Restraint or Seclusion are also entered in to the Safety Learning System 
as a matter of process. 
 

8. Exemption 
 
No exemption allowed for this policy directive. 
 

9. National Safety and Quality Health Service 
Standards 

 
The Australian Commission on Safety and Quality in Health Care has developed 10 
National Safety and Quality Health Service Standards (the Standards). 
 
The Standards provide a nationally consistent and uniform set of measures of safety and 
quality for application across a wide variety of health care services. They propose 
evidence-based improvement strategies to deal with gaps between current and best 
practice outcomes that affect a large number of patients. 
 
This policy guideline contributes to the standards in the following way: 
 

 
 

National 
Standard 1 

 
Governance 

for Safety 
and Quality 

in Health 
Care 

 

 
 

National 
Standard 2 

 
Partnering 

with 
Consumers 
 
 
 

 
 

National 
Standard 3 

 
Preventing 

&amp; 
Controlling 
Healthcare 
associated 
infections 

 
 

National 
Standard 4 

 
Medication 

Safety 
 
 
 
 

 
 

National 
Standard 5 

 
Patient 

Identification 
&amp; Procedure 

Matching 
 
 

 
 

National 
Standard 6  

 
Clinical 

Handover 
 
 
 

 

 
 

National 
Standard 7 

 
Blood and 

Blood 
Products 

 
 

 

 
 

National 
Standard 8 

 
Preventing 

 &amp; 
Managing 
Pressure 
Injuries 

 

 
 

National 
Standard 9 

 
Recognising &amp; 
Responding to 

Clinical 
Deterioration 

 
 

 
 

National 
Standard 10 

 
Preventing 

Falls &amp; 
Harm from 

Falls 
 
 

? ? ? ? ? ? ? ? ? ? 
 

10. Risk Management 
 
Risks to SA Health staff and patients are protected by the following documents:  
 

  Restraint and Seclusion in Mental Health Services Policy Guideline,  
  Chief Psychiatrist Standard - Restraint and Seclusion   Recording and Reporting  
  Chief Psychiatrist Standard - Restraint and Seclusion   Application and 

Observation  
 

11. Evaluation 
 
Restraint and seclusion is monitored, evaluated and reported on by the Chief Psychiatrist 
and the five Local Health Networks (LHNs) as required by sections 90(1)(b) and 98(2)(c) 
of the Mental Health Act 2009 (the Act). Data from the OCPP and LHNs is separately 
reported nationally to the Safety Quality Partnership Standing Committee.  
 
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All three documents mentioned in Part 10 will be evaluated through the above 
mechanisms.  
 

12. Definitions 
 
In the context of this document: 
 

  chemical restraint means: no agreed definition available. 
 

  critical incident means any incident of restraint or seclusion where the consumer 
or staff were injured, the incident lasted more than 8 hours or intubation was 
utilised in the process of sedation for the management of challenging behaviours. 
 

  least restrictive means:  the concept of allowing the consumer to be cared for in 
an environment which places the least amount of restriction on freedom of 
movement while maintaining their safety and the safety of others. 
 

  mechanical restraint means: The application of devices (including belts, 
harnesses, manacles, sheets and straps) on a person s body to restrict his or her 
movement. This is to prevent the person from harming him/herself or endangering 
others or to ensure the provision of essential medical treatment. It does not 
include the use of furniture (including beds with cot sides and chairs with tables 
fitted on their arms) that restricts the person s capacity to get off the furniture 
except where the devices are used solely for the purpose of restraining a person s 
freedom of movement. The use of a medical or surgical appliance for the proper 
treatment of physical disorder or injury is not considered mechanical restraint. 
 

  physical restraint means:  The application by health care staff of hands-on 
immobilisation or the physical restriction of a person  to prevent the person from 
harming him/herself or endangering others or to ensure the provision of essential 
medical treatment. 
 

  restraint means: The restriction of an individual s freedom of movement by 
physical or mechanical means. This applies to person s receiving specialist mental 
health care. 
 

  seclusion means: - Defined as the confinement of a person, alone in a room or 
area from which free exit is prevented. (National Documentation, MHSRP, 2009) 

 

13. Associated Policy Directives / Policy Guidelines 
 

  Office of the Chief Psychiatrist and Mental Health Policy Seclusion and Restraint 
Standard   Application and Observation Requirements 
 

  Restraint and Seclusion in Mental Health Services Policy Guideline 
  

  National Practice Standards for Mental Health Workforce, 2002, Commonwealth of 
Australia 

  National Standards for Mental health Services, 2010, Commonwealth of Australia 
 
 

 
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14. References, Resources and Related Documents 
 
Australian Commission on Safety and Quality in Health Care (ACSQHC) (September 
2011), National Safety and Quality Health Service Standards ACSQHC, Sydney 
 
Work Health Safety Policy Guideline   Prevention and Responding to Workplace 
Challenging Behaviour, Violence and Aggression (WHS GD 043) 
 
Work Health Safety Policy Guideline   Hazard identification and risk assessment tool 
(WHS FOR020) 
 
Work Health Safety Policy Guideline   Factsheet   worker support (WHS FS022) 
 
SA Health Policy Directive   Prevention and Responding to Challenging Behaviour 
 
SA Health Policy Directive - Prevention and Responding to Challenging Behaviour   
Challenging behaviour toolkit 
 
SA Health Policy Directive   Minimising the use of Restrictive Practices 
 
SA Health Policy Directive   Minimising the use of Restrictive Practices   Restrictive 
practices toolkit.  
 
Mental Health Policy Guideline   Restraint and Seclusion in Mental Health Services  
 
Chief Psychiatrist Standard   Restraint and Seclusion   Application and Observation 
 
 

 
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	Restraint and Seclusion Recording and Reporting_Cover_July2015
	Restraint and Seclusion Recording and Reporting_policy_July2015

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