Death After Restraint Can Be Avoided

AUTHOR: Derrick Pounder, Professor of Forensic Medicine
Department of Forensic Medicine, University of Dundee
Royal Infirmary, Dundee DDI 9ND

An Editorial Letter
Published in the, British Medical Journal
BMJ April, 1998;316:1171

Farnham and Kennedy's recent editorial on sudden death in patients with acute psychiatric illness(1) who are being restrained does not reflect the forensic literature fairly. It omits evidence from key publications (2, 3) and twice misattributes statements to a paper that specifically excluded such deaths from the reported study.(4)

The current consensus on "restraint asphyxiation" is reflected in a guidance statement of the United States Department of Justice.(5) Any person who is restrained prone has trouble breathing when pressure is applied to his or her back or when handcuffed and "hog tied,"(2, 3) and obesity exacerbates this. People's natural reaction is to struggle more violently, which may be met with still more restraining force, resulting in greater oxygen deficiency and, in some cases, death. Risk factors include any condition, such as ischemic heart disease or excited delirium,(2) that increases susceptibility to cardiac arrhythmias, as well as intoxication with alcohol or drugs.

Recommendations given to police officers on how to prevent such deaths include releasing people from the prone position as soon as they are handcuffed, not sitting on them, and never tying handcuffs to a leg or ankle restraint (hog tying).(5) A form of hog tying restraint known as the police leg lock was prohibited in Denmark in 1994, after a campaign by the human rights organization Amnesty International when an incident had left an 18 year old permanently brain damaged. There is evidence that restraint procedures that compromise respiratory movements are potentially dangerous, and this needs to be taken into account in any debate on their use in a healthcare setting.

1. Farnham FR, Kennedy HG. Acute excited states and sudden death. BMJ 1997; 315: 1107-1108. (1 November.)

2. O'Halloran RL, Lewman LV. Restraint asphyxiation in excited delirium. Am J Forensic Med Pathol 1993; 14: 289-295.

3. Reay DT, Fligner CL, Stilwell AD, Arnold J. Positional asphyxia during law enforcement transport. Am J Forensic Med Pathol 1992; 13: 90-97.

4. Bell MD, Rao VJ, Wetli CV, Rodriguez RN. Positional asphyxiation in adults. Am J Forensic Med Pathol 1992; 13: 101-107.

5. Department of Justice. Positional asphyxia sudden death. Rockville, MD: National Institute of Justice, 1995 (National Law Enforcement Technology Center Bulletin.)

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