Deaths Due to Physical Restraint

Background: Physical restraint is used primarily for patients at risk of falling, those with motor unrest and agitated behavior, and those who manifest an intention of doing harm to themselves or are at risk of suicide. The use of freedom-restraining measures (FRM), and, in particular, the use of physical restraints against the patient's will, can be a serious intrusion of basic human rights and, as such, an act of violence against the patient. The improper use of physical restraints can cause injuries of varying severity, which can sometimes be fatal. Methods: We analyzed all cases of death under physical restraint that were recorded in the autopsy reports of the Institute of Forensic Medicine in Munich from 1997 to 2010. Results: Among the 27 353 autopsies conducted over the period of the study, there were 26 cases of death while the individual was physically restrained. Three of these cases involved patients who died of natural causes while restrained, and one was a suicide. The remaining 22 deaths were caused solely by physical restraint; all of them occurred in patients under nursing care who were not continuously observed. The immediate cause of death was strangulation (11 cases), chest compression (8 cases), or dangling in the head-down position (3 cases). In 19 of these 22 patients, the restraints were incorrectly fastened, including two cases in which improvised non-standard restraints were used. One nursing-home patient died because of an abdominal restraint even though it had been correctly applied: She was mobile enough to slip through the restraint till it compressed her neck, and then unable to extricate herself from it, so that she died of strangulation. Conclusion: To prevent such deaths, we recommend from a forensic medical standpoint that all possible alternatives to FRM should be used instead. If direct-contact restraints are truly necessary, they must be applied as recommended and the restrained person must be closely observed.