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MISLEADING AND INACCURATE INFORMATION REGARDING TEAM TEACH HOLDS.

Written by George Matthews

 

Photographs of techniques can be misleading and easily misrepresented which is why TT provides video files of all holds, allowing for a dynamic interpretation related to context and circumstance.

 As Director of Team Teach, having personally sat through as an observer, the 6 weeks of the Gareth Myatt Inquiry, l am fully aware of the need for all restraint techniques to be risk assessed and continually monitored and evaluated. As a company, we receive and monitor 6 – 8 weekly reports from services using our ground restraints

TT techniques are not risk free, but our on-going analysis of incidents and any associated injury rates for children, young people, vulnerable adults and staff over the last 20 years provides a very strong evidence base for their operational safety. There has been no significant or serious patterns of harm emerging from the use of tt techniques.

 We welcome all individuals who have concerns about any of our holds to arrange a visit to our office and to looks at the figures and discuss, in person, with myself as director of Team Teach, any anxieties they may have about the use of Team Teach techniques or ideas on how they can be improved, this would be more honest and useful than spreading misleading and inaccurate information at any conferences, etc... The focus of all our energies should be on agreeing the essential knowledge, skill and understanding staff should acquire and must have, when they hold individuals in various positions. This would have been time better spent and produced more positive outcomes for all concerned.

All participants on TT courses receive very explicit information and advice concerning the dangers that can occur regarding restraint and positional asphyxia. (See appendix 1 in the course participant’s Workbook.)

All TT techniques have undergone (2006, 2009, 2012 and 2015) a thorough legal and medical review carried out by three independent medical and legal experts. See medical risk assessment statements available vai the documentation link, at the bottom of the web page.

Director's statement / advice regarding: "Ground Holds" 

Employers, leaders and managers are legally obliged to make and evidence decisions that they believe to be in the best interests of the people they educate and care for, including adopting appropriate risk reduction and positive behaviour strategies as identified in individual positive handling plans and risk assessments.

The Team Teach position regarding ground holds has not changed. We have received no evidence or data, (we monitor all ground recovery reports every 6-8 weeks returned from services) in the last 20 years, to suggest that there are any significant injury patterns or serious harm arising from the use of such specific Team Teach responses)

Information concerning "face down holds" and the Welsh Assembly Guidance: 

"The Welsh Assembly Government is of the view that no restrictive physical intervention technique is 100% safe and should therefore be avoided wherever possible. Best practice suggests prevention to avoid restraint, through positive risk management and finding alternative ways of dealing with the situation. Providers should undertake a full risk assessment before any technique is employed and staff should be properly trained or practised in using restraint.

The 'Framework' is not statutory guidance, but sets out general principles that should inform practice on the use of restrictive physical intervention. 

Practitioners should continue to use their professional judgement to determine whether use of a particular restraint technique is an appropriate response to a given situation. 

It does not have the power to prohibit the use of a particular physical intervention technique but should be regarded as a "best practice" guidance. 

(Graham Davies Pupil Engagement Team WAG 20/1/09)

The Smallridge and Williamson review (June 2008) of restraint in juvenile settings provides a balanced and informed view in this area.

"Our conclusion is that some, but not all, prone restraint positions have a significant effect on breathing. It is clear that recommendations given previously, either to consider all prone restraint as dangerous or to consider prone restraint as presenting no additional risk, are not supported by empirical results."

And

"We are aware that the secure estate is looking to us for guidance on prone restraint. But there are no simple answers. We are wary of over-simplification over prone restraint and are cautious on the issue. Where a young person is held face down with pressure only on the limbs the evidence is that there is likely to be only a small effect on lung function, and in these cases prone may be quite safe for most young people, for most of the time. However, more 'forced' prone restraint, when body weight is applied to the back or hips may be unsafe for almost everyone.( 6.34)

In the light of the competing evidence we feel that we cannot make any recommendation to ban prone restraint, but we consider it prudent that when prone restraint is used there should be a re-assessment of the risks after control has been obtained in the initial restraint. There should be procedures in place to ensure that a senior member of staff responds to the incident, assesses the situation, evaluates the competing risks and implements an alternative to prone if safety demands." (6.35)

In 2003 and 2011, Coventry University carried out 2 studies into blood oxygenation levels in individuals during periods of being held in accepted restraint positions. The early study compared blood oxygenation levels from standing to prone and standing to supine to attempt to establish if one position was more of a risk then the other. They found that there is less than a 5% decrease in these levels in either position. This means that the actual reduction is not statistically significant in either the prone or supine position. It also established that there is no difference in oxygenation levels when comparing prone to supine providing no pressure was applied to the torso. The second study examined blood oxygenation levels from standing to the seated position. This study found that there was a statistically significant decrease in blood oxygenation levels when an individual is placed in the seated position, when leaning forward and being held. This is compounded when an individual has a BMI of more than 25. This would suggest that external factors such as the health of the individual, pressure applied to the abdomen and relative body position (i.e. leaning forward) have a much greater impact on blood oxygenation levels than first thought. Therefore the prone position itself is unlikely to be the cause of death. It is far more likely that pressure applied to the torso or a separate health risk is in fact the compounding factor. It is important that all physical risks are identified in robust personalised planning and review. Equally, it is essential that de-escalation strategies that effectively reduce the risk of restraint are employed rather than relying on "safe" restraint techniques. It is far more effective to address the risks involved in restraint by not applying restraint.

Health and Safety legislation (1974 & 1996) and The Children Act (1989) should drive decision makes in this area. Employers and employees are required to comply and be able to demonstrate, how they have complied with health and safety legislation and how they have acted (steps taken) in the best interests of children.

As a training provider, Team Teach provides a range of strategies and responses, so that employers can select the knowledge, understanding and skills that are required to reduce risk in their workplace. These personalised responses to reducing risks should be documented in the individual risk assessments and positive handling plans. 

It is employers who are legally accountable for maintaining a safe workplace; where an employee feels unsafe, or feels that the children and young people they look after are unsafe, they should bring this matter to the immediate written attention of their employer. Both the employer and employee have recourse to the Health and Safety Executive, as well as the Local Safeguarding Children Board and their MP, should the matters not be resolved in a reasonable and responsible way.

Essentially, if services can do without ground holds, in particular Front Ground Recovery and still maintain a safe workplace, then you would hope that such a "last resort" response would not be used. We strongly support and encourage services and individuals to continually look at how they can reduce all aspects of risk and restraint. (See Risk and Restraint Reduction template "Gold Award" provided on the Home Page of the tt web site)

If however, the Front Ground Recovery response has proved historically, via documented risk assessments, to be a tool that reduces risk, then what viable alternative or placement strategy is going to be used, should this no longer be the case? 

Should Front Ground Recovery be no longer used and children or staff get injured as a result, then this could be a costly (physical, emotional and financial) consequence for all involved, especially the employer. 

Children, young people and vulnerable adults need staff who feel safe and secure around them. Without the necessary tools to provide a safe working environment, the anxieties of all individuals and as a result, incidents of challenging behaviour will increase. It is very difficult to provide a quality teaching, caring and learning environment when we all feel anxious.

Two U.K high profile restraint related fatalities (Gareth Myatt & Jimmy Mebenga) occurred whilst the individuals were being held in a seated position. Yet there has been no outcry to ban the seated position, just quite rightly the techniques that were used whilst held in the seated position. Rather than a "Two legs good and four legs bad" mentality and a blunt: "Let's ban the use of the 'face down' position", we should concentrate our energies and discussions, on what went wrong and what can be learned from the applications of the holds in those positions?

As researchers in the U.S.A ("Learning from tragedy: A survey of child and adolescent restraint fatalities" M.A. Nunno et al. Child Abuse & Neglect 30 (2006) 1333 /1342 / 1341) are keen to point out:

"Our caution to policy makers concerned about lowering the risk of serious injury and deaths due to these restraints and building safer therapeutic environments for children is that they may legislate or regulate solutions that give a false sense of safety while actually producing greater risk. Safety might be better served if risk reduction efforts focused on eliminating adverse environmental causes for aggression and violence, eliminating dangerous staff practices (sitting on children, choking or lying on them, placing weight on the their upper torso, and ignoring their distress signals), and strictly enforcing the restraint application standard of self-harm or harm to others. All restraint positions were represented in this sample and all positions can be lethal, especially when misapplied or misused."

USE OF REASONABLE FORCE. GUIDANCE FOR SCHOOL LEADERS, STAFF AND GOVERNING BODIES - Techniques that present unacceptable risk. 

"A panel of experts (Physical Control in Care Medical Panel – 2008) identified that certain restraint techniques presented an unacceptable risk when used on children and young people. The techniques in question are: 

• the ‘seated double embrace’ which involves two members of staff forcing a person into a sitting position and leaning them forward, while a third monitors breathing; 

• the ‘double basket-hold’ which involves holding a person’s arms across their chest; and 

• the ‘nose distraction technique’ which involves a sharp upward jab under the nose. 

These particular techniques were part of The Youth Justice Board's preferred approach Positive Care & Control (PCC) http://www.guardian.co.uk/society/2011/jan/10/adam-rickwood-new-inquest-youth-custody

Position statement for Team-Teach services / tutors: 

"We have no such techniques within the Team-Teach framework. Our techniques are designed to promote and protect positive relationships, which you cannot do if you use pain compliance to control and manage behaviour. 

The following information is provided to every participant who attends our courses: "In an effort to safeguard everyone involved in a violent incident where physical interventions are necessary, the skills and techniques taught are subject to ongoing risk assessment and review. Whilst some physical injury potential can be reduced, there always remains some risk when two or more people engage and force is used to protect, release or restrain. It is also recognised that staff may choose to respond with a technique from outside the Team‐Teach framework. This does not necessarily render the use of any such skill or technique improper, unacceptable or unlawful. Its use must be judged on whether or not it was reasonable, proportionate and necessary in those particular circumstances." (Page1 TT Workbook)

Deliberately hurting children in order to bring them under control, has no part within our curriculum. Other training providers, may have a different view and may well serve a different service context and population, where for example, custody may be the central purpose of the service.

TT training in seats allows only a single elbow to be part of a sustained hold and that the person's ability to breathe (since they are being held in a fairly upright position) should not be compromised. This is clearly evidenced within the Standing Graded holds to seats video clips." 

Photographs of techniques can be misleading and misrepresented which is why TT provides video files of all holds, allowing for a dynamic interpretation related to context and circumstance.

The Wrap hold is a single person hold designed for smaller children (not obese) where the arms are held down, crossing below the belly button and the hands held against the child’s hips. The arms are NOT held across the chest. The second member of staff is able to monitor the airways breathing and circulation of the child. (See a video file description by a child themselves within the Let’s share area on the home page of the tt web site.)It should not be confused with "The Basket Hold", different staff standing position, different arm holding positions, which is a specific technique taught by a different training provider.

Our techniques have been in use for nearly 20 years, all serious incidents involving any injury to staff and individuals are reported to us and we look to see if there are ways to improve what we do and to reduce risk for all involved. No techniques are risk free, but the evidence, and l welcome those that differ, including the individuals spreading misleading and inaccurate information, to visit our offices and go through the summary returns and data we have received during the last two decades.

 On-going analysis of incidents and any associated injury rates for children, young people, vulnerable adults and staff over the last 20 years provides a very strong evidence base for their operational safety. All participants on our courses receive very explicit information and advice concerning the dangers that can occur regarding restraint and positional asphyxia. There have been no significant or serious patterns of harm emerging from the use of any tt techniques.

 

All TT techniques have undergone (2006, 2009, 2012 and 2015) a medical review. See summary comments from independent medical experts below. (George Matthews, April 2015)

REVIEW OF RESTRAINING TECHNIQUES - AN ORTHOPAEDIC POINT OF VIEW by Dr Mr Avadhoot Kantak  Consultant Orthopaedic Surgeon

                “I have reviewed the team teach knowledge database and the techniques utilized. In general all the restraining techniques are very well devised. Considering the unpredictable circumstances in which these techniques are used, it is difficult to precisely estimate the potential injuries that may be sustained; though my assessment assumes a more controlled setting. I have concentrated on the upper body involvement but some of the manoeuvres will need good balance control and may involve the lower limbs as supports.” Mr Avadhoot Kantak  Consultant Orthopaedic Surgeon M.S (Orth), D.N.B, F.C.P.S, M.R.C.S(Ed), Dip SICOT, Dip SEM, F.R.C.S (Tr & Orth), M.B.A (January 2015)

Review of Techniques and Team Teach Training system by Dr Anthony Bleetman  (PhD FRCSEd FCEM DipIMC RCSEd ) Consultant in Emergency Medicine. Honorary Senior Clinical Lecturer at the University of Birmingham Medical School.  Associate Clinical Professor at the University of Warwick Medical School. Member of the Faculty of Examiners of the Royal College of Surgeons of Edinburgh

I have reviewed the videos and have a few comments. The videos are well presented. In general, Team Teach skills remain low-level control techniques that carry a low risk of injury to staff and subjects and seem suitable and appropriate for use with children and young adults.

T Wrap Technique: This series of skills involves crossing the subject’s arms across the torso and also involves flexion of the trunk. In susceptible subjects and in certain high-risk situations, there may be a risk of positional asphyxia. This does not preclude the use of the skill set but requires staff to be aware of positional asphyxia and be ready to de-escalate in the presence of warning signs delivered in training.

 None of the skills provided by Team Teach deliberately cause pain.

• None of the skills reviewed cause excessive extension or flexion of joints. (April 2009).

It is not possible to accurately quantify the medical risks for any particular skill as this will depend on a number of factors including: relative size, strength and gender of staff and subject; accuracy of executing the skill; the dynamics and environmental constraints of the situation; physical and mental constitution of staff and subject; escalation/de-escalation of the situation and personal vulnerabilities of both parties (April 2009)