Reply

We thank the authors for taking the time to respond ^{Reference Quinn, Cavanagh, Kilcoyne, Haines-Delmont, Ryan and Lodge1}  to our paper. ^{Reference Tromans, Sawhney, Odiyoor, de Villiers, McCarthy and Boer2} The commentary authors are right to emphasise the human rights of patients and the potential adverse effects of long-term segregation (LTS) and seclusion. As stated in our paper, we agree with many aspects of Baroness Hollins’ report ^{Reference Baroness3} concerning these principles. LTS and seclusion should be a risk management strategy of last resort when other interventions have not been effective, and we would stress that they should be used in the least restrictive way and for the shortest duration possible, and in a way that does not result in the person suffering inhumane or degrading treatment.

However, in our view, the authors of the commentary and the authors of Baroness Hollins’ report ^{Reference Baroness3} adopt a narrow perspective on the issue of LTS and seclusion. There is insufficient consideration of the rights of other patients, staff and the wider public, who might be put in harm’s way without the use of LTS and seclusion. The duty of care that practising clinicians owe their patients must be shaped not only by the autonomy of individual patients, but also with due consideration of the consequences for those patients themselves if others come to harm. We are a public service in addition to being a patient service.

As clinicians working in in-patient units are only too aware, they are often asked to manage situations that are difficult and deteriorating. The authors present few alternatives to LTS and seclusion that are evidence based and rooted in real-world care. The authors state that ‘enforced isolation breaches disabled people’s human rights and is prohibited in many countries’; however, this statement was not supported with a reference and our rapid searches did not identify any nations where such practice is prohibited. It would have been helpful if the commentary had highlighted which countries have achieved this and how, and provided some insight into their facilitators and barriers to applying their models to the UK, including influences of resources, training, culture and demographics. Savage et al ^{Reference Savage, Lepping, Newton-Howes, Arnold, Staggs and Kisely4} report that, while the use of seclusion is variable across nations, the evidence suggests that it is used widely. This widespread use may reflect the reality that when interventions are needed to safeguard the patient or others from persistent violent behaviour, LTS and seclusion may pose the least risk of harm given the available alternatives.

The authors state that Baroness Hollins’ report is based on reviews of 191 people who had experienced LTS, with a thematic analysis of the first 26. This review, however, is not published in a peer-reviewed journal and has therefore not been independently scrutinised, nor are the data supporting the report publicly available for independent scrutiny. A thematic analysis on a small subgroup may be affected by confirmation bias and may not reflect the views and experiences of all those who have experienced LTS and seclusion. Our paper provides an example of an individual experience that clearly differed from the main themes outlined in Baroness Hollins’ report, with their mother reporting her daughter as flourishing in LTS and describing her as ‘the happiest and most settled she has ever been’.

Finally, the response criticises the tone of our paper. This is a subjective evaluation and mirrors our concerns over the tone of the Hollins report (the title of which, in our view, was emotive and misleading) and the subsequent response to our article. We do, however, acknowledge the pain and trauma that patients can experience as a result of LTS and seclusion. We totally support all efforts to minimise the use of LTS and seclusion, and support rigorous safeguards for its implementation. Hence, we propose that it might be more productive to engage in a pro-active process of discussions, debates and a scientific exploration of different perspectives, to find solutions and safeguards in this very important area of practice that has been highlighted by both groups of authors.