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The purpose of this paper is to improve the quality of care of patients presenting with challenging behaviour.

Current guidelines are described, and adherence to the standards is audited, with a particular emphasis on physical restraint.

The results of the clinical audit revealed that in the substantial majority of episodes of challenging behaviour, non-physical techniques were used prior to the need to intervene with physical restraint; however, when physical restraint was used, there was limited use of staff debriefs to facilitate reflection- and work-based learning. A potential diagnostic link to the likelihood of use of prone position restraint was also a finding. The results of a quality improvement project undertaken in response to the findings of the clinical audit demonstrated significant and sustained improvements in adherence to most standards.

Continuous improvements to the safety of both patients and staff when managing acute challenging behaviour requires ongoing quality improvement interventions underpinned by the application of human factors principles.

The completion of this audit cycle suggests that it is useful to measure specific points of care processes, however, continuous improvement interventions are indicated to lead to sustained improvement – in this paper this is demonstrated by the safer management of challenging behaviour.

A small but significant number of people die during restraint by hospital staff, police or prison officers. One possible mechanism for this has been termed ‘positional asphyxia’. There is literature to suggest that deaths that occur in circumstances involving restraint may be related to certain positions, but early research has been contested. This article presents a balanced review of the literature and findings and concludes that the evidence remains unclear. However the literature does point to practical measures that should be adopted by those whose work is likely to require restraint of extreme violence, to avoid risk of death. These are summarised.

The practice of restraint is controversial as deaths in care or custody have been a consequence of restraint. The purpose of this paper is to clarify research from national and international literature to ascertain any common findings in order to provide guidance for staff on safe and effective restraint techniques where there is no other resort in the management of violent and aggressive individuals.

The researchers undertook a review of the literature on the medical theories relating to restraint‐related deaths and an analysis of deaths in custody in the UK for the time period 1 Jan 1999 to 1 Jan 2010.

Findings showed that certain groups are particularly vulnerable to risks while being restrained. There are also biophysiological mechanisms which staff need to be aware of when restraining an aggressive or violent individual.

It is evident that those in vulnerable groups when restrained in a prone position, or in a basket hold, for a prolonged period and who are agitated and resistive, are most at risk of death in custody. Consistency in reporting relevant deaths locally and nationally is necessary to facilitate analysis of key information and prevent deaths in custody in the future. Staff training and awareness are also key factors.

The purpose of this paper is to identify a common theme linking the articles in this issue of IJHG. The review editor elucidates on this topic while presenting key findings from the articles which comprise the current issue.

The design is a general review describing the articles under review while expanding on the subject matter through reference to other authors.

The Review provides readers with a brief overview of the current articles enabling them to select the ones which reflect their needs or interests.

IJHG is the only Emerald journal providing a Review section of this type.

Less lethal weapons have become a critical tool for law enforcement when confronting dangerous, combative individuals in the field. The purpose of this paper is to review the medical aspects and implications of three different types of less lethal weapons.

The paper conducted a comprehensive medical literature review on blunt projectiles, irritant sprays including oleoresin capsicum (OC), and conducted energy devices such as the Taser™. It reviews the history, mechanisms of action, intended and other physiologic effects, and medical safety risks and precautions of these devices. In particular, the paper focuses on the issue of sudden in‐custody death and less lethal weapons, reviewing case reports, animal research and human investigative studies on this topic.

In general, these three different types of less lethal weapons have been effective for their intended use. Each type of less lethal weapon has a number of physiologic effects and specific medical issues that must be considered when the weapon is used. There is no clear evidence that these devices are inherently lethal, nor is there good evidence to suggest a causal link between sudden in‐custody death and the use of irritant sprays or conducted energy devices.

While further research on the physiologic effects of these devices is needed, this paper provides law enforcement with a medical review of less lethal weapons including blunt projectiles, irritant sprays such as OC, and conducted energy devices such as the Taser.

This paper argues that, together with improved protection structures and energy dissipation systems, a favourable occupant position with sufficient support and restraint could reduce fatalities in aviation accidents. The crash responses of three different occupant positions were compared to justify the proposal of supporting a pilot in the rather unusual prone position. The normal seated and supine seated positions have already been adopted and implemented in aircraft. The occupant's response to specified crash pulse shapes in these two positions was compared with that of an occupant in the prone position. To obtain the best prone support configuration, different concepts were considered during the analysis. A dynamic event simulation program called ADAMS was used to perform the analysis, and existing injury criteria and a study of common causes of aviation fatalities and human body tolerance limits were used to compare the results. The study indicates that higher crash survivability in the prone position could be achieved if several guidelines are followed.

The paper presents data on street trials held with pepper spray in four police forces in The Netherlands and compares these with other research findings, specifically with regard to the safety and effectiveness of pepper spray and the position of pepper spray in the use‐of‐force continuum. There is little doubt that the use of Oleoresin Capsicum can be a real bonus in situations where suspects have some sort of impact weapon or are violent. However, designating pepper spray as the preferred option in situations where suspects are verbally resistive seems unreasonable and could even be seen as a form of abuse. The solution to safe and responsible police interventions in potentially dangerous situations should not be sought one‐sidedly in technology, but also in improving tactical and technical skills of police officers.

The purpose of this paper is to describe the nature and impact of a restraint reduction strategy implemented within a secure learning disability service in response to the national Positive and Safe programme.

The strategy was comprised of three primary interventions – Safewards, positive behavioural support and data-informed practice – and utilised a programme management approach to ensure effective delivery. Baseline measures were collected from 12 months of data prior to implementation of the programme and the frequency of each category of restrictive intervention was then measured prospectively on a monthly basis throughout the duration of the programme.

Upon completion of the programme the following results were achieved: elimination of prone restraint – elimination of mechanical restraint – 42 per cent reduction in general use of restraint – 42 per cent reduction in use of seclusion – 52 per cent reduction in rapid tranquilisation.

The paper adds to the growing body of evidence that carefully designed interventions can reduce the frequency of seclusion and restraint. In this case, Safewards and PBS have combined to exert their effect. Data-led practice and senior leadership were also found to be of critical importance. Finally, the need for a stable workforce is considered.

The use of physical interventions in the management of aggressive and violent behaviour continues to divide opinion and practice. In learning disability services, it is acknowledged that any physical intervention must be non‐aversive and considered as part of an overall programme which emphasises positive alternative behaviours. The author considers this understanding in the light of recent research and experience.

Traditional methods of addressing workplace violence have relied almost solely on reactive measures. Methods of de‐escalation, strategies to calm the already distressed person down by means of positive communication, or responding to an actual or potential act of violence by means of physical control have formed the focus of training initiatives provided for staff. This approach has suggested an acceptance of the premise that violence in certain services is an inevitable problem that must be managed. This paper proposes that many incidents can be prevented and outlines the emerging evidence to support a structured, holistic approach. Additionally, it provides an overview of the recent policy agenda, the evidence base and examples of some recent and ongoing development work that attempts to change practice.