Prone/Facedown - what are your views?

On the 3^rd December, we published a posting on this blog ‘Ban prone or facedown techniques’.

PLEASE NOTE: (at 21st Dec) there are 5 comments/feedback below.

This posting has generated quite a bit of debate, mostly on Twitter, with people taking positions on the matter. Some of the exponents are experienced trainers in the field of behaviour management and physical intervention, based here in the UK and elsewhere e.g. in Asia Pacific and the US.

Having debated the issues since the 3^rd December, I remain absolutely clear that prone/facedown is potentially dangerous, degrading and should be banned.

But I have an open mind, apart from the debates e.g. on Twitter, I have read documents and viewed websites from those who strongly advocate the use of such techniques – and I think that further debate is healthy.

Therefore, I am updating my arguments and understandings below, and I actively encourage colleagues to have their say – by adding comments in the ‘Post a Comment’ box below. Comments can take up to 24 hours to be posted, please either add your name, a link to your website or Twitter username.

Prone/Facedown is Restraint:

It’s important to confirm that Prone/Facedown is a form of Restraint; and Restraint is one of four categories of Physical Intervention. Many people misunderstand that any form of Physical Intervention is Restraint, but this is incorrect. Restraint is commonly understood to be the positive application of force with the intention of overpowering a child/adult. Practically, this means any measure or technique designed to completely restrict a child/adult's mobility or prevent a child from leaving.

There are clear ‘rules’ about where Restraint can be used, as set out in our posting PhysicalIntervention: when is it ok?  NB we haven’t just grabbed these ‘rules’ from the air, they form the basis for policies and procedures we produce for multitude local authorities and independent providers and are legally verified.

The Prone/Facedown debate:

There are 2 schools of thought or rather positions that people take about this. Some argue that Prone is different from facedown.

I’d like to hear more about this i.e. when is Prone – I think everyone agrees this means that ‘Prone’ means that the person is laying on their front  - other than facedown? I believe the argument is that if the person’s face is to the side i.e. laying on their front with their face looking right or left, this isn’t ‘facedown’.

I’m not sure about you, but if I were being held by two or three people in a Prone position/on my front, I think they’d have some difficulty arguing I wasn’t facedown too.

What is interesting is that there are people who strong argue that Facedown and Prone are the same thing e.g. a US website The Truth about Prone Restraint states “Prone restraint simply means that the subject of the restraint is in a face down position. It is not the name of a particular restraint technique as there are many ways to restrain someone face down.”  That’s pretty clear, prone = facedown.

Frankly, I believe this is a matter of semantics, for me, Prone can only means facedown – and I think the debate should not centre around the difference between the two. Prone (even if we agree it isn’t ‘facedown’) is potentially dangerous and is degrading.

The Arguments for using Prone:

As stated above, let’s set aside the debate about whether prone and facedown are the same thing.

The arguments for using Prone seem to be that, in some circumstances, it’s the only alternative other than using ‘mechanical’ restraints e.g. handcuffs.

If this is the case, why do some training providers teach techniques that do not include Prone - to Children's Homes staff working with the same highly challenging young people?

Some argue that staff are sometimes confronted by extremely dangerous and violent young people who simply cannot be Restrained or contained without resorting to the Prone technique, e.g. stating that they either don’t have enough staff to use other, less risky, techniques; or that staff are adequately trained.

To this, I say either train your staff more comprehensively, increase your resources (e.g. get more staff on duty) or review the criteria you use for admission i.e. are you admitting young people who ought to be placed elsewhere e.g. in Secure Accommodation. Please don’t say “We have to use Prone because we don’t have enough staff/resources”, this is nowhere near being an argument for Prone.

Why is Prone risky?

Even those who argue for its use agree that there are risks associated with it.

In effect, when placing a child/young person on their front – even if their head is to the side – there are risks of positional asphyxia, a form of asphyxia which occurs when someone's position prevents them from breathing adequately; some die suddenly and without apparent reason.

Research has suggested that restraining a person in a Prone position is likely to cause greater restriction of breathing than restraining a person face up.

It is particularly risky where contributory factors exist e.g. obesity, prior cardiac or respiratory problems, and the use of illicit drugs.

 “In the heat of battle”:

By the time you get to using any form of physical intervention, even low level intervention, upon a young person, everyone involved is stressed, some are frightened (staff and young people alike) and – as we know – perceptions reduce, people use force more force than intended etc.

What is required in such situations is people who are grounded, with a strong sense of values, highly trained and having worked with other like minded people on multiple occasions, with a clear understanding of the risks, with all necessary information about the young person at their fingertips. Maybe, just ‘maybe’ in these situations a textbook Prone Restraint can work safely and effectively.

But this is not the way that children’s homes operate, it’s more likely that staff will have had a day’s training, possibly no refresher training in the 12 months since, hardly any opportunity to use the technique outside the classroom and limited opportunity to use it consistently/with the same colleagues, available information about the young person is scant or nonexistent and – frankly – the decision to ‘jump in’, quite literally, will be made with next to no planning.

Recently, I interviewed a training instructor who advocates the use of Prone, I asked him “Is it possible that staff might use the Prone technique inappropriately e.g. without full information being available about a child’s asthmatic condition, where another lower level technique would be more appropriate or because they just fall back on the Prone technique because that feels like it’s the safest option – get the child under control”.

The answer, reluctantly, was “Yes”, the trainer admitted that “in the heat of battle”, the margin for error is enormous.

I should note that the trainer wasn't advocating the use of such language or philosophy ( i.e. 'in the heat of battle'), his comments were that this is how some staff behave or feel when confronted with highly challenging siutaions.  The fact is that confrontation results in 'fight or flight' behaviours and it takes very well trained and grounded people to manage it without it turning into a fight or battle. In such situations, things go wrong.

Thankfully, there have been no child deaths in the UK as a result of Prone techniques being used, this is one of the loudest arguments used by people who argue to retain it.

Fair enough, but let’s not wait or take the risk – and we don’t have to - there are suitable less risky alternatives out there in the market place.

So I say, lets ban it but I am still open to hearing from those who argue there is a place for it; to this end, have you got a comment or feedback about this posting? If so please add a comment below: please either add your name, a link to your website or Twitter username.  You can also Contact Us