Injuries and Death Resulting from Restraint

Abstract

Article 2(1) of the Human Rights Act 1998 (UK) states that everyone’s right to life is protected by law1; however, this is not an absolute right. Exceptions under Article 2(2) provide qualification so that there is no contravention if loss of life results from defense of a person against violence or in order to effect a lawful arrest, so long as the force that is used is no more than is absolutely necessary. A peculiarity of the language sees the word restraint applying simultaneously to the physical act of restricting or curtailing movement, the means or apparatus used to cause the restriction, and the moderation of behavioral excess. All of these factors are of concern to the pathologist with regard to the approach to what often are emotive and controversial cases. Numerous factors conspire to complicate the analysis of cases where death has occurred during restraint, some of which include the relative paucity and occasionally contradictory nature of empirical physiologic data concerning cardiorespiratory functioning in situations of severe stress, the difficulty in determining the significance and effects of drugs (both therapeutic and illicit) identified in postmortem specimens, preexisting natural disease processes, determination of the sequence of events and methods used to enforce restraint, and the effect of complex neuropsychiatric syndromes. Fundamentally, restraint is used to prevent persons from harming themselves or others. In any robust physical interaction between human beings there is the risk that one or the other party will suffer injury, but the aim of restraint should be an acceptable balance between minimization of that risk and effectiveness and rapidity of control. The high mortality associated with firearm use has stimulated the search for so-called less-lethal technologies, which simultaneously provide adequate protection for police or other parties with responsibility for public/patient safety. This chapter reviews some of the commonly used restraint modalities and the injuries that may ensue. Consideration is given to the concepts of restraint asphyxia, excited delirium, and psychiatric factors involved in some restraint-related deaths. Finally, a suggested approach to the autopsy and pathologic investigation is presented, along with a discussion of the formulation of the cause of death.