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Pixel art: a doctor with a clipboard and a nurse stand outside a heavy seclusion room door with a vision panel and an intercom. A clock and a review sheet with ticks hang on the wall.

Trainee hub · On the ward

Seclusion reviews: the timetable, the checks and the write-up

If you work on an inpatient ward, you'll be asked to review someone in seclusion early on, often at night. Here's what's due when, what the review has to cover and how to write it up.

By Dr Raj Joshi, ST6 General Adult Psychiatry

InteractiveAbout 10 minutes

Seclusion is one of the most restrictive things we do, and the medical review is where a doctor decides whether it carries on. The rules here are England's Code of Practice unless I say otherwise. Your trust's policy fills in the detail, and you'll be expected to follow it. Where it differs from the Code, it should say why.

Most of this page is built to be tapped rather than read. Start with the map. If you're on your way to a review now, open the pocket card.

Start with the map
00

The map

Tap a branch to open it. A branch gets a tick once you've been through its section.

01

Is it seclusion?

The Code's definition has four parts. Tap each one.

Seclusion refers to the , , where it is of for the purpose of the .

Code of Practice 26.103

If it meets the definition, it's seclusion, whatever the ward calls it and even if the patient asked for it. "Therapeutic isolation" with the door held shut still gets every safeguard. 26.104

If they can leave, it isn't seclusion. Going to a quiet room by choice, with the door open, is de-escalation. On a children's unit, planned time-out is a behaviour strategy, but if it has the features of seclusion, it's seclusion. 26.58

Long-term segregation is a different thing. It's for a risk to others that doesn't go away, and an MDT decides it with the commissioner. It has its own reviews: an approved clinician daily, the MDT weekly, and an external hospital every three months if it lasts that long. 26.150, 26.155, 26.156

02

The clock

Set when seclusion started and who authorised it, then move the slider to see what's due. It follows England's Code unless you pick another nation.

Where you work
Who authorised it?
  • Observation recordEvery 15 min
    Someone suitably skilled within sight and sound throughout, writing a record at least every 15 minutes. Next entry by 05:00. 26.118 to 26.124
  • First medical reviewCheck
    Should have happened by 03:00. If it hasn't, it's overdue: go now. 26.116
  • Nursing reviewBy 06:00
    Every 2 hours, by two registered nurses, at least one of whom wasn't involved in the decision to seclude. 26.134
  • Medical reviewBy 07:00
    Every 4 hours after the last medical review, until the first internal MDT review, nights, weekends and bank holidays included. These times assume the first review was at 1 hour. If it was at another time, count 4 hours from when it happened. 26.131
  • First internal MDT reviewAs soon as you can
    As soon as practicable. Overnight and at weekends it can be medical and nursing staff with the on-call senior manager. Set the time it happened above. 26.137 to 26.139
  • Independent MDT reviewAt 10:00
    If seclusion is still going: 8 hours in a row, or 12 hours in 48. An approved clinician, a nurse and others who weren't involved in the incident, plus the IMHA if they have one. It's good practice for them to consult those involved in the original decision. 26.141, 26.142

England: Mental Health Act 1983 Code of Practice (2015), 26.112 to 26.143. Your trust's policy can set the detail differently, and where it does, it should say why.

This is for learning the pattern. On the ward, the seclusion record and your trust's policy decide.

03

At the door

The Code lists what a medical review covers. Here it is in the order I do it. The review has to be in person, not over the phone. 26.133

How much to show
  • Before you go in

    Read the record, the drug chart and the plan.

    Check the start time and reason, the last few 15-minute entries and the latest nursing review. Look for anything given since the last review, rapid tranquillisation especially. Then agree with the nurse in charge how you'll do it: through the door, or inside with enough staff. Under 18? A senior doctor approves seclusion and an MDT reviews it at the earliest opportunity, and a child of 12 or under is never secluded in a locked room. NICE 1.7.24, 1.7.26; 26.57

  • The room

    Warm enough, clean and safe, with a toilet and somewhere to wash.

    Ask what the temperature is: staff outside should be able to see and change it. Someone restrained by several staff, or given high doses of medication, can overheat. Is the room clean and fresh, with a mattress, pillow and blanket? Can they see a clock, and does the intercom work? Look for anything they could hurt themselves with. If something's wrong, tell the nurse in charge and write it down. 26.109, NICE 1.4.47, MWC 2019

  • Breathing, colour, injuries, then a brief MSE.

    Look before you talk: breathing, colour, how alert they are and any injuries. Then observations if they'll allow them, food, fluids and the toilet. Then a short mental state examination, as far as you can. Write down what you saw and heard.

  • Over-sedation first, then dystonia and stiffness.

    Find out what's been given and when. After sedation, a skilled professional should be outside the door at all times. The post-dose checks still apply in seclusion: at least hourly, and every 15 minutes while they're asleep or sedated. 26.122, NICE 1.4.45, 1.4.52

  • Does anything need to change?

    Look at regular, as-required and rapid tranquillisation doses together. If something isn't working, or doses are stacking up, change it or ask your senior.

  • Is the reason for seclusion still there?

    Compare with the last review. What have they said and done since? This is usually what decides the outcome.

  • The one that goes missing.

    In one PICU audit, junior doctors recorded risk to others in half their reviews and risk to self in 5%. Ask about self-harm and look for anything they could use. Accidental harm counts too. If something has to come out of the room, take that and leave them clothed. Tear-proof clothing needs an MDT risk assessment and the RC's authority. 26.161 to 26.163

  • Is it still right?

    Decide whether it needs to change, especially after sedation or while they're asleep.

  • The question the review exists to answer.

    If not yet, what needs to change? Could it be applied more flexibly, with the door open with staff, a meal on the ward or a visit? Write down why it continues. 26.111

  • Before you leave

    Tell them what happens next.

    Tell the patient what needs to change for seclusion to end and when you'll be back. NICE asks us to tell them the reviews will happen. Then agree the plan with the nurse in charge. 26.148, NICE 1.4.49

0 of 7 checked
04

Ending it

Seclusion should end as soon as it isn't needed. Any medical review, MDT review or independent MDT can end it. So can the nurse in charge, after speaking to the responsible clinician or duty doctor, and that conversation can be by phone. 26.144

It ends when the patient has free access to the ward again, or moves into or back to long-term segregation. Opening the door for food, the toilet or your review doesn't end it. Nor does applying it more flexibly, like a meal on the ward with staff. 26.111, 26.145, 26.146

Afterwards: the staff debrief

NICE asks for a short debrief with the staff involved, including a nurse and a doctor, once it's safe and people have settled. It works best as an open discussion: the job is to ask and listen, not to give a verdict. A simple structure is OPEN. NICE 1.4.55, 1.4.61

  1. Open

    Check everyone's all right and whether anyone was hurt. Say it's about learning, not blame.

    "Is everyone OK? Was anyone hurt?"

  2. Play it back

    Go through what happened in order, from each person's view: what led up to it and what was tried first. NICE 1.4.56

    "What did you see, from the start?"

  3. Explore

    What helped, what didn't, and how people are feeling about it.

    "What would we do differently next time?"

  4. Next steps

    Changes to the care plan, risk and observation level, support for anyone who needs it, the incident form, and the formal review within 72 hours. NICE 1.4.62, NI 11.93

    "What are we changing, and who's doing it?"

  • Ask open questions, then wait. Silence is fine.
  • Hear from everyone, starting with the most junior, so senior voices don't steer it.
  • Keep to what happened, not who's at fault.
  • Ten to fifteen minutes is usually enough. Follow up one to one with anyone who's shaken.
  • Anyone involved should get to talk it through with someone who wasn't. NICE 1.4.60

The patient gets their own debrief, when they're ready, with someone they choose. Explore their account rather than defending the decision. Ask what helped, what didn't and what could change, and write it in their own words. Remind them about advance statements and how to raise a concern. 26.169 to 26.171, NICE 1.4.58

05

Writing it up

Tap what you found and the note fills in as you go. Anything you haven't tapped or typed stays as a highlighted [blank], so the note only says what you checked. There are no boxes for patient details, and nothing leaves this page.

In the audits, the lines people skip are risk to self, side effects and the observation level. The bar on the note shows which of the seven checks are still blank, and it warns you when a choice doesn't fit the rules.

The review

Which review
Who authorised seclusion

Type both times.

Day 1 is the day seclusion started. Your times move the clock to match. Moving the clock doesn't change the note.

From the clock: first MDT not held yet, no seclusion earlier in the last 48 hours. Change these in the clock.

Legal status
Before you went in
How you saw them
The room

Physical and mental health

Consciousness
Physical health
Behaviour
Talk and thinking

Medication

Given since the last review
Side effects
The prescription

Risk and observation

Risk to others

Since the last review

Risk to self

Room and self-harm

Observation level

The decision

Seclusion
Before you left
0 of 7 checksSee note

Your note

Format

0 of 7 checks covered.Physical and mental healthSide effectsThe prescriptionRisk to othersRisk to selfObservation levelCan it end, or loosen?Also blank: which review and the times.
SECLUSION: [which review]
Seclusion started [time] on [date]. Authorised by [name, role]. Reason: [what happened, and the harm to others it was to prevent].
Legal status: [detained under which section, or informal].
Seen in person at [time]. [Through the vision panel, at the door or in the room.]

Room: [temperature, clean, bedding, toilet and washing, clock and intercom].
Physical health: [not recorded: breathing, colour, injuries]
Mental state: [not recorded]
Medication since the last review: [what was given, if anything].
Side effects: [not recorded]
Prescription: [not recorded]
Risk to others: [not recorded]
Risk to self: [not recorded]
Observation level: [not recorded]

Decision: [not recorded]

Next reviews: [pick which review this is, above].

[Name, grade, contact], [time].
After you paste it, fill in each [bracket] in the record.
06

The law, briefly

The timetable comes from the Code of Practice, not the Act itself. Everyone the Code is addressed to must have regard to it, and any departure should be recorded with its reasons.

In Munjaz (2005), Ashworth's policy reviewed secluded patients less often than the Code said. Medical reviews were at 4, 8, 12 and 24 hours on the first day, twice a day to day 7, then three a week. The argument was mainly about patients secluded for more than a week. The House of Lords upheld the policy by three to two. Lord Bingham said a hospital should depart from the Code only if it has cogent reasons. In 2012 the European Court of Human Rights found no breach of Articles 5 or 8.

So your trust's policy can differ from the Code in places. Where it does, it should say why.

How we got here

  • 1839 John Conolly brings non-restraint to the Middlesex County Asylum at Hanwell. He keeps seclusion for extreme violence.
  • 1856 Conolly defends seclusion against the charge that it's solitary imprisonment.
  • 1983 The Mental Health Act 1983. Seclusion is left to the Code of Practice.
  • 2005 Munjaz: depart from the Code only with cogent reasons.
  • 2010 Olaseni Lewis, 23, dies after being restrained on a mental health ward.
  • 2015 The current Code of Practice, with chapter 26 on restrictive interventions.
  • 2018 The Use of Force Act becomes law. Most of it comes into force in 2022.
  • 2020 The CQC's review of restraint, segregation and seclusion: Out of sight, who cares?
  • 2023 Baroness Hollins calls the seclusion and segregation of autistic people and people with a learning disability solitary confinement.
  • 2025 The Mental Health Act 2025 becomes law. A revised Code will follow.
  • 2026 Scotland consults on new guidance on restraint and seclusion.

Swipe or scroll sideways for more.

07

Go deeper

Everything this page is built on. Filter by where you work or what you want from it.

Where

Showing 17 of 17

08

What I'd do before your next on-call

  • Read your trust's seclusion policy once. Find where it differs from the Code, especially on sleeping patients and on who can authorise seclusion.
  • Find the forms. Know where the seclusion record and the medical review template live before you need them at 3am.
  • See the room. Ask a nurse on the PICU to show you the seclusion suite: the vision panel, the intercom, the clock and where you'd stand.

Raj

This is my reading of the Code of Practice and NICE guidance, not a substitute for them or for your trust's policy. Written 29 October 2026, to be reviewed by October 2027.

Main sources: Mental Health Act 1983 Code of Practice (2015), chapter 26; NICE NG10 (2015); Mental Health Units (Use of Force) Act 2018 statutory guidance (2021); R (Munjaz) v Mersey Care NHS Trust [2005] UKHL 58. The rest are in Go deeper.

Written by Dr Raj Joshi, ST6 General Adult Psychiatry.

This version was published . Next review .

Revision material for the MRCPsych examinations. Not clinical guidance, and not for use in patient care.

Pocket card

Before you go in

Read the record, the drug chart and the plan. Agree with the nurse in charge how you'll do it. Look at the room: warm enough, clean, a clock they can see, a toilet.

The seven checks

  1. Physical and mental health
  2. Side effects of medication
  3. The prescription
  4. Risk to others
  5. Risk to self
  6. Observation level
  7. Can it end, or be applied more flexibly?

Then tell the patient what needs to change and when you'll be back. Write down the decision and the reason.

The timetable (England)

  • A written record every 15 minutes, someone within sight and sound throughout
  • First medical review within an hour, or at once if they're new, not well known or have changed. If a psychiatrist authorised it, that assessment was the first review.
  • Two nurses every 2 hours
  • A doctor every 4 hours until the first MDT, then at least twice a day
  • First MDT as soon as practicable, then daily
  • Independent MDT at 8 hours continuous or 12 in 48

It ends

When it isn't needed. The nurse in charge can end it after a call with you. A door opened for food or the toilet isn't the end.

Then a staff debrief: Open, Play it back, Explore, Next steps.

Open the clockWrite it up

England's Code. Your trust's policy has the detail.

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