Use of restraint at mental health unit inadequately recorded, report finds

Key information about the use of restraint was inadequately recorded at a young people’s mental health inpatient unit where improvements are needed, according to a report.

Healthcare Improvement Scotland (HIS) and the Mental Welfare Commission (MWC) published the report on Thursday following a joint unannounced visit and inspection at NHS Tayside’s Dudhope Young People’s Inpatient Unit in October 2025.

Based in Dundee, Dudhope is a specialist child and adolescent mental health inpatient unit with 12 beds which provides a service to children and young people across the north of Scotland.

It is a tier four unit – these being highly specialised facilities for young people who need assessment and treatment for complex mental health needs.

The report found some young people at Dudhope experienced restraint and where it was used on more than one occasion it related to nasogastric tube feeds or keeping a young person safe.

In the report, inspectors noted a number of areas which require improvement, including that “key clinical information around significant events, such as restraint, was not being recorded adequately in clinical records”.

They said this poses a “significant risk” and must be addressed, with regular audits carried out for assurance.

The inspectors also said “significant delays” in maintaining the health care environment must be addressed, including maintenance of fire doors and completion of fire risk assessment actions.

They noted a number of areas of good practice, including “nurturing and caring” interactions between the young people on the unit and staff, and found that parents and carers felt involved and had confidence and trust in the clinical team.

They have issued a number of recommendations which they said NHS Tayside must prioritise to meet national standards.

These include ensuring staff are provided with adequate training to safely carry out their roles.

Robbie Pearson, chief executive of HIS, and Julie Paterson, chief executive of MWC, said in a joint statement: “We found there to be a well-functioning multidisciplinary team at Dudhope unit which ensured that practice is fully compliant with mental health law.

“We saw positive examples of a supportive senior management team, who provided a positive working environment for staff to enable them to do their job to the best of their ability.

“However, we also found things that need to be improved. This includes risks in how clinical information is recorded, persistent gaps in specialist staff, a lack of adequate staff training, and delays in maintaining a safe environment.

“We are confident that the requirements and recommendations are the right ones to ensure improvements in the care that young people receive.

“An improvement action plan has been developed by NHS Tayside and we expect the NHS board to address the areas for improvement and prioritise the requirements to meet national standards.”

NHS Tayside welcomed the report.

It said: “These visits provide important feedback on our services and we take the requirements made in the report seriously.

“A comprehensive action plan has been developed to address the areas of improvements and requirements that were identified, including key clinical information being recorded adequately in clinical records, staff training, and timely maintenance of the health care environment.

“Steps have already been taken to make improvements and work is ongoing to ensure all of the requirements made in the report are completed in a timely way.

“We are pleased to see that inspectors also noted several areas of good practice in the report, such as observing that all young people were treated with dignity and kindness, and observing encouraging and compassionate interactions between staff and young people. They also noted that parents and carers felt involved and they had confidence and trust in the clinical team.

“The unit’s school, its staff and leadership were also described as an integral part of the Dudhope team. Inspectors noted they were told that the young people got access to whatever level of education they needed.”

Mental wellbeing minister Tom Arthur said: “While the report identifies good practice, we take very seriously the concerns around the inadequate recording of clinical information, including restraint.

“Accurate record-keeping is essential to patient safety and accountability, and I have made clear to Tayside that we expect them to address this as a priority.

“Restraint must always be properly recorded, monitored and audited – used safely and only as a last resort. I have asked the MWC to undertake national monitoring of restraint use to standardise recording and provide essential oversight across inpatient settings.

“Staff commitment is clear, but urgent action is needed to ensure care meets the standard young people deserve.”

He said the Scottish Government will monitor progress “closely”.