The report has not been made public but has been seen by the BBC.
It found that untrained staff were carrying out risky restraints on patients and that the number of restraints was high.
It said face-down, and particularly face down in a prone position, are the highest tariff interventions of physical restraint, and the most dangerous techniques to deploy.
Carseview Centre was the focus of a BBC documentary last year
The report looked at a sample of 40 cases and found more than half were patients being restrained face down on the floor for longer than 30 minutes.
The longest restraint was one hour and 45 minutes.
“That is completely against all guidelines,” Prof Tyrer said.
“You may have to do things for five minutes or up to 10 minutes but to go beyond 40 minutes there is something badly wrong in the organisation of a unit if that is allowed to continue.”
Prof Peter Tyrer chaired the group which wrote the guidelines on how to handle mental health patients
Carseview is a hospital to care for patients with mental illness from depression and anxiety to schizophrenia and psychosis.
In July last year, BBC Scotland broadcast allegations by patients of bullying by staff, illegal drug-taking and being pinned to the floor unnecessarily.
Experts called it abusive and said the unit should be closed down.
NHS Tayside responded by commissioning an internal report into Carseview to go alongside independent reports into mental health in Tayside.
The internal report says a whistleblower has come forward and accused Carseview of “very serious concerns over leadership, safety and malpractice”.
The internal report has not been seen by the public
It came up with 11 recommended actions including urgent action on staff training and critical action on illegal drugs on the ward.
It said the restraint policy should emphasise the safety of patients as well as staff and that the culture of the unit should be “based around the caring and compassionate leadership approach”.
NHS Tayside said the recommendations covering patient care and culture were “now being progressed”.
Prof Peter Stonebridge, acting medical director for NHS Tayside, said a “steering group has been established” to focus on restrictive care practices, including the reduction of face-down restraint.
Joy Duxbury said there seemed to be a toxic environment at the unit
Joy Duxbury, professor of mental health at Manchester Metropolitan University, told BBC Scotland: “I think this is a terribly toxic environment.
“The figures on physical restraint are exceptionally worrying.
“These are very vulnerable clients who are being restrained, in my view, unnecessarily and by far too many staff in too many situations.
“For me, given what we know about psychological and physical trauma of the use of restraint in such setting, this is of significant concern.”
Marnie Stirling said the unit was supposed to be about recovery not punishment
Marnie Stirling, who had two stays in Carseview with anxiety and depression, spoke to the BBC documentary last year.
Reacting to the report, she said: “If you think about mental health, it’s supposed to be about recovery. This isn’t recovery, it’s further punishment for people.”
David Fong spent a month in the unit after experiencing psychosis in 2013.
‘Total disgrace’
He claimed staff used restraint violently and repeatedly during his time there.
His mother Lorraine said: “This is a total and utter disgrace that this has gone on for seven years and maybe longer.”
David told BBC Scotland that staff were quick to see frustration and anger arising from detainment as aggression.
“Staff are too keen to initiate restraint and offer little or no de-escalation when no actual aggression has been displayed by the patient,” he said.
Former patient David Fong said he had his face rubbed along the floor during restraint
“I ask how many of these restraints were actually needed and if some are instigated by staff rather than patients?
“I personally was physically assaulted with the application of intense pain through twisting of arms, wrists and fingers or a member of staff’s knee being dug into my back, had my face rubbed into the floor causing loss of skin from my face, and had verbal abuse screamed at me during restraint.
“I also could not have been the only patient that these tactics were being used upon.”
A separate report looking at the patient experiences came up with separate 23 recommendations in December.
It is feeding into an independent inquiry, which was announced in the Scottish Parliament last year, and is still ongoing.
The independent inquiry into mental health services in Tayside has retired to consider the key issues hampering the system’s ability to care for patients.
Launched following pressure from the families of suicide victims in Dundee, the inquiry’s evidence stage has concluded after receiving hundreds of submissions from the public.
Alongside other evidence, these will now be examined by the inquiry, chaired by former chief inspector of prisons David Strang.
Mr Strang said: “I am pleased with the response we have received to our public call for evidence. More than 200 people have submitted written documents and personal statements and there have been more than 60 oral evidence sessions held.
“Evidence has been submitted from a wide range of people including patients, families, carers, NHS employees and third-sector organisations.”
David Strang is chairing the inquiry
Agencies such as Police Scotland, student welfare teams and Dundee Drugs Misuse Commission have also contributed.
The evidence stage has taken several months, with discussions held with parties with an interest in improving mental health services.
The inquiry has visited psychiatric units including the Carseview Centre, the Rohallion Clinic and Stracathro in order to understand the systems currently in place.
The information it has gathered to date will be used to identify key issues in mental health services.
A statement from inquiry chiefs said: “The next stage of the inquiry’s work is to analyse all the data evidence, relevant government reports, statistical data, internal NHS review documents and data, in order to identify common themes which will then be the subject of further investigation and analysis.”
The inquiry was commissioned by NHS Tayside last year after campaign group Lost Souls of Dundee claimed it had identified at least 10 suicides which could have been prevented in the area.
A second charity football match in aid of a young Dundee dad who took his own life after suffering from depression is to be held in the summer.
Lee Welsh, 27, was found dead at his Peddie Street home in the city’s West End in August 2017.
At the time, his dad Phil said that Lee, whose daughter Poppy was then aged seven, had battled mental health issues for the previous nine years.
Last year Lee’s childhood friend, Steve Martin organised a football match in memory of his mate which raised more than £1,000 for the Dundee Association for Mental Health (DAMH).
The event was so successful that a second one has been organised for July 20 this year.
It will be held at North End Park and this time the money raised will be donated to Art Angel on behalf of the Not in Vain for Lee charity.
As well as football there will be other attractions on the day including a bouncy castle, face and henna painting, a pipe band, live music and a demonstration by Dundee Mods Scooter Club.
Phil – who has actively raised awareness about mental health issues among young people since his son’s death – was thrilled with the turnout and the money raised last year.
He said: “It really was an absolutely brilliant day.
“We hope we can get the same response this year.
“It’s all about looking to the future now in raising money for our mental health charities.”
The number of people with mental health issues being readmitted to hospital in Tayside within a month of their discharge is increasing.
More than 16% of Tayside adults discharged from hospital, having been admitted on mental health grounds, were back within a month in 2016/17, according to new figures.
The readmission rate has increased from 11.9% in 2012/13.
NHS Tayside is above the Scottish average for mental health hospital readmissions in the most recent statistics compiled by ISD Scotland.
At 16.3%, it was behind only NHS boards in Dumfries & Galloway and Lothian.
The majority of patients readmitted after an initial stay in hospital were affected by mood disorders (36.9%), delusional type disorders (19.2%) and adult personality and behavioural disorders (15.8%).
North East Scottish Conservative MSP Bill Bowman said the increase in readmissions for depression is “very troubling”.
The ISD figures also recorded NHS Tayside region had the fourth highest suicide rate in Scotland, behind Forth Valley, Highlands and Orkney – 14.4 per 100,000 between 2012 and 2016.
Mr Bowman said: “At some point, one in four people will experience a mental health condition.
“NHS Tayside staff are doing their best to deal with the growing number of people who come to them with symptoms of depression and low mood.
“Because Tayside has such a high suicide rate, NHS Tayside needs resources to dig into why people come back to hospital so quickly.
“If it’s because of underfunding in areas run by councils and community healthcare partnerships, the SNP government needs to assess the potential damage it is doing by making cuts to local authority budgets.”
A spokesperson for NHS Tayside said: “Mental illnesses can be unpredictable and there are many reasons why a patient may require to be readmitted following discharge from hospital.
“Patients can sometimes experience a new episode of illness for which admission to hospital is the most appropriate course of treatment.
“Patients are discharged following clinical assessment from a consultant psychiatrist and are followed up locally within the community.
“There is no direct relationship between the length of time a patient is in hospital and the need to be readmitted.”
She added: “Anyone can become suicidal; the reasons can be different and very complex and it is not always due to mental illness. Each suicide is a tragedy and the impact on those left behind lasts a lifetime.
“Every suicide in Tayside is comprehensively reviewed by the Tayside multi-agency Suicide Review Group to look at the circumstances surrounding each individual case.
“f people are feeling suicidal, the best thing to do is talk and tell someone how they are feeling. Speak to someone you can trust or call a helpline. If you’re worried that someone else is suicidal, ask them – asking someone directly about their feelings can help them.”
Further help and information can be found by downloading the “Suicide? Help!” app, visiting www.suicidehelp.co.uk or calling NHS 24 on 111, Samaritans on Freephone 116 123 or Breathing Space on 0800 838587 or www.breathingspacescotland.co.uk
An independent inquiry into mental health services in Tayside is currently under way.
Wilma is still heartbroken over the loss of her son Gavin (left)
A grieving mum is still seeking answers 11 years after her son died at the Carseview Centre.
Gavin Allan was just 26 when he died from the “adverse affects of heroin” on January 17 2008.
Gavin Allan
Wilma Hughes
His mum Wilma Hughes, from Douglas, said she still doesn’t know what happened in the hours leading up to her son’s death.
Wilma said: “I’m still looking for answers about how my son was able to get the drugs that ultimately killed him.
“It’s 11 years since Gavin died but I’m still grieving.
“I’ve decided to speak out now because things like this are still happening.
“Nothing can be done that will bring my son back but I want to speak out and stop this happening to someone else’s loved one.”
Wilma said that although he was never properly diagnosed, she believed Gavin could have been suffering from ADHD as a teenager.
She said: “I took him to the doctor but I was just told he was boisterous.”
Wilma said after he left school aged 16, Gavin started to dabble in drugs – but she wasn’t aware of that at the time.
She said by the time her son was in his 20s, he was smoking heroin and had to give up work.
“One night Gavin came to me and said he needed help,” Wilma said.
“He came to stay with me for a while but he became increasingly unwell and was suffering from mental health issues.
“He was on prescribed medication for drug-induced psychosis but things came to a head when he fell from his bedroom window and I found him lying on the ground.”
Gavin spent time in hospital following the incident, as well as a period in Carseview.
Wilma said: “It was while he was in Carseview and supposedly under 24-hour supervision that he was able to get away and find the drugs that resulted in his death.
“He managed to slip away, get himself to the Hilltown and bought heroin. He brought it back to Carseview and took it there. I don’t understand how he was able to leave the hospital without them knowing and without the staff being aware that he was missing. I want justice for my son.”
A spokeswoman for NHS Tayside said: “Our thoughts remain with the family.
“Due to patient confidentiality, we cannot comment on matters relating to individual patients.”
Suicide rates in Dundee are higher than any other city council area in Scotland, according to a new report.
The Scottish Suicide Information Database also shows that men accounted for three-quarters of suicides across Tayside in the last seven years.
According to the report, there were 164 deaths caused by suicide in Dundee with an average of 16.7 per 100,000 population between 2011 and 2017.
Angus along with Perth and Kinross Councils recorded 98 and 126 suicides respectively.
For Tayside as a whole, 388 suicides were recorded with an average per 100,000 population of 14.1.
Men were more likely to take their own lives, with the rates across Scotland highest among those aged 35-54 and in deprived areas.
Nearly three-quarters of those who died had contact with healthcare services in the year before their death.
An inquiry is currently under way into NHS Tayside’s mental health services after a number of concerns surrounding the Carseview Centre.
Phil Welsh, whose 28-year-old son Lee took his own life last year, said the latest statistics were “damning”.
He said: “It’s clear that there’s a situation here that isn’t working.
“I think the fact there is an inquiry shows there’s something amiss.
“Mental health is a discussion point now but it’s all well talking, we need support for people afterwards and that is why we badly need a crisis centre.”
A spokeswoman from NHS Health Scotland said: “National suicide prevention programmes need to incorporate a comprehensive public health approach which seeks to reduce stigma, improve mental wellbeing in the whole population and address the underlying causes of poor mental health.”
