Reducing harm from ligatures in mental health wards and wards for people with a learning disability

This ligature point recording template has been designed to support staff in identifying and recording ligature risk points, controls and actions required to mitigate risks associated with the built environment.

It has been developed with support from 40 different mental health and learning disability trusts, including private sector organisations, along with experts by experience and people who use services.

The template is designed to be used in all areas where patients may be present. It is not designed to be used in areas such as the staff office or restroom that are not accessible to patients. These areas should already have management controls in place to stop patients coming into these areas.

This recording template should be used in conjunction with the supporting Tiers and mitigating controls guidance.

Levels of risk

To support staff in identifying ligature risk points, risks are categorised into 3 levels or ‘tiers’:

• Tier 1 (more of a residential feel/therapeutic focus):
  Areas where patients have high supervision and patients are not typically left alone for long periods.
• Tier 2 (more of an institutional feel/safety focus):
  Areas where patients may spend time with minimal supervision; these will typically be freely accessed or open areas.
• Tier 3 (more of an institutional feel/safety focus):
  Areas where patients may spend a lot of time alone with minimal or no supervision.

Ligature risk points identified in tiers 2 and 3 areas should be removed where possible. In some limited cases, for example if a ward or service is supporting patients to return to the community, it may be appropriate for the ligature point to remain, However, assessors should consider if the risk outweighs the need for a therapeutic environment, and may wish to include the rationale and/or mitigating controls in the assessment.

See Tiers and mitigating controls guidance for full details.

Mitigating controls

To support staff in taking appropriate actions to mitigate risks, for each level or ‘tier’ of risk, there are 3 risk mitigation control categories:

• Environmental – factors that surround the local design of the environment, patient access to different environments, staff awareness of their environments and consequent risks, and management of ligature material and anchor points.
• Individualised – factors relating to patient risk and care planning, level of therapeutic observations and engagement, recovery orientated practice, appropriate staffing levels/ skill mix.
• System/process – current policies and procedures that support staff to manage risk based on individualised assessment and support appropriate actions and resource requirements.

Each level or ‘tier’ of risk has specific factors to consider for each category of mitigation control, but please note that this is not an exhaustive list.

See Tiers and mitigating controls guidance for full details.

How to use the recording template

Part 1: Pre-assessment review

Aim: To help staff identify and understand local risks for individual wards/service areas before starting a visual ligature risk assessment.

Action:

• Carry out a desktop review of a variety of sources including, for example, previous incident data and ligature risk assessments, to identify risks and any trends in the data.
• Record whether these areas have been considered before.
• Review and record information about staff training, how ligatures are managed on the ward/service area, and how information is shared with staff, including flexible workers.

Part 2: Ligature point risk recording template  

Aim: To identify and record any potential ligature anchor point risks, and record the controls and actions required for each risk.

Action:

• Carry out a visual inspection (walk around) of the ward/service area to review and assess ligature point risks.
• For every risk assessment, record:
  • Type of service (e.g. PICU, Older Adult)
  • Ward/unit/ area name
  • Ward/ unit/ area location
  • Ward/team manager
  • Date ligature point risk assessment completed
  • Date of last ligature point risk assessment
  • Names and roles of assessor(s)
• For every ligature risk identified, record:
  • Room/area name/identification code
  • Room/area description
  • Tier
  • Location of identified
  • Ligature anchor point
  • Description of ligature point
  • Existing controls/mitigating controls
  • Recommendation from assessment
  • Action required
  • How will actions be taken forward

Part 3: Local Information guide

Aim: To give an overview of the risks, controls and mitigations for the individual ward/service area. This includes how to respond to a ligature event and how to report new ligatures risks.

Action: Using information from the desktop review and visual inspection, use this template to record:

• Specific identified risks and controls to minimise harm
• Availability of items that may be used as a ligature and controls
• How to respond to a ligature event:
• Location/type of ligature cutters (include pictures if helpful):
• Location of resus equipment:
• Incidents debrief/ support/ learning arrangements staff and patients:
• How to report a potential ligature risk e.g. damaged room/ area, new risk identified following a ligature event 

Download the recording template