This guidance is written for staff with responsibilities for:

• caring for patients on mental health wards, and on wards for people with a learning disability
• assessing and managing risks to patients in the inpatient care environment
• those buying, installing and maintaining fixtures and fittings for mental health wards and wards for people with a learning disability.

The main focus is on removing or reducing the risk of patients taking their own lives or harming themselves using a ligature, particularly in combination with an anchor point. However, the practices covered will have wider benefits for patients and staff.

A ligature is anything, like a cord or other material, that could be used for the purpose of hanging or strangulation. A ligature anchor point is anything that could be used to attach a ligature. Ligatures do not necessarily need to be attached to a ligature anchor point.

Staff working in inpatient services should be aware of the potential harm that can be caused by use of a ligature in the ward environment, and work hard to identify and reduce risks.

Inpatient care environments, patient populations and relative risk of harm will vary by context and over time, so there can be no standardised approach to assessing ligature risk. It is also important to acknowledge that risk cannot be completely eliminated and that some risks may be difficult or even impossible to predict.

Removing or reducing the means and opportunity for people to harm themselves is only one aspect of managing risks in this area.

We have identified 5 key factors that should be considered in working to reduce harm from ligatures:

• Therapeutic engagement: A vital part of supporting patients’ recovery is the quality of the interaction between staff and patients, which can positively influence the effectiveness of safety plans. These plans should be person-centred and created with the patient to plan how to manage times of distress that may result in causing harm to themselves. In this guide we use the term ‘therapeutic engagement’ to describe this positive relationship between patients and those trying to help them.
• The built environment: Controlling the built environment reduces opportunities for a patient to use fixtures, fittings, or furniture or their personal items (such as clothing) as ligatures or ligature points to cause harm to themselves or attempt suicide.
• Staffing and skills: Good therapeutic engagement relies on having the right staff with the right skills and support and – critically – the time to spend with patients to build trust and rapport. Engaging staff in robust training and cohesive and effective teamwork can improve the outcomes for patients. It can also improve staff effectiveness and job satisfaction. Wards with lower staff turnover have fewer deaths by suicide, and so retaining staff and supporting them well (including through training) leads to safer care.
• Technology: This can increasingly play a part in keeping patients and staff safe by, for example, enabling staff to remotely observe patients who need a high degree of supervision to keep them safe, without having to continually disturb them.
• Procurement: How services buy and bring into use furniture, fixtures, fittings and equipment (sometimes called ‘procurement and implementation’) can also help keep people safe, by making best use of the money available, buying the right things, and using them to best effect.

After each of the 5 key factors listed in this section, we set out some key considerations that services may want to consider and ask themselves.