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

This guidance on levels or ‘tiers’ of risk and factors for mitigating controls for ligature point risks should be used in conjunction with the ligature point risk recording template.

Tier 1

Low privacy/less opportunity to be alone. More reliance on clinical controls/more of a residential feel/more of a therapeutic focus.

Ward/service area type: Areas where patients have high supervision and are not typically left alone for long periods.

Examples (not limited to those detailed):

• Activity room
• Interview room
• Clinic room

Mitigating controls

Environmental

• Staff are familiar with the environment that they are working in and have enough awareness of risks relevant to this specific area (for example, ligature points).
• Options for managing ligature points:
  • Remove all identified ligature points.
  • Where removal is not possible, individualised/system/process controls must be applied to minimise risks in areas with known ligature points.
  • Consider use of potential technological solutions to aid risk management.
  • Patient access is restricted when staff are not present.

Individualised

• Individualised risk assessment and management, knowledge of individual patient risks and corresponding levels of therapeutic engagement and observation levels to ensure patient’s whereabouts is known.
• Activities individually risk assessed before patients access area and undertake any activity.
• Appropriate staffing levels/staffing skill mix in accordance with patient acuity/risk management.

System/process

• Staff have undertaken awareness training and are competent in ligature management, therapeutic observation, and engagement.
• Robust MDT meetings where individual risks are considered in the context of the specific environments patient can access. Assessments, management plans and therapeutic observation levels are made amongst the MDT members, rather than by one individual.
• Local induction procedure for temporary staff (for example students and agency staff) regarding the individual ward/ unit area (for example, challenges to clear line of sight when undertaking therapeutic engagement and observations and known ligature point/ risk areas).
• Shift handover systems that include clinical assessment of acuity, safety, and risk of each patient and corresponding management plans being discussed at every handover. A summary of any incidents occurring since admission should be highlighted at each handover.
• Ensure at least one member of staff is always present in the room when it is accessible by patients
• Management of and access to ligature material; protocols to manage items brought on to the ward by patients, carers/families and/or staff and correct disposal of personal protective equipment (PPE).
• Search procedure available to support the reduction of ligature material entering the ward environment.

Tier 2

High privacy/greater opportunity to be alone. Less reliance on clinical controls/more of an institutionalised feel/more of a safety focus

Ward/service area type: Areas patients may spend time with minimal supervision. These will typically be freely accessed or open communal areas.

Examples (not limited to those detailed):

• Lounges
• Day Rooms
• Dining Rooms

Mitigating controls

Environmental

• Staff are familiar with the environment that they are working in and have enough awareness of risks relevant to this specific area (for example, ligature points).
• Options for managing ligature points:
  • Remove all identified ligature points.
  • Where removal is not possible individualised/system/process controls must be applied to minimise risks in areas with known ligature points.
  • Consider use of potential technological solutions to aid risk management.
  • Consider any adaptions to/in the room or equipment needed in response to patients’ individual needs and/or the Equality Act 2010, that may introduce ligature risks.
  • Environmental design that is conducive to clear lines of sight with minimal opportunity for blind spots and controls to mitigate blind spots (for example, safety mirrors, technological interventions).

Individualised

• Individualised risk assessment and management, knowledge of individual patient risks and corresponding levels of therapeutic engagement and observation levels to ensure patients whereabouts is known.
• Appropriate staffing levels/staffing skill mix in accordance with patient acuity/risk management.
• Staff awareness of limitations to clear lines of sight and these are considered when assessing individual risk and management plans and inform levels of therapeutic engagement and observations.
• The private nature of the environment is considered, and risk assessed to inform the individual level of therapeutic engagement and observations (for example, higher observation level may be needed in areas with higher levels of privacy).

System/process

• Staff have undertaken awareness training and are competent in ligature management, therapeutic observation, and engagement.
• Local induction procedure for temporary staff, (for example, students and agency staff) regarding the individual ward/ unit area (for example, challenges to clear line of sight when undertaking therapeutic engagement and observations and known ligature point/ risk areas).
• Robust escalation plans, should observation of a patient not be possible at an assessed level, with staff awareness of these procedures (for example, raising alarm, location of ligature removal equipment, emergency response protocol).
• Shift handover systems that include clinical assessment of acuity, safety, and risk of each patient and corresponding management plans being discussed at every handover. A summary of any incidents occurring since admission should be highlighted at each handover.
• Management of and access to ligature material; protocols to manage items brought on to the ward by patients, carers/families and/or staff and correct disposal of personal protective equipment (PPE).
• Search procedure available to support reduction of ligature material entering the ward environment.
• Staff are knowledgeable about available adaptations/equipment that could maximise lines of sight.

Tier 3

High privacy/ greater opportunity to be alone. Less reliance on clinical controls/more of an institutionalised feel/more of a safety focus.

Ward/service area type: Areas patients may spend a lot of time alone with minimal or no supervision.

Examples (not limited to those detailed):

• Bedroom
• Bathrooms
• En-Suites
• Toilets

Mitigating controls

Environmental

• Staff are familiar with the environment that they are working in and have enough awareness of risks relevant to this specific area (for example, ligature points).
• To balance patient safety and dignity, removal or environmental mitigations and controls should be in place to allow privacy when using these areas – for example collapsible curtain/shower rails, anti/reduced ligature showerheads and doors.
• Consider any adaptions to/in the room or equipment needed in response to patients’ individual needs and/or the Equality Act 2010, that may introduce ligature risks.
• Staff awareness of lines of sight, and where they need to be to maximise lines of sight.
• Technology to monitor private areas (for example, contact free patient management platform). However, use of vision based technology should take into account a patient’s need for privacy, and only used with the patient’s consent or in their best interests as agreed as part of a recognised process. 
• Consideration of use of differing environments to manage immediate risk – for example de-escalation suite, seclusion room, PICU transfer if appropriate.

Individualised

• Individualised risk assessment and management, knowledge of individual patient risks and corresponding levels of therapeutic engagement and observation levels.
• Appropriate staffing levels/staffing skill mix in accordance with patient acuity/risk management.

System/process

• Staff have undertaken awareness training and are competent in ligature management, therapeutic observation, and engagement .
• Robust escalation plans, should observation of a patient not be possible at an assessed level, with staff awareness of these procedures (for example, raising alarm, location of ligature removal equipment, emergency response protocol).
• Consideration of room location when bed planning (for example, rooms that are easily visible/ have clear line of sight/ near team office).
• Management of and access to ligature material; protocols to manage items brought on to the ward by patients, carers/families and/or staff and correct disposal of personal protective equipment (PPE).
• Search procedure available to support reduction of ligature material entering the ward environment.
• Staff are knowledgeable about available adaptations/equipment that could maximise lines of sight.