Management of Ligatures Policy

1 Key Words: ligature , Environmental, Inpatient, Settings Version: V3 Adopted by: Quality Assurance Committee Date adopted: 16 August 2016 Name of originator/author: Health and Safety Compliance Team Name of responsible committee: Health and Safety Committee Date issued for publication: July 2016 Review date: February 2019 Expiry date: August 2019 Target audience: All staff Type of Policy (tick appropriate box) Clinical Non Clinical Which Relevant CQC Fundamental Standards? 15 All premises and equipment used by the service provider must be: clean, secure, suitable for the purpose, for which they are being, properly used, maintained and appropriately located for the purpose for which they are being used. Management of Ligatures Policy This Policy describes the arrangements in place for assessment of ligature risk in in-patient settings CONTRIBUTION LIST Key individuals involved in developing the document Name Designation Bernadette Keavney Head of Trust Health and Safety Compliance Jo Nicholls Patient Safety Manager Vicky McDonnell Trust Lead Quality and Patient Safety Circulated to the following individuals for comments Name Designation Members of the LPT Health and Safety Committee Agreeing committee Members of the Patient Safety and Experience Group Members of the Directorate Health.

2 Safety and Security Action Groups Contents Equality Statement 6 Due Regard 6 1 Introduction 6 2 Purpose 7 3 Scope 7 4 Responsibilities 8 Executive Management 8 Responsibilities of the Chief Executive Officer 9 Director of HR and Organisational Development 9 Chief Nurse/Executive Director of Quality and Innovation 9 Responsibilities of Directorate and Clinical Directors 9 Responsibilities Of Line/Ward Managers and Team Leaders 10 Responsibilities of Individual Employees 10 LPT Estates and Facilities 11 Health and Safety Compliance Team 11 Patient Safety Team 12 5 ligature Policy Statement 12 6 Approach to Risk Assessment and Risk Management 13 Risk Assessment Methodology 13 Risk Management 13 Risk Reduction Strategies 14 7 Legislation and Best Practice Guidance 14 8 Training 15 9 Monitoring and Audit 15 10 Assessment Tools 15 11 References 15 Appendix 1 17 Appendix 2 Guidelines for Assessing and Managing ligature Points 18 Appendix 3 ligature Environmental Risk Assessment 24 Appendix 4 Guidelines for the Storage and use of ligature Cutters 25 Appendix 5 Risk Assessment Form 29 Appendix 6 Risk Assessment Tool Pocket Guide 43 Appendix 7 Training Requirements 45 Appendix 8 The NHS Constitution 46 Appendix 9 Due Regard Screening Template 47 Appendix 10 Monitoring Table 48 Version Control and Summary of Changes Version number Date Comments (description change and amendments)

3 1 February 2013 New Policy 2 April 2013 Update of risk assessment & monitoring table June 2014 Update of risk assessment example provided 3 June 2016 Review of Policy Titles amended to reflect organisational change All LPT Policies can be provided in large print or Braille formats, if requested, and an interpreting service is available to individuals of different nationalities who require them. Did you print this document yourself? Please be advised that the Trust discourages the retention of hard copies of policies and can only guarantee that the Policy on the Trust website is the most up-to-date version. For further information contact: Health and Safety Compliance Team 0116 295 1662 Definitions that apply to this Policy ligature Point A ligature point is any point which is load bearing (for the purposes of this Policy able to support over 40 Kg) that can be used to tie or secure a cord, sheet or other tether that can then be used as a means of hanging.

4 Collapsible fittings are typically designed to collapse when weights in excess of 40 Kg are applied. ligature (noun) Any item that when placed around the neck can restrict the airway. The item can be used with a ligature point or independently. ligature (verb) To use an item placed around the neck to restrict the airway with the intention of causing bodily (self)-harm Risk Assessment A care examination of what in the practice and areas, could cause harm to people or the organisation so that the individual or organisation can weigh up whether they have taken enough precautions or they should do more. ligature Cutter Purpose specific and single use items for cutting Ligatures . They must not be used for any other purpose than dealing with emergency situations involving Ligatures . Due Regard Having due regard for advancing equality involves: Removing or minimising disadvantages suffered by people due to their protected characteristics.

5 Taking steps to meet the needs of people from protected groups where these are different from the needs of other people. Encouraging people from protected groups to participate in public life or in other activities where their participation is disproportionately low. Page 6 of 48 Equality Statement Leicestershire Partnership NHS Trust (LPT) aims to design and implement Policy documents that meet the diverse needs of our service, population and workforce, ensuring that none are placed at a disadvantage over others. It takes into account the provisions of the Equality Act 2010 and promotes equal opportunities for all. This document has been assessed to ensure that no one receives less favourable treatment on the protected characteristics of their age, disability, sex (gender), gender reassignment, sexual orientation, marriage and civil partnership, race, religion or belief, pregnancy and maternity.

6 In carrying out its functions, LPT must have due regard to the different needs of different protected equality groups in their area. This applies to all the activities for which LPT is responsible, including Policy development and review. Due Regard LPT must have due regard to the aims of eliminating discrimination and promoting equality when policies are being developed. Information about due regard can be found on the Equality page on e-source and/or by contacting the LPT Equalities Team. The Due regard assessment template is Appendix 4 of this document. 1 Introduction Ligaturing is the most frequently used method of suicide and/or attempted suicide for mental health service users, whether in-patient or community. This Policy is intended to address the environmental issues within inpatient settings. Ligaturing may involve suspending the body from a high ligature point hanging although many deaths also occur through asphyxiation or strangulation, without suspension of the body, using a ligature point below head height or the use of a ligature which is not attached to a fixed point.

7 A significant proportion of suicides are believed to occur through impulsive acts, using what may be seen as reasonably obvious ligature points. Because of this data, the National Suicide Prevention Strategy for England (DoH) 2002) states that likely ligature points in mental health service environments should be removed or covered. Where it is not possible to remove structures identified as ligature points or where obstructions to the observation of patients have been identified the Trust will adopt other risk controls including changes to buildings, fittings, operational Management and clinical Management of the patient. Page 7 of 48 Death by hanging from non-collapsible rails in an inpatient setting is a National Patient Safety Agency (NPSA) never event . Never events are serious, largely preventable patient safety incidents that should not occur if the available preventative resources have been implemented.

8 Due to human ingenuity and/or a lack of a technical solution, it is not possible for all potential ligature points to be addressed and a judgement therefore has to be made about the likelihood of something being used as a ligature point. Equally, there may be some potential ligature points that need to remain, as removing them will create a greater risk to the service user grab rails in elderly units / disability accessible rooms. Operational Management systems need to be in place for these areas / equipment / patients at risk. The Trust is committed to identifying, removing or managing potential ligature points and other risks for suicide and self-harm within the inpatient environment. This Policy should be seen as an integral part of other measures to reduce the risk of suicide. Clinical risk assessment, observation and engagement form part of the overall strategy for managing ligature risk and patient safety.

9 2 Purpose This Policy intends to address the environmental and clinical risks posed within a service that could assist a service user attempting suicide using a ligature . This Policy does not cover other risk factors in suicide prevention. These are included within clinical risk assessments and policies associated with patient safety. This Policy includes guidance, plus an audit tool, for assessing potential ligature points and ligature risks and for recording the assessment findings. Where ligature points are identified action must be taken. Actions can include Management /operational/clinical solutions or physical solutions that will be funded through planned preventative maintenance (PPM) or the Trust s Capital Programme. The Policy aims to ensure that the appropriate level of operational Management of ligature risk is maintained for the safety of service users and prevention of suicide; and that appropriate technical advice is sought and action taken regarding the specification of anti- ligature fixtures and fittings within the inpatient environment.

10 3 Scope The following areas are required to conduct annual (as a minimum) environmental ligature risk assessments: All inpatient settings accommodating patients with mental health, learning disability or eating disorders. Page 8 of 48 Rehabilitation units and other healthcare environments as applicable to and proportionate to risk identified Facilities accessible to mental health and learning disability in-patients (therapies areas, enclosure recreational areas such as gardens and day patient service areas). In addition to the annual reviews, environmental ligature risk assessments must be reviewed whenever there has been significant change ( change of use, modification of the building, following a serious incident involving suicide or attempted suicide using a ligature ) Where ligature risks are identified they are removed or managed.