DISCLAIMER: Any legal information is provided for general informational and educational purposes only and is not a substitute for professional advice. Accordingly, before taking any action based upon such information, we encourage you to consult with the appropriate professionals.
Not having a Ligature Policy is like building a house without an architectural plan. Every building plan starts with a foundation that is deep enough and uses the correct materials to safely hold the structure above it. This plan requires an architect, or if the building is large enough, a structural engineer (expert), to ensure the foundation is well-designed and fit for purpose.
Continuing this analogy, your policy is the foundation of your architectural plan, upon which ligature management is built. The related procedures are the rooms which rest on the policy, and the processes form passageways to connect everything together in a system.


What is a policy?
A policy is a formal statement or document which outlines the intentions of an organisation to manage a particular issue, in this case Ligature. Policy development is usually driven by law and regulations.
A policy:
- outlines why it is necessary – the objectives and purpose of the policy.
- includes a commitment from senior management – policy sign off.
- includes the organisational aims in that particular area – saving lives from ligature.
- specifies the scope – who is affected, and the circumstances the policy will be applied to
- delineates roles and responsibilities – can be referred to generally, or in more detail.
- provides guidance for expected actions and standards of behaviour, from staff and the organisation.
- ensures consistency and conformity in objectives and practice.
- outlines any legal or regulatory requirements.
- should be reviewed and updated at regular intervals, or when new requirements are made available, to ensure information is current and relevant.
- has legal implications in legal proceedings. In this case, if there is a death in service by ligature, a coroner’s inquest and an investigation by the regulating body (CQC, Ofsted, NHS) will be carried out.
- must be clearly communicated to all relevant staff.

What is a procedure?
Procedures – which can be referred to as Standard Operating Procedures (SOPs) – have a narrow focus. They describe step-by-step actions that should be taken in specific instances, with the aim of achieving high quality, standardization, and consistent work performance. Procedures have a beginning and an end, and should be followed to achieve the desired outcome/s.
A procedure informs the who, what, where, when, and how of operating in a designated area in particular situations. Regardless of skill level, following procedures is part of your responsibilities, and ensures the safety of your staff and patients/service users.

Some examples of procedures regarding ligature management:
- How to do a ligature anchor point risk assessment,
- How to create a ‘hot/heat map or grid map’ of each room;
- What specific actions to take on finding a patient or service user with a ligature around their neck;
- How to use ligature cutters safely;
- What to do if the patient or service user requires emergency first aid;
- What to do if the patient requires emergency medical assistance from paramedics and transfer to hospital;
- What to do if the patient/service user dies;
- How to order ligature cutters & where to store them & related documentation;
- How to document a near miss ligature incident,
- How to document a critical ligature incident,
- how to refer staff for debriefing and other support offered by the organisation; etc.

Who is involved in writing the ligature policy and procedures?
This needs to be a collaborative effort from various levels within the organisation.
Example: In hospitals it is usually the health and safety manager who is responsible for policies related to safety. But as health and safety personnel often have no psychiatric knowledge, training, or ligature experience, a team is required in these instances. After collaborating, it is wise to ask a ligature expert to look at your policy and procedures as they will quickly pick up when there are problems. This can save a patient’s life and the organisation from litigation or regulator changes.
In my years working in this field, I have come across many organisations who, lacking in knowledge and expertise in this area, searched the internet for policies and developed their own ligature management policy by copying and pasting from other organisations, sometimes from several different organisations.
This is problematic as different settings have completely different ligature management requirements. A general acute hospital cannot have the same policy as a mental health hospital. Likewise, supported living housing cannot have the same policy as hospital settings, and neither can schools.
An example of faulty instructions in a policy
I was consulting and training in two different work settings on two different occasions. Whilst going through their policy (they did not have any procedures), I identified that the person writing the policy had copied and pasted some information directly from the internet – the problem was that the instructions given, were for hanging from a harness.
The instructions in these two policies were as follows: “If the person has been hanging for 20 minutes or more, the paramedics must be notified”.
If you put the word ‘hanging’ into an internet search, two types of hanging will come up – one by the neck and the other from a safety harness or safety rope.
Someone unfamiliar with the differences between the two will not know how to identify the difference.
To clarify, for a person hanging from a harness or safety rope, they often will have been hanging from a height (window washers, construction workers, mountain climbers, etc.)



The medical condition caused by this type of hanging is called harness suspension trauma or harness hanging syndrome. The instructions given in these two policies were for this type of hanging and NOT ligature hanging.
The online article they used erroneously recommended that the paramedics (or the person rescuing the hanging person) should sit the person up rather than lie them down, once the person was returned to the ground.
However, the HSE and recent research has refuted this advice, stating that current evidence supports immediately placing the victim in the supine position (lying down on their back) following rescue, with a swift ABC assessment (airway, breathing, cardiac activity) to follow, and CPR if necessary. This is exactly the same emergency treatment that a person who is rescued from hanging from the neck should receive.
What an expert would have immediately identified:
- Why was the hanging person not immediately rescued/cut down from the ligature as soon as they were found, instead of waiting 20 minutes? The rule for a ligature around the neck is remove it as soon as possible, to relieve pressure from the blood vessels in the neck. If the person is hanging by the neck, if possible, their body weight should be lifted whilst waiting for the ligature cutters to cut them free.
- The person hanging by the neck will most likely have died in that 20 minutes, or at least sustained severe brain injury.
- The person rescued from a ligature should be placed flat on their back with the body, neck, and head in alignment – this serves to not exacerbate any neck injury (if present) and facilitate CPR (should it be necessary).
Very Important
All ligature policies should state that a person can use a ligature to hang, as well as for strangulation (where the ligature is tied directly onto the neck with no use of an anchor point).
In many policies I find mention of environmental risk assessment, but no mention of the risk of not using a ligature anchor point, which would require a clinical patient risk assessment and enhanced observation to keep the patient safe. So, removing all possible ligature anchor points does not remove the risk of the patient placing a ligature.
Ensuring legal and regulatory compliance and avoiding prosecution
Legislation and guidelines (via regulatory bodies, such as CQC and Ofsted) inform us of our responsibilities in respect of ligature management in each setting or service.
These could be: Psychiatric hospitals, Acute general hospitals, supported living for children (mental health and learning disability), supported living for adults (mental health and learning disability), prison and probation services, crisis centres, housing associations, SEN schools for ASD and learning disabilities, CAMHS, forensic units, etc.
Below we will discuss the formation or development of a ligature policy and procedures based on:
- Legislation and regulations
- Coroner’s inquest
- Legal precedence set by legal case
Legislation, Regulations and Guidelines
The Health and Social Care Act 2008 – regulation 12 Safe care and treatment.
The intention of this regulation is to prevent people from receiving unsafe care and treatment, as well as avoid harm or the risk of harm. Providers must assess the risks to people’s health and safety during any care or treatment, and make sure that staff have the qualifications, competence, skills and experience to keep people safe.
CQC can prosecute for breach of this regulation and refuse registration if the provider cannot comply with this regulation.
Note: CQC is the regulator for places of care for adults and Ofsted is the regulator for places of care for children (under 18).
The Act and regulations are preventative in nature, but should a death occur, the coroner’s inquest will determine the cause of death. However, it is CQC or Ofsted who will determine if safe care and treatment was adequately delivered.
Resources
Self-harm and Suicide Prevention Competence Framework for Children and Young People
Self-harm and Suicide Prevention Competence Framework for adults and older Adults
Self-harm and Suicide Prevention Competence Framework for working with the public
Self-harm and Suicide Prevention Competence for Carers and Service users
All 4 guidelines can be found on the link below:
Coroner’s Inquest
Death by suicide and the coroner’s inquest:
Should a death in service by suicide occur, the coroner is required to investigate the cause of death. Death by suicide is known as an unnatural death and will result in an inquest – a public, fact-finding hearing to establish who the deceased was, together with where, when and how they came to die. Those findings are recorded on a ‘record of inquest’ form, which includes the medical cause of death and a conclusion (formerly known as a verdict).
The deceased may have a history of self-harm or previous suicide attempts; there may have been chronic mental illness and simply no evidence of any third-party involvement, but suicide must still be proven by evidence.
Legal Precedence by Case
R (Maughan) v HM Senior Coroner for Oxfordshire.
Mr Maughan had been remanded at HM Prison Bullingdon in Oxfordshire. When prison staff entered his cell on the morning of 11 July 2016, they found his body in a seated position at the end of his bed; he appeared to have tied a ligature around his neck and suspended himself from the bed frame.
The Prisons and Probation Ombudsman undertook an investigation. It criticised the prison for failing to act on the evident risk that Mr Maughan presented, with his history of earlier suicide attempts, mental health issues and substance misuse; it also noted the prison had failed to use its internal suicide prevention policies and procedures.
The case came before the Senior Coroner in October 2017. In addition to considering any failings on the part of HM Prison Service, the jury had to determine whether Mr Maughan took his own life.
Even though this specific case involves Prison Services, it is relevant to any place of care.
Possible Consequences
Failure to use its internal suicide prevention policies and procedures can at its worst result in closure of a mental health setting. At the very least, the regulatory body for that particular service/setting will be notified and must undertake an investigation.
If the relatives of the deceased believe that there was clinical negligence, they can make a formal complaint or commence legal action.
It is during the investigation that internal suicide prevention policies, procedures and processes will be scrutinised.
As a Manager, ask yourself:
- Is my ligature policy up to date and fit for purpose?
- Has it been audited by a ligature specialist?
- Are there procedures attached to the ligature policy?
- Are there procedures for each of the identified issues – 10 examples are given earlier in this document?
- Have I carried out risk assessments of the following:
- the organisation, in terms of management, policy, procedures, and budget;
- the staff, in terms of knowledge, competency, skill mix and sufficient staffing;
- the built environment, in terms of ligature anchor points and visibility of the patient/service user;
- the patient/service user, in terms of suicide risk with a formulation for care
- Do my staff know what to do if a person in my care places a ligature around their neck?
- Do my staff know how to use and care for ligature cutters – have I measured their competency via a drill/dummy practice? (Note: if you are unsure as to which ligature cutters are needed in your service, please check our website www.aticc.co.uk for our blog on ligature cutters. It outlines the niche of each ligature cutter as well as links where you can buy them).
- Do I have processes and services available for the care of my staff, who may become traumatised by the experience of rescuing someone from ligature – especially if the person died.
- Have I measured the competency of all staff to carry out rescue from ligature according to the competency framework?
Will your ligature policy and procedures keep those in your care and your staff, safe? And are they sufficient to protect you from any kind of litigation?
If not, please contact us to assist you in this regard.
Lindsay Smith: +44 (0) 779 303 1914 lindsay@aticc.co.uk
Karyn Taylor: +44 (0) 757 000 4692 karyn@aticc.co.uk
