Does Your Organisation need a Ligature Management System?

Over the years, I have been asked by many different settings Hospitals, supported living), to conduct what they called a ‘ligature risk assessment’. In the majority of cases, it turned out that staff in these settings understanding of ligature risk was only related to environmental risk, where potential ligature anchor points were identified.

Whilst on site and talking with staff, I discovered that the components required for keeping a suicidal patient safe, were not interrelated or connected or in many cases not risk assessed. I also found that many of the clinical staff were not familiar with the terms ligature and ligature anchor point.

Definitions:

Ligature = the item that the patient would use to tie around the neck whether attached to an anchor point (hanging) or not (strangulation). Common examples of ligatures: sheets, plastic aprons, latex gloves, bin liners and clothing of all types (bra’s, knickers, hoodie strings, track suit trouser strings, leggings, hospital gowns, etc.)

Ligature anchor point = a fixed point where a patient could tie a ligature in order to hang themselves. Very important to note that ligature anchor points can be at any height. In the past it was thought that ligature anchor points were high up and the patient’s feet were off the ground. This is called complete hanging. A partial or incomplete hanging is where parts of the patient’s body are touching the ground.

I am usually called upon following a ligature incident (some fatal, some not).

Case Study:

A suicidal patient had been admitted via A&E/ED to an acute general hospital as the referring psychiatric hospitals were full. The patient was admitted to a female medical ward with a support worker to observe & support her.

The support worker turned her back on the patient to wash her hands and when she turned back the patient had tied a ligature around her neck using the sheet. The support worker screamed for help and the ward manager came running. The ward had no ligature cutters, so tuff cut scissors from the dressing room were fetched and utilized. All the staff on the ward involved were traumatized, but especially the support worker, who subsequently refused to work with mental health patients.

I entered the hospital 3 weeks after this incident. Again, I was asked to do a ‘ligature risk assessment’ even though the patient had not used a ligature anchor point.

In the case of an acute general hospital, it is impossible to get rid of ligature anchor points as they are necessary for the medical or surgical care of the patients. The intervention of choice in this setting was enhanced care or increased observation provided by a support worker.

What had not been considered in this case:

  • Organisational risk
    • The availability, communication and access to a ligature policy and relevant procedures were not available for staff to follow. (I have often found that these documents have not been developed. Mostly because there is no guidelines for General Acute Hospitals). 
  • Patient risk
    • the suicide risk assessment of the patient’s mental state – the patient had been assessed in A&E/ED by a mental health nurse as requiring hospitalisation for active suicidal ideation & threat. An untrained (in suicide and ligature risk) support worker was allocated to ‘observe’ the patient. This presented a risk to both the patient and the staff member.
  • Staff risk
    • The training, skill and competence of the support worker regarding therapeutic engagement during 1:1 observation in suicidal patients was lacking:
      • regarding materials for use as a ligature in the patient environment, how to safely remove a ligature, what ligature cutters to use for various materials, where to access ligature cutters in the ward, etc. The training, skill and competence of the ward staff regarding how to use ligature cutters, where they were kept in the ward, how to care for them following an incident, where to replace them, etc.
      • Debriefing and support for staff who have been traumatized by critical incidents.

Following the incident the hospital had ordered ligature cutters (of one type only) to be placed in each ward. They were to be placed in the crash cart in a specific drawer of the crash cart.

The mouth opening of the ligature cutter that had been ordered was only 10mm. This cutter would not have been effective to remove the ligature from the patient’s neck as it was a twisted sheet, which was too thick to fit through the narrow opening.

Most wards that I visited post this incident were  unaware that there were now ligature cutters in the crash cart. No instructions accompanied the ligature cutters, staff had not received any training regarding the care and use of the ligature cutters.

If the patient had died as a result of the ligature, the organisation would have undergone an investigation certainly by the NHS and the CQC as well as a coroner’s inquest.

A CQC rating of ‘Inadequate’ means that the service is performing badly and CQC have taken enforcement action against the provider of the service. Some hospitals or supported living homes have been closed following a death by suicide if the CQC deems that the systems and working practices are unsafe for patients.

The patient’s family may also raise a complaint or litigate, citing medical negligence. 

How would a management system have helped in this case?

ISO (International Organisation for Standardization) describes a management system as the way an organisation manages the interrelated parts of its business in order to achieve its objectives.

The level of complexity of the system will depend on each organization’s specific context – for instance, a hospital is part of a highly regulated sector, and may therefore need extensive documentation and controls in order to fulfil their organisational objectives and their legal and ethical obligations. Whereas a supported living setting will require a much simpler system.

In the case of a ligature management system, the organisational objective is to ensure the safety of the person experiencing a suicidal mental health crisis.

There are other benefits to implementing an efficient and effective ligature management system over and above the preservation of life:

It is a cost-effective approach to preventing ligature incidents, building organisational trust and reputation, ensuring operational consistency, helps with continuous improvement, ensures good communication, increases staff morale and engagement and utilizes evidence-based decision making.

Achieving these objectives and benefits will not be realized if the process is a tick box exercise and a mere desktop initiative.

The process of implementing and evaluating any management system can be generally summarised by the following steps:

  1. All management systems begin with understanding the context of their organisation, understanding internal and external issues that may impact the system (e.g. guidelines, legislation and internal issues can include governance, culture, etc.)
  2. Then consulting the multi-disciplinary team to understand their needs and expectations of, in this case, a ligature management system
  3.  Then the multi-disciplinary team should be involved in identifying and assessing hazards and risks and how they should be mitigated.
  4. Planning is based on these identified hazards and risks.
  5. The plan is implemented with continuous or frequent monitoring, with changes if the intervention is not bringing satisfactory results. (this is called continuous improvement).
  6. Finally, the system is evaluated by means of an audit of the system to ensure that the system is fit for purpose and achieving the required outcomes. 

In this blog we are going to introduce Ligature related Hazards and Risks

What is the difference between a hazard and a risk?

While these terms are often used interchangeably, in risk management and in management systems they have a particular meaning.

Assessing Ligature Related Hazards and Risks

The table on the following page offers a framework by which you can identify the various hazards which could lead to potential risks for ligature in an organisation.

Use the questions asked in the table to determine your organisations current readiness to manage a ligature incident.

Organisational RisksBuilding & environmental risksPatient/Service user risk for suicideStaff knowledge & competency concerning ligature management
Does the organisation have a ligature policy? Is it fit for purpose?Have ligature anchor point risk assessments been carried out in every room relevant to the person at risk?Does the patient suicide/self-harm risk assessment comply with NICE guidelines? Is the risk assessment evidence based?Have the staff read, understood & signed the related policies and procedures?
Does the organisation have a step-by-step procedure for staff to follow in the event of a person placing a ligature on themselves?Are staff who carry out such anchor point hazard identification and risk assessments competent to do so?Who (staff member) does the initial risk assessment with a treatment formulation? Has their competency been measured?Have the staff attended mandatory self-harm/suicide/ligature training?
Does the organisation have enough staff (bands & skills) to reduce the risk to a person who has been assessed as high risk for ligature/suicide?Will anchor point hazard reduction be carried out? What is the budget for this?Who does the ongoing hazard identification & risk assessment whilst the patient is in the hospital awaiting transfer to a mental health facility?Has staff who have attended the training been assessed for competency, by participating in a departmental drill?
Will anchor points identified in the building be risk reduced (changed to a reduced ligature fixtures) or removed? Is this relevant to this service/setting?Has technology been introduced in order to remotely observe patients in crisis without having to disturb them?Have they been trained to carry out such a hazard identification and risk assessment & act accordingly?Do staff know how to use ligature cutters?
Has a specific budget been set to manage the ligature risk?Procurement of technology and reduced ligature equipment and fixtures Are there procedures for ligature cutters? Acquisition, use, after use, etc.
Are specific roles & responsibilities allocated? Are those with allocated roles trained and competent to carry out such roles?Does the organisation carry out hazard identification and risk assessment when new equipment is introduced to the setting? Have staff been trained in therapeutic engagement and hosting self-harm or suicide conversations during supportive observation or enhanced care?
Does the organisation get expert consultation during procurement of anti-ligature fixtures?  Knowledge of legal frameworks – mental health act, confidentiality & consent, capacity, data protection, shared decision making, diversity & equality, etc.
Does the organisation comply with the required legislation, regulations, guidelines and best practices? CQC provided new ligature management guidelines in Nov 2023   

Ligature Management System Process Flow:

The diagram below outlines the key steps for each phase of the Ligature Management System (LMS).

In the planning phase, policies, procedures and processes are developed based on the identified hazards and risks, in addition to current legislation and guidelines.

A risk mitigation plan is developed to mitigate the identified risks in each of the areas of risk:

  1. Organisational risk,
  2. Built environment & procurement of technology and reduced ligature equipment and fixtures
  3. Patient risk,
  4. Staff knowledge and competency, appropriate skills mix and safe staffing ratios.

Education and training is based on the competency framework and identified risks.

Training necessary for competency:

  • Comprehensive ligature risk assessment (all 4 areas)

  • Ligature anchor point risk assessment for all staff responsible for environmental ligature hazard identification and risk assessment

  • Rescue from ligature for all front-line staff who may have to rescue a person who has ligatured themselves – including where the ligature cutters are, how to use them effectively, aftercare of the cutters post-use, and emergency response protocols

  • Dynamic clinical suicide and ligature hazard identification and risk assessment of the patient, as well as therapeutic risk taking (re-introduction of ligatures as the patient becomes less actively suicidal in order to move towards hospital discharge and independent living).

  • Therapeutic engagement skills

  • Understanding personality disorders
  • Understanding depression and bi-polar disorder
  • Understanding self-harm and suicide
  • Hosting conversations around self-harm or suicide during enhanced observation
  • Understanding the link between trauma and mental health for trauma informed care and practice
  • Therapeutic debriefing training (to be used for staff following critical incidents) Often referred to as Critical Incident Stress Debriefing (CISD) or Post Critical Incident Stress Debriefing (PCISD).

Monitoring and evaluation:

All hazard and risk mitigations are monitored and evaluated for effectiveness and continual improvement.

Monitoring is conducted at regular and ad hoc intervals throughout the system.                 

The purpose is to determine if the system is aligning to the plan & achieving the desired outcomes, and to make corrections if needed.

Some ideas for monitoring:

  • Simulations or drills to determine staff competence and emergency response to the use of a ligature
  • Regular internal inspections/audits using the implementation plan, guidelines, regulations and legislation as criteria for the internal audit. This will prepare the organisation for external inspections/audits (By CQC or Ofsted)
  • Competence on use of technology – if surveillance cameras are used, body scans, computer/software skills if staff are reporting digitally.
  • Competence in the assessment of reduced-ligature fittings and fixtures for wear and tear
  • Multi-disciplinary reviews/reflective practice to identify any near misses, areas of concern and discuss opportunities for improvement (this is often erroneously called debriefing).
  • Reviewing guidelines and regulations to ensure compliance and updates are immediately implemented – e.g. the CQC have recently updated their ligature documentation (November 2023)
  • Incident reviews, documentation of root cause analysis, corrective and preventive actions taken and reflective practice for continuous improvement
  • Technology checks to ensure working as expected (calibrations, data input is correct using GIGO principle (garbage in, garbage out), emergency alarm systems, door closures, use of keypads and swipe card, etc.

Some ideas for evaluation:

  • Evaluation of policy objectives to annual plan and regular monitoring
  • External audit for compliance to legal requirements and relevant guidelines
  • External audit for system, policy and procedure conformity
  • Evaluation of ligature incidents and near misses

Regular monitoring and evaluation ensures accountability and reduces risks of incidents. The outcomes of your monitoring and evaluation will assist with informed decision making and continuous improvement.

By implementing a comprehensive ligature management system, we can create safer environments, prevent or reduce the number of ligature incidents, and affirm our commitment to the dignity and safety of all individuals in our care.

By reviewing your current practices, engaging with experts and committing to continuous improvement – your actions can save lives, create a culture of care, respect and dignity for all. Please contact ATICC Ltd for a free 30–45-minute consultation to discuss your organisations needs.

References:

The following three documents give excellent guidance on the requirements for suicide prevention generally, with the CQC document specifically focusing on ligature:

  1. National Suicide prevention strategy for England: 2023 to 2028 – GOV.UK.
  2. NCISH report – published March 2023. This annual report provides findings relating to people aged 10 and above who died by suicide. https://nspa.org.uk/resource/national-confidential-inquiry-into-suicide-and-safety-in-mental-health-annual-report-2023-including-easy-read-version/
  3. CQC Reducing harm from ligatures in mental health wards and wards for people with a learning disability – published November 2023 https://www.cqc.org.uk/guidance-providers/mhforum-ligature-guidance
  4. Self-harm and Suicide Prevention Competence Framework for Children and Young People
  5. Self-harm and Suicide Prevention Competence Framework for adults and older Adults
  6. Self-harm and Suicide Prevention Competence Framework for working with the public
  7. Self-harm and Suicide Prevention Competence for Carers and Service users

All 4 guidelines can be found on the link below: https://www.rcpsych.ac.uk/improving-care/nccmh/competence-frameworks/self-harm-and-suicide-prevention-competence-frameworks