Corporate Ligature Risk Assessment and Management Policy Document Control Summary Status: Version: Author/Title: Owner/Title: Approved by: Ratified: Related Trust Strategy and/or Strategic Aims Implementation Date: Review Date: Key Words: Associated Policy or Standard Operating Procedures New v1.0 Date: April 2017 Nick Hulme - Health, Safety and Security Advisor Liz Lockett - Associate Director or Quality and Risk Policy and Procedures Committee Date: 18 May 2017 Policy and Procedures Committee Date: 18 May 2017 Risk Management Strategy May 2017 May 2020 Ligature; Management; Assessment; Risk; Health; Safety; Environment Ligature Risk Assessment SOP Safe Use and Storage of Ligature Cutters SOP Page 1 of 5
Contents 1. Introduction... 3 2. Purpose... 3 3. Responsibilities... 3 4. Ligature Assessments... 5 5. Ligature Cutters... 5 6. Testing Of Magnetic Fixtures and Fittings... 5 7. Further Information... 5 8. Process For Monitoring Compliance And Effectiveness... 5 Change Control Amendment History Version Dates Amendments Page 2 of 5
1. Introduction Three-quarters of people who kill themselves while on a psychiatric ward do so by hanging or strangulation. A ligature point is anything which could be used to attach a cord, rope or other material for the purpose of hanging or strangulation. Ligature points include shower rails, coat hooks, pipes and radiators, bedsteads, window and door frames, ceiling fittings, handles, hinges and closures. Due to human ingenuity and/or the lack of a suitable technical solution it is not possible for all potential ligature points to be removed. It is therefore necessary for a judgement to be made regarding the likelihood of an item being utilised as a ligature point and the opportunity for a service user to utilise the potential ligature point. Such ligature points are managed locally by staff. 2. Purpose This policy and its associated documents intend to address the environmental risks posed within an inpatient area 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 and risk management. The policy aims to ensure that the appropriate level of operational management of ligature risk is maintained for the safety of service users and that appropriate technical advice is sought and action taken regarding the specification of anti-ligature fixtures and fittings within the inpatient environment. 3. Responsibilities The Board The Board has overall responsibility for the health, safety, and welfare of all staff, service users, visitors and others within the Trust. The Board will be informed of health and safety matters on a regular basis and ensure adequate resources are made available to provide and maintain the necessary standards of health and patient safety in the Trust. Chief Executive The Chief Executive is responsible for monitoring and reviewing health and safety in the Trust. Facilities and Estates The Facilities and Estates department are responsible for supporting the ligature risk assessment process and will act on actions, as appropriate, following an assessment of ligatures. For example, this may require remedial action to mitigate risks such as removing or replacing ligatures. Page 3 of 5
Managers and Supervisors Managers responsible for inpatient wards, 136 suites and/or Trust owned places of safety will bring this policy to the attention of all their staff and ensure that these are observed. Ensure that this policy is implemented within the service area of their responsibility. Ensure environmental and patient risk assessments are undertaken, which identify potential ligature points and ligatures / incidents of self-harm and the adequacy of the systems and clinical practices that manage these risks. Environmental ligature risk assessments must be reviewed as required or on significant change (i.e. change of use, modification of the building or after a serious incident involving suicide or attempted suicide using a ligature). Managers should communicate any risks via their risk register using the locally agreed process for undertaking this. Ensure control measures and safe systems of work including clinical practice (i.e. observations etc.) as necessary are developed and implemented. Ensure ligature cutters are available, stored and used in line with the Safe Use and Storage of Ligature Cutters SOP. To complete, review and make aware of, to all staff, the mitigation plan following a ligature risk assessment and it associated risks. Implement this policy and suicide prevention strategies. Managers of inpatient areas, 136 suites and (Trust owned) places of safety have the responsibility to ensure this policy is implemented and that the necessary risk assessments are carried out, acted upon and recorded. Employees The Health and Safety at Work Act etc. 1974 states the following duties: Every employee has a duty of care for the health and safety of people at work and of other persons who may be affected by work activities. Employees must take care of themselves and others at work and co-operate with the implementation of health and safety systems. Staff have a duty to follow all safe systems of work, procedures, and clinical management plans in place to control the risks of suicide. Furthermore, staff must report any hazard that could increase risk of suicide using the Trust s incident reporting system. This information should be reported to the ward manager/nurse in charge immediately and where appropriate staff should take immediate remedial action. For example, such hazards may include a broken collapsible curtain track, improperly fixed collapsible rail, unlocked door to a secure non-patient area which contains ligature points etc. All staff (including bank and agency staff) on every shift should be familiar with the location of the ward/unit s ligature cutter and how to access it. Health and Safety Advisor The Health and Safety Advisor is responsible for providing advice where requested, assisting with the review of ligature risk assessments and in due course, reviewing this policy. Periodic health and safety inspections will also be carried out which include aspects of risk assessment. Page 4 of 5
4. Ligature Assessments Every 12 months, a suitably trained person will carry out ligature assessments on each inpatient ward. These will be arranged for a mutually agreed time and date. Following the risk assessment, a mitigation plan is required from the ward to detail the mitigants and highlight how risks are being managed locally. In cases where the ward is unsettled, the ligature assessments may be rearranged. Information on this process and further detail can be found as part of the Ligature Risk Assessment SOP and associated SOPs. 5. Ligature Cutters All staff (including bank and agency staff) on every shift should be familiar with the location of the unit s ligature cutter and how to access it. These should be made available, stored and used in line with the Safe Use and Storage of Ligature Cutters SOP. 6. Testing Of Magnetic Fixtures and Fittings Every 12 months, Facilities and Estates will arrange for a competent contractor to attend inpatient units to carry out testing of magnetic equipment to ensure it complies with national and Trust standards. All wards will be notified prior to the attendance of the contractor. 7. Further Information For further information on this policy or associated SOPs, please speak with the Health, Safety and Security Advisor or a member of the Risk Management Team. 8. Process For Monitoring Compliance And Effectiveness Compliance of this policy and associated SOPs will be monitored through annual audits, incident reporting, mandatory training, offered advice, published documents and committees and meetings. Page 5 of 5