Ligature Risk Assessment Policy Who Should Read This Policy Target Audience Inpatient Ward Managers Matrons Service Managers Urgent Care Service Managers CAMHS Version 1.0 November 2015
Ref. Contents Page 1.0 Introduction 4 2.0 Purpose 4 3.0 Objectives 4 4.0 Process 4 4.1 Annual Ligature Risk Assessment 5 4.2 Risk Assessment Methodology 5 5.0 Procedures Connected to this Policy 9 6.0 Links to Relevant Legislation 9 6.1 Links to Relevant National Standards 10 6.2 Links to Other Key Policy 10 6.3 References 10 7.0 Roles and Responsibilities for this Policy 11 8.0 Training 11 9.0 Equality Impact Assessment 11 10.0 Data Protection Act and Freedom of Information Act 12 11.0 Monitoring this Policy is Working in Practice 12 Appendices 1.0 Ligature Point Identification Tool 13 2.0 Ligature Risk Assessment 14 Version 1.0 November 2015 2
Explanation of terms used in this policy Collapsible Fittings - Collapsible fittings are typically designed to collapse when loads in excess of 40 kg are applied Environment - The external surroundings, conditions with which a person interacts; this may include the physical or built environment (e.g. buildings, fittings etc.) Ligature - Something which binds or ties; any item that when placed around the neck can restrict the airway. A ligature can be used with a ligature point or independently Ligature Cutter - This is purpose-specific equipment for cutting ligatures. Ligature cutters must not be used for any other purpose than dealing with emergency situations involving ligatures Ligature Point - This is anything that is load-bearing and could be used to attach a cord, rope or other material for the purpose of strangulation Ligature Risk Assessment - A Trust tool for assessing ligature risks in the environment Patient/Service User - These terms are used generically and cover patients, clients or any person who uses services managed by Black Country Partnership NHS Foundation Trust Policy - Sets out the aims and principles under which services, Groups, or units will operate. A policy outlines roles and responsibilities, defines the scope of the subject covered, and provides a high level description of the controls that must be in place to ensure compliance Residual Risk - Compensating actions may be sufficient to reduce the risk of the ligature to an acceptable level - this is called the residual risk Significant Event - For the purposes of this policy an incident involving a ligature point that attracts a level grading on datix of moderate or above Version 1.0 November 2015 3
1.0 Introduction National Confidential Inquiry into Suicide by People with a Mental Illness (July 2015) shows that hanging continues to be the main method of suicide for mental health service users. Hanging may involve strangulation or asphyxiation caused by suspending the body from a high ligature point, or by using a ligature point below head height. A significant proportion of suicides are believed to occur through impulsive acts, using what may be seen as reasonably obvious ligature points. The National Suicide Prevention Strategy for England (2012) states that one of the most effective ways to prevent suicide is to reduce access to high-lethality means of suicide. The strategy also identifies those methods most amenable to intervention as hanging and strangulation and, consequently, advocates the removal of ligature points. Due to human ingenuity and/or a lack of a technical solution, it is not possible for all potential ligature points to be addressed. Therefore, a judgement has to be made about the likelihood of something being used as a ligature point and what compensating actions may be used. Equally, there may be some potential ligature points that need to remain, as removing them will create a greater risk to the service user i.e. grab rails in elderly units / disability accessible rooms. Operational management systems need to be in place for these areas / equipment / patients at risk. Black Country Partnership Foundation Trust acknowledges its responsibilities to identify all likely ligature points in inpatient wards, inpatient therapy areas, and other premises where inpatients access a service within the Trust. 2.0 Purpose This policy intends to address the environmental risks posed within a service that could enable a service user attempting suicide to use a ligature. This policy does not cover other risk factors in suicide prevention. Other risk factors are included within clinical risk assessments and policies associated with patient safety. This policy includes guidance and instruction for identifying and assessing potential ligature points and ligature risks, recording the findings and identifying mitigating actions as appropriate to the level of risk. Actions to address ligature point risks can include reporting, management/operational/clinical solutions or physical solutions which will be funded through planned preventative maintenance (PPM) or the Trusts Capital Programme. This policy aims to ensure that there are regular assessments of ligature points and appropriate management thereafter. 3.0 Objectives Black Country Partnership Foundation Trust s Ligature Risk Assessment Policy: Makes explicit the organisation s commitment to identify and manage all likely ligature points in inpatient wards, inpatient therapy areas, and other premises where inpatients access a service within the Trust Describes the responsibilities for ligature risk identification, assessment and management within the organisation 4.0 Process The following areas require annual (as a minimum) environmental ligature risk assessments to be undertaken: Version 1.0 November 2015 4
All inpatient units Facilities accessible to inpatients (i.e. dining and therapy areas) Ligature Risk Assessment Policy Environmental ligature risk assessments must be undertaken annually. Where there has been some significant change since the last assessment (i.e. change of use; modification of the building) a new assessment must be undertaken. A significant event involving the use of a ligature point (whether or not the patient was harmed) should trigger a review of that ligature point. Environmental ligature risk assessments are required for all Trust areas accessible to inpatient service users including enclosed communal areas such as therapy areas, separate dining facilities or recreational areas such as gardens. This is to ensure that where ligature risks are identified they are removed or managed. The Trust Ligature Risk Identification Tool and Ligature Risk Assessment Tool assists staff in carrying out this task. 4.1 Annual Ligature Risk Assessment An annual assessment should be completed for each identified area, using the Ligature Risk Identification Tool. Ligature Risk Assessments are working documents and should be reviewed and updated following a significant event involving a ligature point (see 4.0). 4.1.1 Wards Copies of the Risk Assessments should be shared with ward staff and be readily accessible on the ward. All ward staff should be aware of the location of assessments for their ward and be able to access them at all times. Completed Ligature Risk Assessments should be forwarded to Group Governance Teams. Group Governance Teams will then report findings through their respective Quality and Safety meetings in order to highlight identified risks and seek approval for recommendations to manage unmitigated high risks. Approved recommendations to manage unmitigated risks which require the investment of additional resources will then be escalated to GMB. 4.2 Risk Assessment Methodology The Trust uses an environmental Ligature Risk Identification Tool (see Appendix 1) developed from the Manchester Audit tool. Ward managers are responsible for identifying ligature points through the Ligature Risk Identification Tool and for completing the Ligature Risk Assessment (see Appendix 2). 4.2.1 Ligature Risk Identification Tool The tool will be applied to all patient areas except those that are not accessible without supervision. The tool uses four elements to identify the level of potential risk attached to a ligature point. Each element is assigned a score from 1 to 3. A higher score denotes a higher likelihood of risk. The scores from each factor are multiplied together to give a final rating from 1 to 81. Version 1.0 November 2015 5
The elements used are: Room Type - the level of supervision normally provided to the area where the ligature point is located Patient Profile - the degree to which patients are considered at risk of attempting suicide and include severity of acute mental illness Ligature Point - the height of the ligature point is taken into account, ligature points located at or above head height afford greater opportunity for patients to attempt suicide Compensatory Factor - Whether there are any other issues such as ward layout that would influence the likely use of a ligature point 4.2.1.1 Room Type Each room in the clinical area will have its own priority. This is rated according to the amount of time most patients will spend in the room without direct supervision from staff or those with unobserved opportunity e.g. toilets. For example: most patients will spend periods of time unsupervised in their bedroom or in the shower. This rating is an assessment of the opportunity a patient could have to use a ligature point. Managers are expected to score the room designation according to usual staff supervision practices. Room Designation Rating: 3 Most patients spend periods of time, in private, without direct supervision of staff: All bedrooms Toilet areas Shower / Bathroom areas Single Sex sitting rooms Some Smoking rooms Other isolated areas of the ward Room Designation Rating: 2 Most patients spend long periods of time with minimum direct supervision of staff and are usually in company of peers: Day rooms Dining rooms Unlocked therapy rooms Unlocked offices Unlocked Store rooms Unlocked Utility rooms Unlocked Kitchens Some Smoking rooms Room Designation Rating: 1 Areas where there is movement of staff and patients through areas that are: General circulation spaces Corridors Locked rooms 4.2.1.2 Patient Profile While mental health service users are at greater risk of suicide than the general population, some patient groups are more vulnerable and susceptible to suicide risk than others. Clinical areas cater for different functional groups of patients who can, therefore, be profiled into groups who could have a significant, moderate or low Potential to use ligature points. The following table suggests a risk rating with associated scale. Please note that the ratings, once again, are in three groups (1, 2, 3) Version 1.0 November 2015 6
High Risk Patient Group: 3 Patients with acute severe mental illness Patients who are unpredictable Patients who are depressed Patient/s who are, or have been, of high risk of suicide or severe self-harm Patients in initial recovery stage following suicide risk or on 1 to 1 observations Young people Patients with challenging behaviour Patients with chaotic behaviour Patients with concurrent substance misuse issues Patients with concurrent severe social need e.g. (marital / family breakup, financial concerns etc.) Medium Risk Patient Group: 2 Patients with chronic or enduring mental health problems Patients who are susceptible to periodic relapses or sub-acute episodes Patients who are not symptom free (e.g. delusions/ hallucinations) Patients who have been assessed as NOT being an immediate risk of suicide Low Risk Patient Group: 1 Patients in self-care groups Patients in rehabilitation Patients who have never been assessed as being at risk of suicide 4.2.1.3 Ligature Point This rating scale requires managers to identify potential ligature point in relation to its height position in the room. TOP AREA OF ROOM MIDDLE AREA OF ROOM LOWEST AREA OF ROOM Low Risk: 1 4 metres and above High Risk: 3 Between 170cm and 4 Metres Medium Risk:2 Between 70cm and 170cm Low Risk: 1 Up to 70cm Any ligature point identified in the area between 170cm and 4metres of the room must be scored at 3, given that it is the most obvious area in which a patient could hang himself or herself. However above 4 metres access to the very top of the room is greatly restricted unless ladders are available and is to be scored as level 1. Anything in the middle section of the room (70cm 170cm) is rated at 2 and anything in the bottom area (below 70cm) of the room at 1. 4.2.1.4 Compensatory Factors Compensating Factors should then be scored. Compensating Factors are things which would reduce the risk. A Compensating Factor must be common practice or relate to the design of the room and must be permanent. For example, the use of continuous Version 1.0 November 2015 7
observation at the time of the audit will not count as a Compensating Factor because this is a temporary clinical management strategy and not a permanent feature. In order to qualify as a Compensating Factor the item must be either a design element (e.g. one which allows for good observation) or a procedural one (e.g. general observation practices of staff) or that of design of equipment. The following table of examples is not exhaustive and local variations may also apply: High Risk Remains: 3 Limited observation through poor design Limited Staff Medium Risk remains: 2 Good observation through good design Limited Staff Medium Risk remains: 2 Limited observation through poor design Good staffing Levels/skill mix Medium Low Risk: 1 Good observation through good design Good staffing levels/skill mix The following table is intended to assist auditing teams in the identification of likely ligature points. It must be noted that these lists are not exhaustive: Bedrooms Windows - frames, catches Doors - handles, hinges, door closers Curtain/ blind rails Exposed pipe work Radiators Ceilings Lights Wardrobes - handles, locks, doors, rails, coat hooks Sinks - taps, soap dishes Beds e.g. can they turned on end? Other Bathrooms/ Toilets/ Showers Doors - handles, catches, hinges, Closing device Hooks e.g. for clothes Bath/ sink taps, grab rails Ceilings Extractor fans Toilet, cistern handles Toilet roll/soap/ Paper towel dispensers Radiators Shower rose or control knob Open pipe work Shower cubicle doors/curtain rail Other Lounges/ Quiet/Therapy Rooms Windows - frames, handles, catch Exposed pipe work Rails for curtains/ blinds Doors - handles, hinges Radiators Light fittings Ceilings Other Corridors Cupboards Fire extinguisher (brackets) Fire bells Doors - handles, hinges Exposed pipe work Other 4.2.1.5 Examples 4.2.1.5.1 Example 1 - Air Vent in the Ceiling of an Older Adult Ward for Patients with Dementia Room Type - (lounge) is in constant use, has high staff and patient movement and consequently high levels of observation and therefore scores a low rating = 1 Patient Profile - provides inpatient services for older adults with a primary diagnosis of dementia with likely clinical presentations including confusion and Version 1.0 November 2015 8
disorientation, however, may also provide services for patients with other diagnoses and therefore scores a moderate rating = 2 Ligature Point - (ceiling) the ligature point is above head height and therefore scores a high rating = 3 Compensatory Factor - ligature point (vent) is in an area with good observation from several corridor areas and therefore scores a low rating = 1 Room Type (1) x Patient Profile (2) x Ligature Point (3) x Compensatory Factor (1) = Overall Rating 6 (low) 4.2.1.5.2 Example 2 - Bedroom Door Handle of an Adult Acute Psychiatric Ward Room Type - (bedroom) patients could spend significant amounts of time unsupervised in bedroom and therefore scores a high rating = 3 Patient Profile - (acute inpatient) provides services for a range of acute presentations including patients with suicidal ideation and therefore scores a high rating = 3 Ligature Point - (approx. 1m) ligature point is above 70cm but below head height and therefore scores a moderate rating = 2 Compensatory Factor - (bedroom) bedroom is located upstairs and not easily observable and therefore scores a high rating = 3 Room Type (3) x Patient Profile (3) x Ligature Point (2) x Compensatory Factor (3) = Overall Rating 54 (high) 4.2.2 Ligature Risk Assessment Once the Ligature Risk Identification Tool has been completed the highest risks (those scoring 54 or 81) should be copied into the Ligature Risk Assessment tool and the rest of the tool completed. The tool aims to not only identify the highest risks but evaluate whether there are any control measures already in place that would adequately mitigate the risk. Where such control measures are not in place or deemed inadequate then recommendations should be identified to mitigate the risk, together with leads and timescales. Managers may wish to consult widely with Trust colleagues in formulating appropriate recommendations. It may be possible that while immediate action is taken within the area (i.e. simply by removing a particular item that could be used as a ligature or ligature point or through changes to operational procedure), potentially some or many ligature points will require some significant expenditure to control the associated risk. The risk assessment should be approved by the appropriate Service Manager or Matron and forwarded to Group Governance / Risk Teams (See 4.1) 5.0 Procedures Connected to this Policy There are no procedures connected to this policy. 6.0 Links to Relevant Legislation Health and Safety at work etc. Act 1974 This Act is the major piece of health and safety legislation in Great Britain. The Act introduced a comprehensive and integrated system to deal with workplace health and safety and the protection of the public from work activities. Version 1.0 November 2015 9
The Act places general duties on employers, employees, self-employed, manufacturers and importers of work equipment and materials. Responsibilities are placed to produce solutions to health and safety problems, which are subject to the test of reasonable practicability. Various regulations are made under the Act, which have the same scope, many of these evolving from European Directives, which enables the potential to achieve clear and uniform standards. 6.1 Links to Relevant National Standards National Confidential Inquiry into Suicide by People with a Mental Illness (2015) This report presents findings from all suicides in the UK from 2003-2013. It highlights areas of health care where safety should be strengthened. Responsibility for this is shared between mental health providers, partner agencies, commissioners (in England), education and training bodies and professional organisations. The findings and recommendations emphasise common areas across the UK countries but countryspecific findings may also require actions by services. CQC Regulation 12: Safe Care and Treatment The intention of this regulation is to prevent service users from receiving unsafe care and treatment, in order to prevent any avoidable harm or risk of harm. CQC understands that there may be inherent risks in carrying out care and treatment, and will not consider it to be unsafe if providers can demonstrate that they have taken all reasonable steps to ensure the health and safety of service users, and to manage any risks that may arise during care and treatment. 6.2 Links to other Key Policies Clinical Risk Management Policy This policy is intended to guide practitioners who work with service users to manage the risk of harm. It sets out the principles and standards required that should underpin best practice across all health settings, and describes the tools that are used to structure the often complex clinical risk management process. 6.3 References National Confidential Inquiry into Suicide by People with a Mental Illness (July 2015) National Suicide Prevention Strategy for England (2012) Version 1.0 November 2015 10
7.0 Roles and Responsibilities for this Policy Title Role Key Responsibilities Executive Director of Nursing, AHPs and Governance Executive Lead - Ensure that appropriate and robust systems, processes and procedures are in place for Ligature Risk Assessment - Allocation of resources to support the implementation of this policy - Ensure that any serious concerns regarding the implementation of this policy are brought to the attention of the Board Trust Board Strategic - Strategic overview and final responsibility for overseeing the management of ligature risks across the Trust in accordance with its primary objective to provide high quality safe care Group Quality & Safety Group Group Governance Team Scrutiny and Performance Monitoring and Support - Ensure ligature risk assessments have been conducted in accordance with policy - Support escalation of residual risks through General Management Board - Escalate any issues to Quality and Safety Steering Group - Provide initial training to manager s performing ligature risk assessments - Update Quality and Safety Group of performance and highlight residual risks for further action Service Manager/ Matrons Ward Manager Implementation - Ensure Ligature risk assessments are completed and approve recommendations - Ensure systems are in place to enable this policy to be implemented within their service area - Ensure that they are familiar with the policy Operational - Complete Ligature Risk Identification Tool at least annually - Complete Ligature Risk Assessment with recommendations for action to mitigate risk 8.0 Training What aspect(s) of this policy will require staff training? Completing Ligature Risk Identification Tool and Ligature Risk Assessment Which staff groups require this training? Ward managers/ Matrons/ Service Managers Is this training covered in the Trust s Mandatory and Risk Management Training Needs Analysis document? No If no, how will the training be delivered? Rolled out individually by Group Governance Teams Who will deliver the training? How often will staff require training Who will ensure and monitor that staff have this training? Group Governance One Off Quality and Safety Group 9.0 Equality Impact Assessment Black Country Partnership NHS Foundation Trust is committed to ensuring that the way we provide services and the way we recruit and treat staff reflects individual needs, promotes equality and does not discriminate unfairly against any particular individual or group. The Equality Impact Assessment for this policy has been completed and is readily available on the Intranet. If you require this in a different format e.g. larger print, Braille, different languages or audio tape, please contact the Equality & Diversity Team on Ext. 8067 or email EqualityImpact.assessment@bcpft.nhs.uk Version 1.0 November 2015 11
10.0 Data Protection and Freedom of Information This statement reflects legal requirements incorporated within the Data Protection Act and Freedom of Information Act that apply to staff who work within the public sector. All staff have a responsibility to ensure that they do not disclose information about the Trust s activities in respect of service users in its care to unauthorised individuals. This responsibility applies whether you are currently employed or after your employment ends and in certain aspects of your personal life e.g. use of social networking sites etc. The Trust seeks to ensure a high level of transparency in all its business activities but reserves the right not to disclose information where relevant legislation applies. 11.0 Monitoring this Policy is working in Practice What key elements will be monitored? (measurable policy objectives) Where described in policy? How will they be monitored? (method + sample size) Who will undertake this monitoring? How Frequently? Group/Committee that will receive and review results Group/Committee to ensure actions are completed Evidence this has happened Completion of Ligature Point Identification Tool and Ligature Risk Assessment Tool 4.2 Risk Assessment Methodology Receipt by Group Governance Teams for all inpatient areas Group Governance Annually Quality and Safety Quality and Safety Minutes of meetings Version 1.0 November 2015 12
Appendix 1 Ligature Point Identification Tool Group Ward Name of Manager Completing Tool Date Room Type Rating Patient population Profile Rating Ligature Point Rating Compens atory Factor Rating Total Room: e.g. Bathroom Ligature Point E.g. Taps 3 3 2 3 54 Version 1.0 November 2015 13
Appendix 2 Ligature Risk Assessment Area/Department: Site: Date: Review date: Risk Score: Risk Assessor(s): Distribution: Post Action: Introduction: Hazard Example - Downstairs bathroom hand basin taps Ligature Point Score 54 Bathroom is unlocked at all times. Bathroom checked on observation round. No formal monitoring of bathroom use. Risk Findings & Controls in Place Recommended Action Lead Person Progress Date Replace hand basin taps with antiligature taps. Comments Resources Required Version 1.0 November 2015 14
Policy Details Title of Policy Unique Identifier for this policy State if policy is New or Revised Ligature Risk Assessment Policy BCPFT-CLIN-POL-09 New Previous Policy Title where applicable Policy Category Clinical, HR, H&S, Infection Control etc. Executive Director whose portfolio this policy comes under Policy Lead/Author Job titles only Committee/Group responsible for the approval of this policy Month/year consultation process completed * N/A Clinical Executive Director of Nursing, AHPs and Governance Governance Coordinator Quality and Safety Steering Group October 2015 Month/year policy approved November 2015 Month/year policy ratified and issued November 2015 Next review date November 2018 Implementation Plan completed * Equality Impact Assessment completed * Previous version(s) archived * Disclosure status Key Words for this policy Yes Yes N/A B can be disclosed to patients and the public Ligature point identification tool, Ligature risk assessment, Ligature cutter, Ligature point, Room type, Patient profile, Compensatory factors * For more information on the consultation process, implementation plan, equality impact assessment, or archiving arrangements, please contact Corporate Governance Review and Amendment History Version Date Details of Change V1.0 Nov 2015 New policy developed for BCPFT Version 1.0 November 2015 15