Anti-ligature Precautions | Be Aware of the Risks

This is an issue that has been raised by Mental Health Trusts in particular. Here we highlight the legal and regulatory context. Useful policies, information and case studies can be found at

Organisations responsible for the care of vulnerable people must ensure that an effective risk assessment regime is in place and that any risks are properly addressed and managed.

This issue comes under the remit of both the Care Quality Commission (CQC) and the Health and Safety Executive (HSE).

The HSE is responsible for enforcing the Health and Safety at Work Act 1974 (HSWA) and associated legislation throughout Great Britain. As a national regulator it aims to reduce death, injury and ill health by securing the health, safety and welfare of workers and protecting others, such as contractors or patients, who may be affected by work activities. Whilst HSE focuses on the health and safety of employees, it also has a role in patient safety under section 3 of HSWA, which states: "It shall be the duty of every employer to conduct his undertaking in such a way as to ensure, so far as is reasonably practicable, that persons not in his employment who may be affected thereby are not thereby exposed to risks to their health or safety.

The CQC was established in 2008 as the independent regulator of health and social care in England. As well as registering providers of a wide range of activities in health and social care settings, it also protects the interests of vulnerable people, including those whose rights are restricted with the Mental Health Act. It monitors compliance and has powers to conduct investigations into serious failures of care.

In July 2012, the CQC and the HSE signed a Liaison Agreement to ensure that both organisations can share appropriate information in a timely manner so that people who use services are properly protected.

There have been a number of tragedies where people at risk were not provided with a physically safe environment. In some cases, Trusts had actually identified that there was a risk, but the work had not been carried out and there was no system in place to ensure that the work had actually been carried out once they had been identified.

In August 2014,NHS Ayrshire and Arran Health Board was fined £50,000 after pleading guilty to breaching Section 3(1) of the Health and Safety at Work Act 1974. A Health and Safety Executive investigation found a number of failings including not taking the required action to remove ligature points from a room in one of its mental health facilities that would have prevented a patient from hanging herself despite the fact that a ligature risk had been flagged up with regard to window restrictors. In this case, the Health Board had previously identified that the window restrictors, which had been placed to prevent people getting out or falling, could be used as a ligature point (i.e. points where material could be tied by people intent on harming themselves by hanging). Although a contractor had been asked to remove these from the hospital’s mental health wards, there was no record of the work being completed or of any check being carried out to ensure that it had been done in every single room.

The HSE investigation also found on admission to the ward there was no specific procedure or policy for checking and removing personal items (in this case boot laces), which might be used as a ligature.

In September 2009, the HSE warned of the importance of risk assessments when caring for vulnerable people. This followed the death of an in-patient and the prosecution of Powys Local Health Board, which was fined £30,000 with £46,849.50 costs earlier that month. An investigation by HSE revealed that the Trust or the Local Health Board failed to act on a risk assessment - carried out by the Trust's predecessor - that identified potential ligature points in the unit.

If issues about ligatures are or have been a concern to your Trust and you would be willing to share your experience, policy or methodology with your Estates & Facilities Management colleagues, please get in touch via e-mail or call us on 01327 227166. We would be happy to publish your experience as a case study and/or add your policy and other documents to our FM Document Exchange for the mutual benefit of our Members.