Guides

• Anything that binds or ties – and in this context used for self strangulation or hanging by being attached to a ligature point.
• Commonly used ligatures include, towels bedsheets and belts, however any material can be used
• Please note that many service users tie ligatures without a ligature attachment point

The most common ligature points used are doors (43%) or windows (18%)

The most common ligatures were a belt (35%) or sheets/towels (27%).

Most deaths by hanging occur in unobserved areas. The majority (68%) of deaths by hanging in a single bedroom or a toilet/bathroom (18%).

The majority of inpatient suicides occur when the patient is under intermittent observation. Deaths under observation tended to occur when observation was carried out by less experienced staff or (temporary or agency) staff likely to be unfamiliar with the patient. In many instances policies or procedures (including times between observations) were not followed, for example:
(a) when staff are distracted by other events on the ward
(b) at busy periods e.g. 7-9am
(c) when there are staff shortages
(d) when ward design impedes observation.

References
The University of Manchester and Healthcare Quality Improvement Partnership (HQIP) 2015 The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness Annual Report: England, Northern Ireland, Scotland and Wales 2015

• Most inpatient ligatures do not use a ligature attachment point (i.e. self strangulation)
• A sense of ‘hopelessness’ is common factor leading up to a suicide attempt
• Ligature incidents have a low degree of ‘openness’ – they are typically carried out in private. In incidents of suicide or self-harm where planning is present it is likely to involve precautions against getting discovered.
• Women are more likely to use self-harm/suicide methods that restrict their breathing compared to men. Where ligatures are used men are more likely to use a ligature point, whilst women were more likely to self-ligature.
• Deaths by hanging on inpatient wards in England are usually from low-lying ligature points (i.e. strangulation).
• Sadly 20-30 deaths per year still occur on inpatient wards by hanging.
• The majority (68%) died by hanging in a single bedroom or a toilet/bathroom (18%).

Anything that could be used to attach or secure a ligature for the purpose of strangulation or hanging

Beds
Should be appropriate to the environment (Fixed Anti-Ligature beds in acute settings).

Brackets, picture rails etc.
Consider bracketed and fixings – remove, box in or chase into the wall

Curtain rails for beds, windows or doors, baths and showers
Must have a low weight bearing capacity i.e. be collapsible or fitted flush to the ceiling

Curtain tracking

• Avoid gaps in fixed tracking
• Fit tracking flush to walls/ceilings

Curtain wires for nets
Avoid the use of curtain wires – consider alternatives

Doors. door closers and door handles

• Consider design, handles, hooks, hinges, any gap between door and frame
• Protruding door handles – consider alternative design
• Closers should be mounted on the outside of doors on the public or staff-controlled side

Electrical conduits/wiring
Should be ‘chased’ into walls, or fitted flush to wall

Exposed pipe work and fixing
Consider height and accessibility

Hinges – doors, wardrobes, cupboards
Consider type of hinge and any gap between door and frame (e.g. consider piano hinge).

Light switch cords

• Should not be nylon cord
• Consider solid pull cords
• Consider infa-red automatic switches
• Consider shortening length of cord

Patient’s lockers/wardrobes
Consider hinges and removal of hanging rails

Radiators
Consider boxing in if appropriate to the environment

Shelving and fixing brackets
Consider the risks

Wardrobes
Consider design, handles, internal hooks, door closing, hinges and any gap created between

Windows and window openings
Design appropriate for the environmental – consider handles, trickle vents, hinges hooks and closers etc.