CHHS18/188 Canberra Hospital and Health Services Operational Procedure Ligature Risk Management for Mental Health, Justice Health and Alcohol & Drug Services Inpatient Mental Health Units Contents Contents..................................................... 1 Purpose...................................................... 2 Alerts....................................................... 2 Scope........................................................ 3 Section 1- Components of the MHJHADS Ligature Risk Management System....................................................... 4 Section 2-Staff Responsibilities.............................5 Section 3 – Risk Dynamics and Risk Zoning....................7 Section 4 – Collateral Risk Assessment Factors..............10 Section 5 – Environmental Safety Checks (ESC)...............12 Section 6 – Ligature and Ligature Point Assessment Audits. . .13 Section 7 – Risk Assessment and Reduction Action Plans......16 Section 8 – Staff Training..................................17 Implementation.............................................. 18 Related Policies, Procedures, Guidelines and Legislation....18 References.................................................. 20 Definition of Terms......................................... 20 Search Terms................................................ 22 Attachments................................................. 22 Attachment 1 – Zoned Floor Plan Risk Map Example..........24 Attachment 2 – Environmental Safety Check.................25 Doc Number Version Issued Review Date Area Responsible Page CHHS18/188 1.0 02/07/2018 01/07/2019 MHJHADS 1 of 53 Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register
Transcript
CHHS18/188
Canberra Hospital and Health ServicesOperational ProcedureLigature Risk Management for Mental Health, Justice Health and Alcohol & Drug Services Inpatient Mental Health UnitsContents
Attachment 3 – Ligature and Ligature Point Assessment Audit Checklist..........................27
Attachment 4 – ACT Health Risk Assessment Template.....................................................35
Attachment 5 – Ligature and Ligature Point Risk Reduction Action Plan...........................38
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Purpose
Mental Health Justice Health and Alcohol & Drug Services (MHJHADS) aims to provide a safe and therapeutic environment for people admitted for care and treatment. This includes ensuring that the environment is as free as possible from ligatures and ligature points.
This procedure is to be seen as an integral part of an overall strategy to reduce the risk of self-harm and suicide and used in collaboration with assessment of mental state, medication prescription, participation in therapy, clinical risk assessment, observation and engagement of mentally ill persons admitted to inpatient units.
Accordingly, this procedure outlines the responsibilities and operational requirements for implementation and is compliant with the MHJHADS ligature risk management system. As is outlined in this procedure, information has been provided aligning with the Australian Commission on Safety and Quality in Health Care’s National Standards for Mental Health Services 2010, by promoting “the optimal safety and wellbeing of the consumer in all mental health settings” (Standard 2.1).
This procedure primarily addresses environmental risks within the inpatient setting that, if not identified and/or managed, could contribute to attempts or completion of acts of self-harm or suicide by hanging.
This procedure aims to: Guide the provision of a safe and therapeutic environment for people with mental
health disorders; Provide a procedural framework to enable staff to effectively identify, assess and reduce
environmental risks; Provide operational guidance for staff that ensures a coordinated approach to the
prevention of self-harm from ligatures and ligature points, consistent with other related clinical, physical, procedural and relational security strategies used in delivering quality care to admitted persons ensuring their safety and wellbeing.
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Alerts
A significant proportion of completed suicides are believed to occur through impulsive acts using the first means to hand and without time for reflection, whilst others are a result of a well-planned and considered approach to self-harm. The most common method of suicide in hospitals and in the general community is self-strangulation by hanging.
Due to human ingenuity and/or a lack of a technical solution, it is not possible for all potential ligatures and ligature points to be eliminated without setting aside a person’s human rights. Therefore a clinical judgement has to be made about the likelihood of something being used as a ligature and or a ligature point.
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Where identification of ligature or a ligature point risk is evident, direct, timely action ensuring the safety and welfare of people accessing an inpatient unit should occur as part of the overall clinical risk assessment.
An anti-ligature or reduced ligature fitting or fixture does not automatically eliminate risk.
Scope
This procedure applies to all persons providing services and those visiting and supporting admitted persons to MHJHADS inpatient mental health units including: Allied health, medical, nursing, visiting medical officers, registrars, locums,
administrative Agency and Casual staff; Students under supervision of MHJHADS allied health, medical and nursing staff; Volunteers; Contractors and tradespersons; Visitors and support persons
In-scope inpatient MHJHADS facilities include: Adult Mental Health Unit (AHMU) – Building 25, Canberra Hospital campus; Brian Hennessy Rehabilitation Centre (BHRC) – Mary Potter Circuit, Bruce; Adult Mental Health Rehabilitation Unit (AMHRU) - University of Canberra Hospital
(UCH) campus; Mental Health Short Stay Unit (MHSSU) - Level 2, Emergency Department, Canberra
Hospital campus; and Dhulwa Mental Health Unit (DMHU) – Symonston.
Note: This procedure does not cover the risk factors associated with the clinical assessment, treatment and management of mental state or managing a person’s behaviour associated with self-harm and suicide. These strategies are undertaken as part of clinical risk assessment process and the allocation of risk categories and the associated levels of observation required for individuals being assessed or admitted for treatment and care.
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Section 1- Components of the MHJHADS Ligature Risk Management System
The key components of the MHJHADS Ligature Risk Management System are: 1.1 Floor Plan Risk Map (FPRM) Floor Plan Risk Maps are to be used as a means of raising staff awareness relative to areas within the inpatient unit identified or zoned as high, medium or low risk. FPRMs (Attachment 1) must be developed and regularly updated for each inpatient unit, including display in prominent location(s) within the unit. FPRM’s are to be colour coded to ensure quick reference and identification of higher risk areas of the unit are highlighted to staff.
FPRMs are also used to assist in the clinical handover process and are to be included as part of the orientation and training of all staff working in MHJHADS inpatient units.
Refer to Section 3 of this document for more detailed content on FPRMs.
1.2 Environmental Safety Checklists (ESC)An Environmental Safety Checklist (Attachment 2) must be completed at the beginning or change of every shift. The purpose of the ESC is to observe for ligatures, ligature points, environmental risks and the presence of prohibited items and follow-up action taken as required.
The ESC supports practices aimed at ensuring all people are as safe as possible from harm, and to ensure that risks are effectively managed. ESC practices are only exercised in so far as it is reasonably practicable without infringing on a person’s human rights. Refer to ACT Health Searching Policy.
Refer to Section 5 of this document for more detailed content on ESCs.
1.3 Ligature and Ligature Point Assessment Audit Tool (LLPAA)A formal Ligature and Ligature Point Assessment Audit Tool (LLPAA) (Attachment 3) is used to identify the presence of ligatures and ligature points.
The LLPAA is incorporated into the MHJHADS Clinical Audit Schedule as part of the integrated system for ligature and ligature point management and must be conducted every six (6) months at minimum, or more frequently where indicated.
Where a change to the environment is proposed (e.g. room refurbishment or change in purpose), a full ligature assessment review will be required.
Refer to Sections 6 and 7 of this document for more detailed content on LLPAAs.
1.4 Risk Assessment and Risk Reduction Action Plans (RRAP)All high risk ligatures and/or ligature points identified in the LLPAA audit are subject to a further formal detailed risk assessment using the ACT Health Risk Assessment Tool
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(Attachment 4). Identified risks must then be addressed through the development of a Risk Reduction Action Plan (Attachment 5).
Once completed by the ADON, the RRAP is to be provided to the Operational Director. Where reduction or removal of a ligature or ligature point requires significant investment of funds by the service, the Operational Director is required to report this to the Executive Director for further action.
Refer to Section 7 of this document for more detailed content on RRAPs.
1.5 RiskmanRiskman is the ACT Health risk reporting system. All staff are required to report near misses, damage, tampering to fittings or other risks that have the potential to increase opportunity or means for self-harm. Riskman incidents are to be followed up promptly by the responsible manager and issues escalated and acted on without delay.
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Section 2-Staff Responsibilities
2.1 MHJHADS Divisional ExecutiveMHJHADS executive inclusive of the Executive Director and Chief Psychiatrist are responsible for ensuring policies, procedures and standards comply with legislative requirements inclusive of those that relate to the identification, mitigation and where possible elimination of ligatures and ligature points within inpatient mental health units.
2.2 Operational Directors Operational Directors are responsible for ensuring implementation of the MHJHADS Ligature Risk Management system, Governance and reporting requirements in their respective mental health inpatient units.Where reduction or removal of a ligature or ligature point requires significant financial investment, the Operational Director is required to report this to the MHJHADS Executive Director for further action.
2.3 Assistant Directors of Nursing (ADONs)ADONs are to ensure completion of and compliance with the following: Floor Plan Risk Maps are developed and displayed in each inpatient unit, and
communicated to staff through line managers; Environmental Safety Checklists are completed each shift; Ligature and Ligature Point Assessment Audits are conducted six (6) monthly at
minimum; ACT Health Risk Assessment Tool is completed for all identified risks and Risk Reduction
Action Plans developed to address and manage these risks; Once completed by the ADON, the action plan is provided to the Operational Director to
action and monitor.
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All staff receive orientation and training that includes the ligature risk management procedure system, Environmental Safety Checks (ESCs) and the use of the Ligature and Ligature Point Audit Assessment (LLPAA) tool.
Ligature and ligature point assessment audit findings and the actions being taken are to be reported by the ADON through the inpatient Work Health Safety Committee and Clinical Governance Committees;
All minor works and the addition of fixtures and fittings are to be subject to a ligature and ligature point assessment and an approval process;
Reporting to relevant Operational Director occurs relative to ligature risk issues identified and documentation is made in Riskman;
Implementation of strategies that reduce the risk of self-harm, suicide and prevention of serious incidents through audits and risk reduction action plans.
Keeping all records associated with the implementation of the Ligature Risk Management Procedure foe Mental Health Inpatient Units
2.4 Clinical Directors Clinical Directors, Operational Directors and ADONs are to work together to ensure the
Ligature Risk Management Procedure is implemented and the necessary actions required under the RRAP are regularly reviewed through both Unit and Divisional Governance systems.
2.5 Clinical Nurse Consultant (CNC) and Nurse in Charge of Shift (NICS) Ensure the completion of Environmental Shift Checks Ensure searching on admission and on return from leave of admitted persons consistent
with approved search policy and procedures. Ensure that staff receive ligature risk management and ligature removal use of ligature
cutter training and that records of staff training are kept
2.6 Multidisciplinary team (MDT) responsibilities All MDT members of each inpatient unit are responsible for the following: Attending orientation and training that includes the ligature risk management system,
use of the Environmental Safety Check and Ligature and Ligature Point Assessment Audit Tool;
Communicating both at clinical handover and at other times risk issues associated with the management of ligatures, ligature points and risks for self-harm or possible harm from prohibited items;
Ensuring that individual work practices are supportive of managing environmental risk including supporting Operational Directors, ADONs and CNCs to meet their responsibilities to implement the ligature risk management system;
Designated Nursing staff are to complete ESCs on each shift; Reporting ligature risk issues to their line manager and utilising the Riskman and SAIR
reporting system to document clinical risk inclusive of electronic medical record system; Familiarising themselves with the ligature risk management system as well as Clinical
Risk Assessment (CRA) and At Risk Category (ARC) procedures, completion of the Suicide
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Vulnerability Assessment Tool (SVAT) and other related policies, procedures and guidelines through their orientation and ongoing supervision.
2.7 Visitors and ContractorsThe management of Visitors and Contractors is also integral to an effective approach to the management of risk by increasing their awareness of risk in terms of bringing at risk items into an inpatient unit. This requires proactive local communication in order to ensure a high level of cooperation occurs especially vigilance for prohibited items.
Visitors and contractors must not engage in behaviour or work practices that compromise the provision of a safe and therapeutic environment. This means that visitors and contractors must comply with all related procedures including search procedures as applicable.
Visitors and Contractors are required to take responsibility for the following prior to entry to inpatient mental health units requiring the safe and vigilant management: Safe and vigilant management of tools and equipment including security of electrical
cords, tool bags and liquids; Cords contained in clothing, shoes, shoe laces, personal items containing elastic and
other items that represent a potential ligature risk such as plastic bags; Comply with direction from staff that certain prohibited items cannot be brought into
the clinical environment due to their associated risks such as scissors, glass bottles and knifes.
Where co-operation in regard to these items cannot be achieved staff are to report any ligature risk issues to the CNC/ADON/Nurse In Charge of Shift.
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Section 3 – Risk Dynamics and Risk Zoning
Within inpatient mental health units there are known areas that present the potential for a greater risk of self-harm and suicide.
Risk zoning is based on recognising the opportunity that a person could have to use a ligature and a ligature point. Areas are zoned according to the amount of time most people will spend in an area without direct supervision or observation from staff.
Three salient risks that must always be actively managed by staff include:1. Means (ligatures and ligature points)2. Motive (mental state)3. Opportunity (the time and the means to act based on mental state)
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Note: Bedrooms, ensuite bathrooms, doors, showers, toilets and isolated areas within all mental health inpatient units are the least directly supervised spaces and present the highest potential risk
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While privacy and dignity are to be afforded to people at all times, a person’s safety and welfare must not be put in jeopardy due to staff not asserting themselves in situations where a risk for self-harm has been assessed and identified. This requires that the necessary clinical judgment is exercised to keep people safe from harm.
Three further pillars of safety and security are also part of the way in which risk is assessed and responded to are:1. Physical Safety2. Relational Safety3. Procedural Safety
Physical safety Physical safety requirements are determined through good design aimed at minimisation of ligature points, the presence of ligatures, and the likelihood of unauthorised entry and exit for attainment of prohibited at risk items. This includes those items brought into clinical areas by staff, visitors and contractors.
Relational safetyRelational security is the knowledge and understanding that staff have gained about a person directly or provided to them by way of collateral information. This process informs the basis of a therapeutic relationship with a person and their carers, and the translation of this information into appropriate interventions that assist in the person’s treatment, care and recovery.
Procedural safety Procedural safety relates to the proper application of a range of procedures, policy, work systems and work practices designed to keep people safe from harm. A comprehensive range of effective procedures anchors the application of therapeutic activity through structure, processes and clinical routines. The routine application of procedures ensures that staff are able to quickly and efficiently establish clear boundaries and enables safe practices to be embedded and applied in a consistent way.
Examples include searching the belongings of a person or the person themselves who is under assessment or admitted for treatment and care and on their return from leave (subject to searching requirements being met – refer to Searching of a Consumer’s Person or Property Policy). Removal of prohibited or at-risk items requires clinical judgment, and clinical leadership to act in circumstances where the risk of self-harm has been identified and a proportionate response is required.
Similarly, entry to bedrooms, ensuites and toilets by staff should not, under all circumstances be considered as an intrusion or a breach of a person’s human rights or of their privacy and dignity. Entry must be approached based on achieving a balance between a person’s privacy and dignity, and their right to be treated and kept safe by assertively managing the risk of self-harm, and paying close attention to assessed risk levels.
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Although it is not possible at all times to individualise the allocation of bedrooms due to movement of persons within and between services, those assessed as having higher clinical risk should be accommodated where possible, in bedrooms closer to the staff station to facilitate increased opportunities for direct clinical observation.
Risk ZoningFloor Plan Risk Maps (FPRMs) are to be used to map and identify risk areas. FPRMs are to be used to assist the clinical handover process by specifically indicating the location of persons in need of higher levels of vigilance particularly in circumstances where ESCs have identified prohibited risk items. FPRMs are also to be included in the orientation of new staff to inpatient areas.
To focus the attention of staff on these areas, a FPRM is to be displayed on each unit and used as a visual prompt to increase staff awareness for specific risk areas. Areas are zoned and colour-coded to indicate Red (High), Amber (Medium) and Green (Low) risk. An example of a FPRM can be viewed at Attachment 1.
For the purposes of this procedure the following approach to risk zoning is to apply:
Red Zone - High RiskPlaces where people receiving treatment and care are alone and away from direct observation and other persons for extended periods. This includes all bedrooms, shower/toilet ensuites, toilets located in common areas, and isolated external areas adjacent to the unit. These areas are to be zoned high risk and colour-coded red.
Amber Zone - Medium RiskAreas where people receiving treatment and care may be unsupervised for periods of time but are within the unit or department environment. Contact with other persons or staff may be occasional, dependent on number of people on the unit and staff duties.Examples may include therapy areas, activity rooms, lounges, kitchens, quiet areas, spiritual rooms, courtyards and gardens etc.
Green Zone - Low RiskCommon areas where people receiving treatment and care are regularly supervised and/or are regularly in the company of other persons e.g. dining rooms, main corridors, reception areas, etc.
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RED ZONE High Risk
AMBER ZONEMedium Risk
GREEN ZONELow Risk
Areas where most people receiving treatment and care spend long periods of time, in private, without direct supervision of staff
Areas where people spend periods of time with minimum direct supervision of staff and are usually in the company of peers
Areas where there is a regular staff presence and other persons moving freely with good lines of sight
All bedrooms Common Lounge Areas General circulation spaces
Ensuite toilet / shower areas Dining rooms/areas Corridors
Toilets in general ward areas
Therapy, recreation, gym and spiritual spaces where staff are not in constant attendance
Interview rooms where staff are in constant attendance
Isolated rooms without good line of sight such as unisex toilets and recreation rooms
Sitting rooms without good line of sight
Family rooms when family are present
Unlocked Laundry areas where staff are not in constant attendance
Laundry areas where staff are in constant attendance
Isolated external areas adjacent to or near the unit
Note: While areas can be categorised and zoned according to the level of risk, unpredictable and opportunistic risks will arise within any environment and vigilance is required particularly at night even in areas zoned and assessed as low risk.
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Section 4 – Collateral Risk Assessment Factors
People being assessed or admitted for mental illness, mental disorders and associated co-morbidities are at greater risk of self-harm and suicide than the general population. Within
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this group certain clinical presentations are more vulnerable and susceptible to self-harm and suicide risk than others.
As inpatient mental health units cater for a range of clinical presentations, individuals are assessed using a combination of static and dynamic risk factors. These factors need to be taken into consideration when CRAs are undertaken and the required ARC observation level is determined or adjusted at clinical meetings or following adverse incidents. SVATs should also be utilized to assist in the assessment of self-harm and suicide.
When clinical risk is being assessed, staff awareness for ligatures and ligature point risks must also be factored into the risks associated with managing the person and their interaction with the physical environment. Staff orientation and training are essential elements in developing staff awareness for these risks.
Note: This is especially important for a person with a previous history of self-harm and suicide attempts as this is an indicator of a higher risk for future self-harm.
Collateral factors can both decrease and increase risk despite inpatient units being zoned as having, low, medium or high potential risk areas for self-harm and suicide.
For example, a person receiving unfavourable news, experiencing circumstances where a family visit does not proceed well, or receiving rejection of a period of leave may increase the potential for self-harm with an associated shift in mental state. Periods spent alone in their bedroom, even though in a known high risk staffed red zone, will require greater levels of vigilance from staff.
Specific reference to these factors must be included in clinical handovers for the purpose of considering whether a person previously assessed as being a low risk for self-harm may need to have their observation level reviewed and increased.
This may also necessitate a person specific ligature risk assessment process as part of the CRA review and this includes the risk presented by personal items that can be used as potential ligatures.
Personal items include such things as mobile phones, phone chargers, hair dryers, , belts, shoe laces, string ties for hoodies and tracksuit pants, bras and pantyhose, under wear, leisure wear clothing makeup, jewelry, nail polish bottles, aerosol cans and soft drink glass bottles and cans. In these circumstances personal items may need to be removed as assessed on a person by person basis in order to reduce risk.
There are also situations, for example when 1:1 continuous observation is used, that reduce the risk of self-harm in bedroom and ensuite areas which have been zoned as red. At these times, the area of high risk is temporarily under constant observation making it less likely that a ligature or ligature point could be used.
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When ARC observation rating is reduced the need for vigilance still remains high. A person who has had their ARC observation reduced and who is later in a low risk green zone area after hours, would still require staff to exercise a higher level of vigilance when undertaking their regular ARC observations; particularly during known high risk periods such as clinical handover and during night shift.
MHJHADS also recognises that inpatient units provide services to older people and that there is a need to balance reducing the risk of ligatures and ligature points against maintaining some fixtures and fittings such as aids to daily living for this group.
Managers need to consider other collateral issues such as staffing levels, staff skill mix, the use of specialling and the level of acuity being experienced on a mental health unit at any time.
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Section 5 – Environmental Safety Checks (ESC)
This procedure incorporates the completion of ESCs (Attachment 2) on all mental health inpatient units to ensure that risks are managed on a shift to shift basis. These checks support the overall intention to keep people as safe as possible from harm.
The purpose of these checks is for staff to observe for any items that could lead to self-harm. As well as prohibited items these checks also assess for ligatures and or ligature points and items such as torn articles of clothing, torn linen/blankets/towels, sharp objects, non-prescription and illicit drugs, drug paraphernalia, cigarettes, tobacco, alcohol, cigarette lighters, knives, plastic bags, glass objects, razor blades and any damage, tampering to fittings and changes in the immediate environment that may increase potential for self-harm and suicide attempt.
While ESCs are completed on a shift to shift basis and opportunistic actions are taken by staff in managing items that can be used for self-harm, these checks need to be well integrated within the overall patient safety, clinical risk and risk management systems.
Completed ESCs are to be utilised at clinical handover as part of the ISBAR staff communication system. They are also an appropriate source of collateral information to inform the clinical risk assessment process and the review of observation levels.
Any risks identified are to be notified to the CNC or the Nurse-In-Charge Shift (NICS), documented in Riskman and in the medical record, and include documentation of action(s) taken to reduce the risk of harm. Information in ESCs needs to be collated by the CNC and used as part of the Unit’s Clinical Governance and risk reporting systems and staff line management system.
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ESCs do not replace or compete with Ligature Risk Management Assessments Audits. Where an environmental check has identified an item(s) that require an extensive ligature and ligature point assessment, the LLPAA tool is then used.
The outcome of ESCs as documented over each six (6) month period should be included in the process to identify the risks to be included in the development of the RRAP.
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Section 6 – Ligature and Ligature Point Assessment Audits
The ADON together with senior members of the unit management team including the Clinical Director (CD), Clinical Nurse Consultant (CNC), Health and Safety Representative (HSR) and any other person relevant to the process must complete a Ligature and Ligature Point Assessment Audit (LLPAA) using the Tool identified at Attachment 3.
The Operational Director and ADON must ensure that an LLPAA is undertaken every six (6) months as a minimum requirement. The audit procedure requires that the audit team physically visits all areas of the unit (both internal and external) accessible by admitted persons.
The areas to be audited include all bedrooms, therapy rooms, activity and recreation rooms, toilets, bathrooms, gardens, courtyards and adjacent public or private areas to which a person may have access. Further, adjacent external areas to the inpatient unit including walking routes and areas where a local search would occur if an ‘at risk person’ was found to be missing are included. Identified risks are to be rated as high, medium or low risk with the outcome of the assessment and analysis of the risk identified agreed upon by the assessment team.
6.1 Ligatures The following examples of ligatures are intended to assist staff and the ligature assessment audit team in the identification of risks.
A ligature can be defined as anything a person can use to constrict blood flow to an area of the body or used to compromise an airway so as to self-strangulate. Ligatures are used either by suspending fully or partially their body for the purpose of suicide by hanging or the constriction of blood flow to a body part.
A ligature can be made from anything that can be used to form a noose that may be tied around the person leading to the closure of an airway or the constriction of blood supply to any part of the body.
An effective ligature does not need to entirely support a person’s full body weight to be effective. It must be noted that the following list of examples is not exhaustive and some of
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these items can be readily repurposed by a person as a means to effect self-harm and suicide.
blind pull cords or chains, draw cords on gown cords, hoodies, tracksuit pants and dressing gowns;
Clothing – shirts, blouses, t-shirts, trousers, leisure wear; Curtains – shower curtains, window curtains, cubicle curtains; Vinyl bed covers; Linen – torn sheets, pillow cases, blankets, towels; Electrical leads (washers, dryers), telephone cable, mobile phone charger leads, head
phone leads, hair dryers, electric bed control cables; Sticky tape and Duct tape Rubber strips from fire doors, rubber dust strips; Coat hangers, cable ties, masking tape, duct tape, string, wool; Shoe and boot laces; Garden hose; and Tumble drier ducting.
6.2 Ligature PointsA ligature point is anything that would support a person’s body weight either entirely or partially allowing the attachment of items from the list of ligatures above to be used for the purposes of constricting a person’s airway and or blood vessels. It should be noted that a knot or noose is not required to achieve the constriction of an airway or a blood vessel.
While it is commonly thought that a ligature point requires a minimum height, the actual height needed can be as little as a few centimeters allowing the person to slump forward or sideways from an almost seated or even prone or supine position. Such a point may include an anchor at floor level (such as a drain cover in a shower area) allowing for a rolling self-strangulation to occur. It must be noted that the following is not an exhaustive list of examples that can be used for the purposes of self-harm and suicide.
Examples of ligature points include: Doors – trapping a ligature between door and frame, particularly at the top; or attaching
a ligature from the top edge of an open door (including wardrobe doors); and door self-closing mechanisms;
Door hinges – either from the hinge itself or that part of a hinge that protrudes from the door frame;
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Handles/ hand rails – bedroom and bathroom door handles, ensuite shower door handles, wardrobe door handles, towel rails, disability rails / grab bars, stair rails;
Ceiling/wall - maintenance access hatch / panel; Curtain tracks and rails, cubical tracking, widow tracking; Windows – trapping a ligature between window and frames, window closer handles,
window opening restrictors, window locks; Pipes – hot and cold water pipes, radiator pipes; Taps, shower roses, sinks, toilets, shower recess floor grates; Wall fittings – fire alarm bells, soap dispensers, paper towel and soap dispensers,
shelves, fire alarm call points, coat hooks, pictures and paintings, mirrors, magnetic locks;
Door hold-backs / hold-open devices, , wall mounted TVs, wall lights, nurse call points; Beds - bed head / headboard, beds upended or propped up on their end / against the
wall, electric beds where the frame or actuating mechanism may be used; Cupboard shelving, coat hooks, clothes racks, drawers; External areas - trees, fencing, gazebos, covered walkways, fire escapes, guttering, rain-
water down pipes, storm water grates; and Walking sticks.
Additional examples of ligatures and ligature points are provided in the LLPAA Tool at Attachment 3.
For inpatient areas, ADONs are also to maintain a list of those items deemed unsafe that are prohibited and not to be brought into the unit by either visitors, contractors or staff. This list is to be posted at the entrance to the Unit in full public view and is to be updated as required. The list is to be reviewed when instances of self-harm or suicide attempt occur as part of the incident investigation process.
This list is also to inform reviews of the ESCs completed on a shift by shift basis.
Any immediate concerns arising from the audit where there are inconsistencies with current policy and procedure; such as the presence of prohibited items; are to be managed by the ADON and the CNC with staff (both clinical and non-clinical) and communicated at staff meetings and clinical handovers.
This may be sufficient to require that a person’s CRA Is reviewed and that a more thorough ligature risk assessment is undertaken using the LLPAA Checklist. As part of this process the SVAT should also be completed (refer to Initial Management, Assessment and Intervention for People Vulnerable to Suicide Procedure).
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The risk presented by any ligatures and/or ligature points must be considered in the context of clinical risk assessment procedures and in the case of an individual’s personal items, these should be removed to a secure environment if they present an unacceptable risk.
The removal of personal items must be based on sound clinical judgement with direct reference to the LLPAA Checklist together with clinical risk assessment and search procedures informing the decision. Any removal of personal items need to be done with due sensitivity and transparency when communicating the decision to a person and their carers and be done consistent with search requirements.
The audit should also be carried out on all new equipment or items purchased or introduced into the care and treatment environment or where the environment or use of an area changes.
LLPAAs must be completed every six (6) months, or whenever changes made to the environment, or after any incident of self-harm that identified an emerging or actual ligature or ligature point risk.
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Section 7 – Risk Assessment and Reduction Action Plans
Any ligatures and ligature points identified during the LLPAA and rated as high by the audit team are to undergo a risk analysis which is to be documented on the ACT Health Risk Assessment Template (Attachment 4).
Based on an analysis of identified individual and grouped risks, appropriate control measures are to be included. The ADON and Operational Director will ensure that once the audit is completed, all agreed high risks are documented and addressed through development of a Risk Reduction Action Plan (RRAP) (Attachment 5).
These plans are developed for identified risks and used to track the completion of the risk reduction strategies adopted within agreed timeframes. ADONs must escalate any identified risks that are unable to be adequately mitigated and managed on the unit to the respective Operational Director and as circumstances dictate to the Clinical and Executive Directors to action and monitor.
Where structural alterations to the environment have been made since the last audit or changes to the clinical environment have occurred, the audit criteria can be revised and the necessary changes made to the FPRM and ESCs.
ADONs must ensure that a ligature risk assessment is undertaken on all new equipment and items obtained and or where the use of the clinical environment changes. The RRAP is also to be updated as required.
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When completed, the risk reduction action plan and the measures to be implemented are to be communicated to all staff (not just clinical staff) working at the unit during staff meetings and clinical handovers. This information should include progress on meeting requirements.The purpose of this procedure is about reducing risk associated with ligatures and ligature points that may enable or provide a person in distress with an opportunity to act upon their thoughts and feelings of self-harm.
It is also important to note that while all risks cannot be completely eliminated, appropriate steps can be taken through the risk reduction action plan to reduce the impact of the risks identified in the clinical environment, so that it can be made safer by collaboration with all those involved in a person’s treatment and care. The following approach to clinical risk is to be adopted in the development of RRAPs:
RemoveThe risk is assessed and it is agreed that if left in place it would put people at risk. The ligature point is removed and the surface finishes made good, as it is no longer required or there is no suitable alternative.
Remove and ReplaceThe risk is assessed and it is agreed that if left in place it would put people at risk. The ligature point is removed and replaced with a specifically designed similar ligature minimised piece of equipment or materials.
Remove and RenewThe risk is assessed and it is agreed that if left in place it would put people at risk. The ligature point is removed and new alternative equipment or materials are installed.
ProtectProvide and install materials that hide and protect a person from a potential ligature point.
ManageThe ligature is assessed and it is agreed that it is impractical or unnecessary to remove’ or there are no other technical solutions’ or it needs to be kept because other risks are even more significant such as the use of a hi-low bed to avoid patient falls.
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Section 8 – Staff Training
Clinical staff will be provided with training in the MHJHADS Ligature Risk Management System, including the use of FPRMs, the completion of the ESCs and the use of the LLPAA Tool.
Implementation of this procedure will occur within each mental health inpatient unit, inclusive of CRA and ARC systems, respective policies and procedures, and the work practice
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and line supervision systems that support them. Training in the use of this procedure will be facilitated through the appropriate CNC in each unit and training records kept.
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Implementation
The Executive Director together with the Chief Psychiatrist and other relevant members of the MHJHADS Executive are responsible for the development of relevant policies and procedures to ensure they comply with relevant standards for the management of ligatures, ligature points and the management and reduction of risk.
This procedure is to be implemented in conjunction with the Operational Procedure for the safe removal of a ligature including ligature cutter use for inpatient mental health units. Both procedures are to be communicated to all staff by the ADON and CNC. New staff will be informed of these procedures during local orientation to the clinical work area and through participation in mental health inpatient inservice programs.
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Related Policies, Procedures, Guidelines and Legislation
Legislation Human Rights Act 2004 Work Health and Safety Act 2011 Mental Health Act 2015 Mental Health (Secure Facilities) Act 2016 Children and Young People Act 2008 Public Advocate Act 2005 Guardian and Management of Property Act 1991 Health Records (Privacy and Access) Act 1997 Carers Recognition Act 2015
Standards National Standards for Mental Health Services 2010 National Safety and Quality Services Standards 2013 National Practice Standards for the Mental Health Workforce 2013 Department of Health National Suicide Prevention Strategy 2015 Australian Charter of Health Care Rights 2008 Standards of Practice for ACT Health Allied Health Professionals
ACT Health Policy and Procedures ACT Health Policy - Searching: Limits to Staff Ability to Search a Consumer’s Person and
Property ACT Health Risk Management Policy and Framework ACT Health Risk Management Guidelines
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ACT Health Policy Work Health and Safety ACT Health Policy Incident Management ACT Health Procedure Incident Management CHHS Clinical Procedure Ligature use in Inpatient Mental Health Units: Response and
Management CHHS Operational Procedure - Initial Management, Assessment and Intervention for
People Vulnerable to Suicide CHHS MHJHADS Standard Operating Procedure - Clinical Handover CHHS - Emergency Department and Mental Health Interface [17/052] CHHS - Dhulwa Mental Health Unit (DMHU): Consumer Observation CHHS-Initial Management, Assessment and Intervention for People Vulnerable to Suicide CHHS- Dhulwa Mental Health Unit; Prohibited and Restricted Items and Items Requiring
Approval CHHS - Searching during Admission to MHJHADS Bed Based Services CHHS -Operational Procedures Adult Mental Health Unit CHHS -Code Blue – Medical Emergency Response for Brian Hennessy Rehabilitation
Centre CHHS Procedure Emergency Response Plans – Code Blue Medical Emergency CHHS Clinical Policy Patient Identification and Procedure Matching CHHS Clinical Policy Dhulwa Mental Health Unit (DMHU) - Use of Force by Authorised
Health Practitioners, Security Officers, Court Security Officers and Escort Officers CHHS Clinical Procedure Dhulwa Mental Health Unit (DMHU) - Use of Force by
Authorised Health Practitioners, Security Officers, Court Security Officers and Escort Officers
CHHS Dhulwa Mental Health Unit: Security Policy and Procedures CHHS Clinical Procedure Care of Adult Patients with Potential Spinal Injury CHHS Operational Procedure Clinical Handover – Mental Health, Justice Health and
Alcohol & Drug Services (MHJHADS) CHHS Operational Procedure Incidents Reportable to the Executive Director and
Intervention Following the Death of a Person – Mental Health, Justice Health and Alcohol and Drug Services (MHJHADS)
CHHS Operational Procedure Mental Health Act 2015 - Notification and Consultation Responsibilities in relation to the Public Advocate of the ACT
CHHS Operational Procedure Justice Health Services (JHS): Duress Alarm and Emergency Response
CHHS Operational Procedure When Death Occurs CHHS Operational Procedure Transport of People Admitted to Mental Health, Justice
Health and Drug and Alcohol Services (MHJHADS) Bed Based Units across the Canberra Hospital Campus
CHHS Clinical Procedure Seclusion of Persons with Mental Illness or Mental Disorder Detained under the Mental Health Act 2015
CHHS Operational Procedure Searching on Admission to Brian Hennessy Rehabilitation Centre
CHHS Policy Restraint of a Person – Adults Only CHHS Operational Procedure Risk escalation and closure
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References
1. West London Mental Health Trust – Ligature Risk Reduction Policy January 20162. Rotherham, Doncaster and South Humber NHS Trust – Suicide Prevention Policy July 3. 20164. South West Yorkshire Partnership NHS Foundation Trust Ligature and Suicide Risk:
Environmental Assessment and Management Policy and Procedure November 2015
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Definition of Terms
Clinical Risk AssessmentClinical Risk Assessment involves assessing the needs of the person receiving care and treatment based on static and dynamic risk inclusive of information about current mental state, history of mental illness, self-harm, substance and alcohol use, personal history, inter personal relationships, recent losses, trauma experienced in their lives, employment, housing issues, their family and social supports.
The collation of information and analysis of this information assists in the identification of potential for self-harming behaviours through the identification of specific risk factors of relevance to an individual, and the context in which they may occur.
This process links historical information to current circumstances, to predict possible future change. Clinical Risk Assessment is a dynamic and ongoing process and should be reviewed on a regular basis, particularly after significant events and prior to changes in the person’s care and treatment plan.
Clinical Risk ManagementClinical Risk Management is the development of one or more flexible strategies that is aimed at preventing an adverse event from occurring or minimising the harm caused. This also includes an action plan which identifies strategies to be implemented and a date for review. It is also the process within the care planning framework that ensures that risks and vulnerabilities for each person are formulated to manage the risks identified through the clinical risk assessment.
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Risk FormulationClinical Risk Formulation is a process in which the clinical team determines how risk might be triggered or become acute. It identifies and describes predisposing, precipitating, perpetuating, protective and prognostic factors, as well as how these interact to produce risk. The formulation should be agreed with the person receiving care and treatment as well as others involved in their care in advance and should take account of information relating to their history and presentation. This will assist in the development of an individualised risk management plan as detailed within the person’s treatment and recovery plan. Risk formulation is informed by tools such as the SVAT.
Floor Plan Risk MapA Floor Plan Risk Map is a visual representation of the workplace that identifies hazard areas. These areas are colour-coded as Red (high), Amber (medium) and Green (low) hazard risk. The Floor Plan Risk Map is developed in collaboration with the Ligature Risk and Ligature Point Audit conducted by the ADON and senior clinicians on the unit. The map is posted for staff to increase awareness for specific risks areas for each inpatient unit. An example of the colour-coded floor plan with corresponding risk zones can be viewed at Attachment 1.
LigatureA ligature can be defined as anything a person can use to form into a noose or tied into a knot for the purpose of closing off the persons airway so as to self-strangulate either by suspending themselves fully or partially or using their body weight either fully or partially for the purpose of suicide by hanging. An effective ligature does not need to be able to entirely support a person’s full body weight to be effective.
A ligature can also be used to wrap around any part of the body to constrict blood flow and compromise the circulation the point whereby the death of tissue can result.
Ligature point or anchor pointA ligature point is any fixture or fitting which is load bearing either entirely or partially that can be used to tie or secure a cord, sheet or other tether that can then be used as a means of self-harm, self-strangulate and in extreme circumstances result in death by suicide.
While it is commonly thought that a ligature point requires a minimum height the actual height needed can be as little as a few centimeters allowing the person to be able to slump forward or sideways from an almost seated or even prone or supine position. Such a point can also include an anchor at floor level such as a drain cover in a shower area.
Anti-Ligature Fittings also known as Reduced Ligature Fittings and Collapsible FittingsThe term means any fitting that is designed in such a way as to prevent a ligature being attached to it, however this does not mean it is not a risk, it is a reduced risk.
These fittings are typically designed to collapse when weight is applied. Although most will collapse under load, anti-ligature fittings may not necessarily collapse under all loads
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imposed on them. An anti-ligature or reduced ligature fitting does not automatically mean no risk. Some items of furniture and other devices manufactured to reduce risk are often called or referred to as anti-ligature.
Anti-ligature devices are to be considered as reduced risk ligature devices. An anti-ligature fitting should cause a ligature to slip off, or the fitting itself should break away from its mount when placed under pressure of weight.
When approved for use, anti-ligature curtain tracking for example should either be the collapsible magnetic type or an approved curtain rail track tested to break away at 15kg or less in accordance with manufacturer’s instructions.
Operational Directors and ADONs should consult with the Health Infrastructure and or the Business Support Services team to establish the full range of anti-ligature devices available on the market for any specific need.
As part of the unit management responsibility all anti/reduced ligature, devices/equipment must be regularly checked and tested as part of the ligature risk management procedure audit on a six monthly basis.
Self-StrangulationAn attempt by an individual to restrict the air entering their own lungs by deliberate constriction of the airway using a ligature.
Unexpected DeathThis is a death that is not expected due to a terminal condition or physical illness.
Attachment 1. Floor Plan Risk Map ExampleAttachment 2. Environmental Safety Check Inpatient Attachment 3. Ligature and Ligature Point Assessment Audit ChecklistAttachment 4. ACT Health Risk Assessment TemplateAttachment 5. Risk Reduction Action Plan
Disclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.
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Policy Team ONLY to complete the following:Date Amended Section Amended Divisional Approval Final Approval 6 Jun 18 New Document Tina Bracher, ED,
MHJHADSCHHS Policy Committee
This document supersedes the following: Document Number Document Name
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Attachment 1 – Zoned Floor Plan Risk Map Example
Low Risk
Medium Risk
High Risk
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Attachment 2 – Environmental Safety Check
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Attachment 3 – Ligature and Ligature Point Assessment Audit Checklist
Mental Health Inpatient Units
Ligature and Ligature Point Assessment Audit Tool Checklist Date: __________
