Ligature Risk Reduction Supports for Mental Health Services

In line with best practice and to support staff in providing safe and effective mental health services, HSE Mental Health Services has developed a Guidance on the Development and Implementation of a Ligature Risk Reduction Policy and Audit Tool and a Ligature Risk Reduction Audit Tool template.

Guidance on the Development and Implementation of a Ligature Risk Reduction Policy and Audit Tool

The purpose of the Guidance on the Development and Implementation of a Ligature Risk Reduction Policy and Audit Tool is to support mental health services to develop their own Ligature Risk-Reduction Policy in line with best practice. A Ligature Risk Reduction Policy and Audit tool will contribute to preventing suicides and self-harm in mental health approved centres by reducing, minimising or removing any ligature anchor points within the approved centre. 

This policy and audit tool will also assist approved centres to be compliant with the Mental Health Act 2001 (Approved Centres) Regulations 2006, Regulations 22 (Premises) and 32 (Risk Management Procedures). Developed in partnership with staff and approved centres in the mental health services, this guidance is an iteration of the CHO 1 Ligature Anchor Point Risk Reduction Policy. Part B of this guidance can be used as a template to develop a localised policy by substituting policy for guidance where appropriate.

Ligature Risk Reduction Audit Tool template

Mental Health Services have also developed a Ligature Risk Reduction Audit Tool template adapted from the CHO1 audit tool developed by Georgina Morrow, QPS manager CHO1 Primary Care Services which is built around the Manchester Tool approach. This approach grades ligature anchor points based on four factors. The four factors are:

  • Room Designation Rating
  • Patient Profile Rating
  • Ligature Anchor Point Height Rating
  • Compensatory Factor Rating

The consistent use of this Ligature Risk Reduction Audit tool will lead to a standardised approach to ligature risk reduction in mental health services. The Explanatory Guidance for the Ligature Risk-Reduction Audit Tool provides a step by step explanation on the use of the tool.