Helen Millard

Evidence was heard that NHS England is undertaking an ongoing programme of work to eliminate ligature points in in-patient and other psychiatric facilities_ It was established that "traffic light' system is in operation which prioritises the work once ligature has been identified in any particular facility. The Court heard that if a is scored red' this equates with an extreme risk and mandates urgent elimination of the point: If however; risk is categorised as amber' this nevertheless represents high risk: The classification according to this traffic light system is based upon the height of the ligature from the If ligature is one metre Or less it is categorised as amber' whereas if it is over one metre above the it is categorised as 'red . Expert evidence was adduced from number of expert witnesses and Consultant Psychiatrists that at least 50% of deaths due to hanging in inpatient psychiatric facilities occur from ligature which are one metre or less in height above the Patients merely need to learn forward and tighten the ligature around their neck under their body weight and collapse into unconsciousness within ten to twenty seconds and death can occur in as little as two to three minutes This evidence was backed up by peer reviewed literature which was also read out during the course of the Inquest principal concern is that there is an obvious incongruity in the classification system as effectively all ligature points, no matter what their height; should be regarded as representing extreme risks. Evidence was heard that the risk is independent of height and consideration needs to be given to classifying all ligature once identified as 'red' and their elimination tackled on an urgent basis. point point point ground. point ground being ground. points they My points