Themes | Mental Health | The Accountability Index

Ligature points

Accessible ligature points in prison cells and mental health wards, posing a risk of self-harm and suicide.

241 items 17 sources 1 inquiry

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Jun 2014 · Cumbria (South & East)

The coroner noted removable bathroom rails created ligature points, staff were unaware they were removable, and an undetected blade was brought onto the ward. Concerns were also raised about fragmented communication preventing an overall view of the patient's escalating condition and the incomplete dissemination of assessments.

Matched on exact phrase terms: ligature, point

Cherylin Norrell-Goldsmith

Oct 2014 · Surrey

The coroner raises concerns about open pipe work in cells as potential ligature points for vulnerable prisoners. Additionally, there are concerns regarding insufficient multi-disciplinary input at ACCT reviews and a lack of accessible recording of significant medical events on non-medical records for prison staff.

Matched on exact phrase terms: ligature, point

Aug 2018 · South Wales Central

The coroner identified insufficient input from outside consultants into the care of mental health patients, delays in rectifying ligature points due to bureaucratic processes, and a lack of effective systems for tracking dangerous items taken from and returned to patients.

Matched on exact phrase terms: ligature, point

Wesley Rowlands

Oct 2020 · Lancashire and Blackburn with Darwen

Redundant television brackets in HMP Garth cells, including the deceased's, remain in place and constitute ligature points. These will continue to be a risk until removed.

Matched on exact phrase terms: ligature, point

David Sutherland

1. SPS should develop a standardised toolkit for auditing cells for the presence of ligature anchor points at HMP Barlinnie and use the toolkit to conduct an audit of potential ligature points within all standard cells. Following from this audit, SPS should take steps to make standard cells at HMP Barlinnie safer by identifying and removing, as far...

Matched on exact phrase terms: ligature, point

1. SPS should take steps to make standard cells at Polmont safer by identifying and removing, as far as reasonably practicable, ligature anchor points present in such cells. In that regard it should: a. Develop a standardised toolkit for auditing cells for the presence of ligature anchor points. This toolkit should, in particular, (i) identify both obvious and...

Matched on exact phrase terms: ligature, point

CQC enforcement action

Warning Notice: Oxleas NHS Foundation Trust

The Care Quality Commission (CQC) served Oxleas NHS Foundation Trust with a warning notice, requiring immediate improvements to its mental health wards for older people. An inspection found out-of-date ligature risk assessments, a lack of clear mitigation for high-risk ligature points, and staff not implementing actions from serious incident investigations. Essential information and action plans were not shared...

Matched on exact phrase terms: ligature, point

Katie Allan; William Brown

1. Double bunk beds should be removed from all cells in any wing or hall within Polmont in which young prisoners are accommodated. SPS must take all necessary measures to ensure that no young prisoner is in future accommodated on a single occupancy basis in a cell in which there is a double bunk bed. 2. All door...

Matched on exact phrase terms: ligature, point

CQC enforcement action

Conditions Imposed: Isle of Wight NHS Trust

Immediately after an inspection, CQC placed conditions on the registration of the trust to minimise the risk of patients being exposed to harm. The trust was required to operate an effective system to prioritise patients needing access to community mental health services. Additionally, an urgent assessment of the physical environment on mental health wards at St Mary’s Hospital...

Matched on exact phrase terms: ligature, point

Oct 2016 · East Riding and Kingston-upon-Hull

The coroner highlighted an incongruity in the 'traffic light' classification of ligature points in psychiatric facilities, where ligatures one metre or less are 'amber' despite posing an extreme risk. It was suggested all such points should be classified as 'red' for urgent elimination.

Matched on exact phrase terms: ligature, point

Weston General Hospital

Take action to address the continuing risks of identified ligature points, particularly non-communal areas.

Matched on exact phrase terms: ligature, point

Not all ligature points had been considered within the environment.

Matched on exact phrase terms: ligature, point

May 2018 · Bedfordshire & Luton

A 'Safer Cell', intended for reduced risk, contained an obvious ligature point due to an inwardly opening window. The coroner suggested design solutions could remove this risk.

Matched on terms: ligature, point

Jul 2022 · Bedfordshire and Luton

The coroner noted that a device forming a ligature point was present in cells on the healthcare wing, including the one where Mr Tamiem died, despite "safer cells" being designed to remove such points. There were no plans to address this identified risk.

Matched on terms: ligature, point

IOPC learning recommendation

Recommendation - Sussex Police, May 2021

The IOPC recommends that Sussex should: a) inform custody officers and staff of the risk of allowing detainees to keep face masks in cells. Such items can be modified to form a ligature which can be used to cause injury to a detainee intent on causing harm to themselves. and b) inform custody officers and staff that the...

Matched on terms: ligature

Dr Sara Lilian Macrae

(i) When staff in a secure mental health ward are presented with evidence that a patient has vocalised suicidal ideation and demonstrated means to complete suicide by presentation of a ligature, urgent action to search that patient’s room and person for any other potential ligatures ought to be taken. In addition, consideration should be given to placing the...

Matched on terms: ligature

Apr 2019 · London Inner (North)

The coroner noted that a door closing mechanism, identified as a ligature point in Mr Goodman's room, was not changed, and the same mechanisms remain in use in other properties managed by One Support.

Matched on terms: ligature, point

Mina Topley-Bird

County Durham and Darlington

Concerns included the electronic notes system's inability to upload PDF medical records and difficulties printing in shared premises. The coroner also noted an incomplete patient safeguarding risk assessment process and unassured ligature point inspections.

Matched on terms: ligature, point

James Paget Hospital

The service must ensure environmental ligature and ligature point risk assessments are completed and actioned.

Matched on terms: ligature, point

IOPC learning recommendation

Investigation into woman’s injury sustained whilst in custody – Metropolitan Police Service, June 2022

The IOPC recommends that the National Police Chiefs Council (NPCC) shares the learning from this IOPC investigation with all force custody leads, asking them to take steps to ensure custody staff understand the ligature risk associated with plimsolls provided to detainees. Where a detainee is assessed as being at current risk of self-harming, any mitigation to the risk...

Matched on terms: ligature

Mar 2015 · Peterborough

The coroner identified that many prison cell doors lack current anti-ligature strips due to no national retrofit programme. There is also an absence of a national pro forma for the ACCT process, leading to over-reliance on current risk assessment.

Matched on terms: ligature

Jun 2021 · West Yorkshire Eastern

HMP Leeds did not have any certified safer cells (anti-ligature cells) at the time of the death and still does not. Even cells with increased safety features do not meet the certified standard, enabling the individual to suspend himself in an ordinary cell.

Matched on terms: ligature

Apr 2022 · Mid Kent and Medway

The coroner noted that older versions of anti-ligature clothing, which the deceased used to form a ligature, remain in circulation and may provide false reassurance to staff regarding self-harm risk, despite subsequent product improvements by the manufacturer.

Matched on terms: ligature

May 2022 · Sefton, St Helens and Knowsley

The coroner noted the absence of statutory requirements or mandatory regulations for fitting ligature alarms in newly built mental health units, and that existing guidance for anti-ligature fixtures is not mandatory.

Matched on terms: ligature

Manchester City

The coroner identified issues with inadequate contemporaneous clinical record-keeping and communication among staff, along with incomplete patient observations and care plans. Further concerns noted patients' access to ligatures, insufficient staff training and supervision, and a lack of clear clinical assessment for repeated self-harm attempts.

Matched on terms: ligature

IOPC learning recommendation

Man died after an attempt to take his own life during a police response – South Wales Police,...

The IOPC recommends that all Police forces should consider equipping all operational police vehicles with some form of implement that would be capable of cutting a ligature of a width greater than a few millimetres. Training should also be given to officers in how and when to use such a piece of equipment. The item of equipment will...

Matched on terms: ligature

IMB recommendation

The Board reiterates the concerns of Dame Anne Owers in her letter of 11 November 2020 to the Director General of Prisons regarding the decision that the making of a ligature by prisoners is no longer a nationally reportable self-harm incident.

Matched on terms: ligature

CQC enforcement action

Warning Notice: Greater Manchester Mental Health NHS Foundation Trust

CQC issued Greater Manchester Mental Health NHS Foundation Trust with a warning notice following an unannounced focused inspection in November at Woodlands Hospital. Inspectors found staff had not completed mandatory training, risk assessments and care plans were not appropriately completed, and people were cared for in unsafe ward environments with issues such as broken furniture, unmitigated ligature risks,...

Matched on terms: ligature

CQC enforcement action

Warning Notice: Devon Partnership NHS Trust

The Care Quality Commission (CQC) told Devon Partnership NHS Trust it must make urgent improvements on Delderfield ward and complete its ligature minimisation work across its acute wards and psychiatric intensive care units. This directive followed an inspection in June 2020 which identified serious concerns regarding patient safety, including risks of self-harm and patient deaths. CQC required the...

Matched on terms: ligature

IOPC learning recommendation

Recommendation - Hampshire Constabulary, November 2020

The IOPC recommends that Hampshire Constabulary should ensure that all custody staff are made aware of the risk of leaving detainees with unsupervised access to cutlery, as such items can be manipulated to cause serious injury to the detainee or others. Hampshire Constabulary should review their custody policies to clarify guidance around the provision of cutlery. Firstly, in...

Matched on terms: ligature

IOPC learning recommendation

National recommendation - National Police Chiefs Council, November 2020

The IOPC recommends that the NPCC ensures that custody staff at all police forces are made aware of the risk of leaving detainees with unsupervised access to cutlery, as such items can be manipulated to cause serious injury to the detainee or others. Custody leads are specifically asked to: a) Note and inform their staff that plastic cutlery...

Matched on terms: ligature

Mar 2014 · Teesside

Inadequate documentation and communication among mental health, healthcare, and prison staff regarding the deceased's condition and self-harm risk were identified. Also noted were insufficient observation, unadministered medication, and deficiencies in CCTV systems and staff training.

Matched on classifier match

Peter Farebrother

Jun 2014 · Shropshire, Telford & Wrekin

Concerns involved delayed patient transfer and staff's non-recognition of constant observation status due to inadequate handover, alongside the return of a ligature risk belt. The report also noted an ineffective sloping door designed to prevent hanging and reduced staff risk awareness on the ward.

Matched on terms: ligature

Dec 2015 · Milton Keynes

The coroner noted repeated issues identified by the PPO regarding the failure to assess risk of self-harm in new prisoners at Woodhill. A specific concern was that nursing staff did not participate in Mr Byrne's health screen or first review.

Matched on classifier match

Mihangel ap Dafydd

May 2016 · Carmarthenshire and Pembrokeshire

The coroner noted that windows in service user areas at Morlais Ward are not ligature-free, and despite plans for this work following a death, it has not yet been undertaken.

Matched on terms: ligature

Francesca Whyatt

Aug 2017 · London Inner (West)

The coroner identified a lack of risk assessment for the East Wing ward's multi-floor layout and insufficient formal guidance on observation competency for agency staff. Further concerns included a lack of clear policy for classifying and investigating ligature incidents as Serious Untoward Incidents.

Matched on terms: ligature

Jan 2020 · West Yorkshire (West)

The jury identified a need for Bradford District Care NHS Foundation Trust to review ligature risks from personal items. Concerns also arose about the design of doors on Oakdale ward, suggesting hinge pin covers.

Matched on terms: ligature

Sep 2019 · Black Country

The coroner identified inconsistent medical note sharing and a lack of a joint care plan between the Mental Health Trust and care home. Insufficient staff training and inadequate self-harm risk management, including observation adherence, were also noted.

Matched on classifier match

Mar 2021 · Birmingham and Solihull

The coroner noted that family concerns about a patient's reported suicide attempt were not recorded, shared, or acted upon, nor included in the MDT meeting. There were also unmitigated ligature risks identified in an en-suite bathroom following an assessment.

Matched on terms: ligature

Corin Bonaparte

May 2021 · Exeter and Greater Devon

An ACCT was not opened despite the patient seeking help from the mental health department at HMP Dartmoor and revealing recent self-harm, suggesting inadequate training; the ambulance was kept waiting 8 minutes at the main gate, suggesting inadequate arrangements for swift ambulance departure in emergencies.

Matched on classifier match

HSSIB recommendation

Mental health inpatient settings: Creating conditions for learning from deaths in mental health inpatient services and when patients...

HSSIB recommends that NHS England, working with other relevant national bodies, develops guidance on how to reduce and respond to non-anchored ligature risks. This will help staff to support people who attempt to hurt themselves with non-anchored ligatures and improve patient safety whilst maintaining a therapeutic environment.

Matched on terms: ligature

Mount Vernon Cancer Centre

The trust must ensure that environmental risk assessments, including ligature risk assessments, are completed and monitored to assess the risk of harm to vulnerable patients.

Matched on terms: ligature

Kettering General Hospital

The service should ensure it introduces a ligature managed and confidential environment for patients experiencing mental health crisis.

Matched on terms: ligature

Ellesmere Port Hospital

The trust must ensure that patients identified with a mental health condition are cared for in a safe ligature free environment and have appropriate risk assessments completed.

Matched on terms: ligature

St Benedict's Hospice

The service must provide appropriate environmental risk assessment and mitigation for the wards of all ligature risks including the use of ligature cutters and staff trained to use these, if required.

Matched on terms: ligature

Durham Diagnostics and Treatment Centre

The service must provide appropriate environmental risk assessment and mitigation for the wards of all ligature risks including the use of ligature cutters and staff trained to use these, if required.

Matched on terms: ligature

Bridlington Hospital

The service should consider having a designated ligature free room in its urgent and emergency care service at Scarborough hospital for patients suffering from mental health illnesses.

Matched on terms: ligature

PPO recommendation

The Head of Custodial Contracts, in conjunction with the MoJ Prison Infrastructure Team and MoJ Property Directorate Technical...

The Head of Custodial Contracts, in conjunction with the MoJ Prison Infrastructure Team and MoJ Property Directorate Technical Standards, should review: • Whether any changes to cell door design are needed. • The frequency of cell door maintenance checks needed to ensure that the anti-ligature features remain effective.

Matched on terms: ligature

CQC enforcement action

Conditions Imposed: Greater Manchester Mental Health NHS Foundation Trust

The Care Quality Commission imposed conditions on Greater Manchester Mental Health NHS Foundation Trust following an unannounced inspection in March 2024. The conditions require the trust to make improvements in specific areas, including effective service management, ensuring a clean, smoke-free environment with suitable cleaning rotas, and providing staff with access to up-to-date ligature risk assessments.

Matched on terms: ligature

CQC enforcement action

Urgent Enforcement Action: Birmingham and Solihull Mental Health NHS Foundation Trust

The Care Quality Commission imposed urgent conditions on the registration of Birmingham and Solihull Mental Health NHS Foundation Trust following focused inspections. Inspectors found several concerns, including ligature risks across services and unsafe storage and transport of medicines. The conditions require the trust to address all ligature risks by 18 June 2021 and implement an effective system to...

Matched on terms: ligature

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