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CHHS18/187

Canberra Hospital and Health Services Clinical ProcedureLigature use in Inpatient Mental Health Units: Response and ManagementContents

Contents....................................................................................................................................1

Purpose.....................................................................................................................................2

Alerts.........................................................................................................................................2

Scope........................................................................................................................................ 2

Section 1 – Background.............................................................................................................2

Section 2 – Roles and Responsibilities......................................................................................3

Section 3 – Initial Response......................................................................................................3

Section 4 – Ligature Cutter Use.................................................................................................4

Section 5 – Types of Self-Strangulation and Ligature Removal Procedures..............................6

Section 6 – Post Incident Actions............................................................................................10

Section 7 – Documentation.....................................................................................................12

Section 8 – Support for Staff, Consumers, Carers and Others Present....................................12

Section 9 – Staff Training........................................................................................................ 12

Section 10 – Ligature Cutter Care Protocol.............................................................................13

Implementation...................................................................................................................... 14

Related Policies, Procedures, Guidelines and Legislation.......................................................14

References.............................................................................................................................. 16

Definition of Terms................................................................................................................. 16

Search Terms.......................................................................................................................... 18

Attachments............................................................................................................................18

Attachment 1 Guide To Ligature Cutter Use.......................................................................20

Doc Number Version Issued Review Date Area Responsible PageCHHS18/187 1.0 02/07/2018 01/07/2019 MHJHADS 1 of 20

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

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Purpose

The purpose of this procedure is to inform staff of action to be taken and their responsibilities for the safe removal of a ligature if first on the scene at a self-strangulation, including the safe use, storage and maintenance of ligature cutters should they need to be used in an emergency within Mental Health Justice Health and Alcohol and Drug Services (MHJHADS) inpatient mental health units.

Alerts

In the event of self-strangulation, staff must immediately call for assistance from other unit staff, including directing a staff member to call a medical emergency and implement Code Blue procedures.

A patient with a self-strangulation injury must be treated as a suspected spinal injury and a compromised airway assumed.

Scope

This procedure applies to all clinical and non-clinical staff working in MHJHADS inpatient mental health units. The role of non-clinical staff extends to situations where they may be first on scene when a self-strangulation occurs. Once an emergency response has been activated non-clinical staff are not required to take part in the direct patient-care responses but may be asked to assist with other tasks

Section 1 – Background

Despite risk assessments and work practices to ensure the safety and wellbeing of people admitted to MHJHADS inpatient units for treatment and care, situations may arise where a person attempts serious self-harm using a ligature. This may occur either by securing a ligature around the neck and attempting to suspend themselves from a ligature point or it may be by tightening a ligature around the neck to obstruct the airway and circulation.

Ligatures can also be used to constrict the blood supply to other parts of the body in order to self-harm.

These situations carry the risk of serious injury or death and require an immediate response to ensure the preservation of life. In these emergencies a ligature cutter will be required. Clinical staff must have a clear understanding of the procedure, be familiar with the emergency response required, and receive training in the use of the ligature cutter and the post ligature management of a person who has attempted self-strangulation or the constriction of blood flow to a body part.



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Back to Table of Contents

Section 2 – Roles and Responsibilities

Assistant Directors of Nursing (ADONs) are responsible for ensuring adherence to this procedure and to ensure: Clinical and non-clinical staff are aware of their role should an emergency response be

required. That clinical staff have read and understand this procedure. Clinicians have access to training in the use and maintenance of ligature cutters. All staff know where ligature cutters are kept and spare cutters are stored. Preserving potential forensic evidence.

Clinical Nurse Consultants (CNCs) are responsible for ensuring: Staff have read and are able to implement the procedure. Appropriate training is provided to clinicians involved in an emergency response inclusive

of the use of a ligature cutter. Support and supervision is provided for staff in the event the ligature cutter is used. All documentation is completed should self-strangulation occur. The procedures for keeping, storage, location, usage and maintenance of ligature cutters

are followed. Preserving potential forensic evidence. Consumers, visitors and contractors who may have been exposed to a self-strangulation

are provided with support.

Clinicians are responsible for ensuring: This procedure is understood and followed. They attend training in ligature cutter use and maintain knowledge and skills relating to

the use of ligature cutters is maintained. Awareness of the location of the ligature cutter in their inpatient unit.

Non-clinical staff are responsible for: Immediately notifying and alerting clinical staff in the event a person has self-harmed.


Section 3 – Initial Response

In the event of self-strangulation, emergency Code Blue procedures are to be followed by staff. Clinicians must be aware of the location of the person who has self- strangulated and note what the ligature is made of (for example rope, elastic or electrical cable) as this may effect the emergency response.

As part of the initial response clinicians must assess the situation to ensure their own safety before entering a location where a person has applied a ligature for the purposes of self-strangulation. In these situations the DRSABC protocol is to be followed.



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DangerResponseSend for help (activate MET response)AirwayBreathingCPRDefibrillation

3.1 Initial Response Risk Assessment ConsiderationsAssessment of the situation should include consideration of the following: Staff must be familiar with the emergency door release mechanisms in each unit as part of

their unit orientation. Clinicians must be aware of the location of the person who has self-strangulated, the type

of self-strangulation (Refer Sections 5-8), the ligature point and what the ligature is made of, for example rope, elastic or electrical cable as this will inform the emergency response.

A dynamic risk assessment safe manual handling principles and techniques will need to take into account the body weight of the person and the type of manual handling required to support the person’s body weight and as far as possible maintain in-line support of the neck, head and spine as the individual is lowered to the floor.

Clinicians will need to assess for other risks in the location including bodily fluids, sharps and/or other items that may cause harm and not attempt any technique that creates unnecessary risk.

To reduce the level of immediate distress, a staff member should where possible ensure that other persons in the area such as visitors and non-essential staff are directed away from the area and out of direct line of sight.


Section 4 – Ligature Cutter Use

A ligature cutter is a purpose designed tool that is able to cut through material such as shoe laces, string, clothing, linen, headphone cable, phone charger cable and similar items. More effort and time will be required to cut through tougher material such as leather and electrical cable.

Figure 1: Ligature cutter used in MHJHADS (not to scale)



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4.1 Method of Use-An OverviewIn order to prepare a ligature cutter for use refer to the procedures outlined in Attachment 1.

Once prepared for use, the position the ligature cutter by placing the rounded and blunt end of the blade flat against the person’s skin so the blade can be positioned under the ligature.It is only the inner curve of the blade that has a cutting edge.

Once the ligature cutter has been inserted between the person’s body and the ligature, the cutter blade is to be turned up so the sharp edge of the blade faces the ligature and away from the person. Clinicians must then use a rocking or sawing motion so the blade cuts through the ligature material.

When cutting a ligature, clinicians should where possible avoid cutting through the knot itself as this will make removal more difficult and it may be required for forensic investigation.

When a ligature is located around a person’s neck, the cut must be made if possible at the side of the neck as the natural soft tissue and hollows of the neck may facilitate easier insertion of the cutter.

Once the ligature has been cut, clinicians should support the person’s head and neck as much as possible while maintaining manual inline stabilisation of the head and neck as the person is lowered to the ground in a supine position to prevent any additional spinal damage that may have occurred.

Once a ligature cutter has been used it must be immediately replaced with a new one and stored either on the emergency trolley or, in a designated location readily known and accessible to clinical staff.




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Section 5 – Types of Self-Strangulation and Ligature Removal Procedures

There are four main types of self-strangulation.5.1 Unconscious Suspended Self-Strangulation5.2 Conscious Suspended Self-Strangulation5.3 Laying Unconscious and Conscious Self-Strangulation5.4 Ligature Use to Constrict Blood Flow to a Body Part

Each requires an individual approach both to assessment of the situation and any attendant risks. Procedures for each type of self-strangulation including constriction of blood flow to a body part as detailed at 5.1 to 5.4 on the following pages.

5.1 Unconscious Self-Suspended StrangulationWhen a person has been found unconscious in a suspended position of self-strangulation, an Emergency Code Blue response is to be activated and interventions commenced as soon as it is assessed as being safe to do so.

When a person is suspended from a ligature point at height the priority is the release of pressure on the neck and the removal of the ligature.

Where possible the person’s upper torso and head should be supported. This will reduce any pulling on the airway while cutting and reduce further airway trauma that may occur if inserting the ligature cutter from the front or back of the neck.

If supporting the person’s upper torso and head is not possible and a dynamic risk assessment indicates that it is needed then the ligature should be cut at a central point located between the person’s neck and the ligature point. With staff supporting the weight of the lower half of the person they should then be lowered to the floor paying attention to in-line support for the head and neck.

5.1.1 Cutting the ligatureWhere the person’s bodyweight can be supported the person should be elevated toward the ligature point to take the pressure off the ligature reducing further airway compromise by taking a secure hold around the thighs or hips to reduce the tension on the ligature.The ligature is then removed using the ligature cutter at a point that is distant from the knot.

Where the person is unconscious clinicians are to implement appropriate Basic Life Support (BLS) and airway management techniques until the arrival of the Medical Emergency Team(MET) or the ACT Ambulance Service (ACTAS) where an assessment for laryngeal injury will be made.



Note: DO NOT pull on the ligature to remove it as there is a risk the ligature will tighten and further compromise the person’s airway.

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5.1.2 Preserving potential forensic evidence The ligature and ligature cutter is to be retained in the event that forensic analysis is

required by Police. If any remains of the ligature are attached to a ligature point, this is not to be removed

until appropriate authorisation from the ADON or Operational Director or Director on Call out of hours.

5.1.3 Reporting requirements The incident is to be reported to the Operations Director and after hours and Public

Holidays the Director on call. The incident should be recorded in Riskman as soon as practicable after the incident. The CNC or NICs should be advised that new ligature cutter is required from spare stock

kept on the Unit.

5.2 Conscious Self-Suspended StrangulationWhen a person has been found conscious and is attempting to suspend themselves for the purposes of self-strangulation an Emergency Code Blue response is to be activated and interventions commenced as soon as it is assessed as being safe to do so.

The priority is the release of pressure on the neck and the removal of the ligature and to not exacerbate the situation.

Where the person resists staff interventions to remove a ligature, it may be appropriate for staff to restrict or restrain the person’s ability to struggle further, especially if their ability to struggle increases the risk presented by the ligature or the clinician’s use of a ligature cutter.

In situations where the person is resisting intervention, clinicians must use appropriate Professional Assault Response Training (PART) approved holding skills and ensure the following: not adding weight to the ligature being aware of and sensitive to the person’s airway needs. remaining alert to the need to limit the possibility of spinal injury.

5.2.1 Cutting the ligatureThe ligature should be cut at a central point located between the person’s neck and the ligature point to avoid further strangulation risk in the event of a struggle. The person should then be placed on the floor and the ligature removed in a safe manner paying attention to in line support for the head and neck.



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Once the conscious person has been lowered, airway management techniques should be applied until the arrival of the Medical Emergency Team (MET) or the Ambulance. An assessment for laryngeal injury is to be made as soon as possible.

5.2.2 Preserving potential forensic evidence In the event of a self-strangulation the ligature and ligature cutter is to be retained in the

event forensic analysis is required by Police. If any remains of the ligature are attached to a ligature point, this is not to be removed



Holidays the Director on call. The incident should be recorded in Riskman as soon as practicable after the incident,

including details of any restraint used. Where restraint has been used, the appropriate notifications and documentation are to be

made by clinical staff, including on the Restraint Register. The CNC or NICs should be advised that new ligature cutter is required from spare stock

kept on the Unit.

5.3 Lying, Kneeling Or Sitting Self-Strangulation - Unconscious And ConsciousWhen a person has been found conscious or unconscious and is attempting a self-strangulation in a lying, kneeling or sitting position an Emergency Code Blue response is to be activated and interventions commenced when assessed as being safe to do so.

The intervention priority is the release of pressure on the neck and the removal of the ligature as soon as it has been assessed as safe to do and not to exacerbate the situation.

Where the person resists staff interventions to remove a ligature, it may be appropriate for staff to restrict or restrain the person’s ability to struggle further, especially if their ability to struggle increases the risk presented by the ligature or to the clinician’s use of a ligature cutter.

In such situations, clinicians must use appropriate PART approved holding skills and ensure the following: not adding weight to the ligature being mindful not to further constrict the airway while the interventions to remove the

ligature occur. remaining alert to the need to limit the possibility of spinal injury.





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5.3.1 Cutting the ligatureThis will be assisted by sliding the person toward the ligature point to reduce the tension on the airway before removal. The ligature must then be removed using the ligature cutter in a safe manner.If conscious, clinicians must support the person and employ airway management techniques and be ready to implement appropriate BLS should this be required until the arrival of more advanced interventions. An assessment for laryngeal injury is to be made as soon as possible.

Where the person is unconscious clinicians are to implement appropriate BLS and airway management techniques until the arrival of the MET or the ACTAS. An assessment for laryngeal injury also needs to be made as soon as possible.

5.3.2 Preserving potential forensic evidence The ligature and ligature cutter is to be retained in the event forensic analysis is required

by Police. If any remains of the ligature are attached to a ligature point, this is not to be removed






kept on the Unit.

5.4 Ligature Use To Constrict Blood Flow To A Body PartAlthough rare, individuals may engage in this type of behaviour resulting in loss of circulation and in extreme situations death of tissue. Should acts of self-harm of this nature occur the priority is the release of pressure on body part and the removal of the ligature so as not to exacerbate the situation.

Where a person has been found to have used a ligature to constrict blood supply to a part of the body an Emergency Code Blue response may need to activated and interventions commenced when assessed as being safe to do so.

In circumstances where the person resists interventions to remove a ligature, it may be appropriate, based on a dynamic risk assessment, for staff to restrict the person’s ability to struggle further.



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5.4.1 Removing the ligatureThe nature of the type of ligature used and the body part to which it has been applied will inform the means of removal. The appropriateness of the use of a ligature cutter will then need to be determined as these are not designed for small digits.

When it is clear that the ligature cannot be removed, or a margin of safety for its removal agreed and/or the person is unable to attend the nearest Emergency Department, then an Emergency Code Blue should be called for inpatient units at the Canberra Hospital, or Emergency Services if the situation warrants.

For units located off the Canberra Hospital campus the appropriate medical emergency code should be called and/or Emergency Services if the situation warrants.

The person should be made as comfortable and kept safe as possible pending the arrival of these services.

5.4.2 Preserving potential forensic evidence Where a ligature is removed the ligature and ligature cutter or other instruments used are

to be retained in the event forensic analysis is required by Police. If any remains of the ligature are attached to a ligature point, this is not to be removed






kept on the Unit.


Section 6 – Post Incident Actions

6.1 Reporting RequirementsCritical incident notifications are to be made by the ADON or by the Nurse in Charge of Shift (NICS) to the Police and to the Operational Director and/or the Operational Director on Call.

The incident must also be reported in Riskman, including the Staff Accident Incident Reporting (SAIR) module where applicable.

Nominated Next of Kin, medical staff and the treating Psychiatrist must also be notified.



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Consumers, visitors and contractors who may have been exposed to a self-strangulation are provided with support.

6.2 Preservation of potential forensic evidenceClinicians involved in the emergency response must retain both the ligature cutter that was used and the ligature itself for later inspection and use by Police. If any remains of the ligature are attached to a ligature point, this is not to be removed until appropriate authorisation from the ADON or Operational Director or Director on Call out of hours.

In the event of injury or fatality, these items will form part of a forensic investigation and will be provided to the police. Once returned at a later date by police, the ligature cutter must be decontaminated and sent for sharpening.

In the event of a fatality, the area in which the self-strangulation has occurred is as far as possible, to be removed from operational use and all of its contents must not be touched or moved. The area is to be secured and no further entry allowed until the Police have arrived.

6.3 Clinical Review and Clinical Risk AssessmentFor persons who are conscious following an attempted self-strangulation a Clinical Review and Clinical Risk Assessment (CRA) must be undertaken and led by a Psychiatrist.

If the incident occurs out of hours the Psychiatrist on call must attend and review the At Risk Category (ARC) observation level and complete a Suicide Vulnerability Assessment Tool (SVAT). Refer to Initial Management, Assessment and Intervention for People Vulnerable to Suicide procedure.

For persons who are not an inpatients at the Adult Mental Health Unit (AHMU) the CRA should include consideration to the need for transfer to the Canberra Hospital (CH).

Where the person is a current inpatient at AHMU and, following medical clearance, is assessed as being suitable for continued care and treatment on the unit, the suitability of the High Dependency Unit (HDU) or Low Dependency Unit (LDU) for the person must be reviewed.

All decisions taken must inform a review of the person’s care plan, and all such changes and relevant information must be documented and conveyed to clinical staff as part of the clinical handover process.

6.4 Ligature and Ligature Point Risk Assessment AuditThe ADON and Operational Director are to undertake any further actions to prevent a recurrence inclusive of a full unit wide Ligature and Ligature Point Risk Assessment Audit using the Audit Checklist Tool.

On completion documented changes are then to be made to the Unit Ligature and Ligature Point Risk Reduction Action Plan.



http://inhealth/PPR/Policy%20and%20Plans%20Register/Initial%20Management,%20Assessment%20and%20Intervention%20for%20People%20Vulnerable%20to%20Suicide.docx

http://inhealth/PPR/Policy%20and%20Plans%20Register/Initial%20Management,%20Assessment%20and%20Intervention%20for%20People%20Vulnerable%20to%20Suicide.docx

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Section 7 – Documentation

All incidents of self-strangulation must be recorded in the person’s electronic medical record as well as in Riskman.Documentation must include any injuries sustained by the person as a result of a ligature cutter being used, as a result of the act itself and/or through the lowering of the person to the floor.

Documentation is also to include notification to police, relatives, carers, nominated person as well as other statutory, serious incident and other line management reporting requirements.

Any injuries to staff must be documented in a Staff Accident Injury Report (SAIR).


Section 8 – Support for Staff, Consumers, Carers and Others Present

All members of staff, consumers, carers and others present are to be offered the opportunity to access and engage with supportive services through the ADON and CNC.

The ADON and CNC should provide all clinicians and non-clinical staff involved with the opportunity to review the incident including their roles and emotions relating to what has occurred via debriefing and access to EAP services.


Section 9 – Staff Training

Non-clinical staff will be provided with training consistent with their potential role in initiating a response if they are first on scene. Clinical staff will be provided with training in the use of ligature cutters and the implementation of an emergency response under this procedure as part of each inpatient units Code Blue response system to emergency situations. Training in the use of the ligature cutter will be facilitated though the CNC and should be consistent with Basic Life Support (BLS) training.




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Section 10 – Ligature Cutter Care Protocol

10.1 CheckingLigature cutter checks (inclusive of the spare) are to be undertaken at the same time that emergency trolley checks are undertaken.

10.2 Storage of Ligature CuttersLigature cutters are to be kept in a designated central place made readily known and accessible to clinical staff for use in an emergency.

The ligature cutter is never to be taken from its designated location except to use as intended.

In the event a ligature cutter is used it must be retained for potential forensic evidence and replaced with a new replacement cutter immediately after use.Additional ligature cutters are to be kept stored on each unit by the ADON in a location that is readily accessible and made known to staff but not accessible or visible to persons who are being assessed or admitted to the unit.

10.3 Cleaning of Ligature CuttersThe ligature cutter is classed as a multi-patient use device and therefore must be disinfected after each use however when a ligature cutter is to be held pending an investigation process by Police and cleaning MUST NOT occur until such times as permission has been given to do so by the ADON.

Once made available for cleaning the ligature cutter should be cleaned of any body fluids and debris prior to being sent for sharpening. During the cleaning process universal safety precautions are to be used. The ligature cutter is placed in the open position on a paper towel on a firm and flat surface. The cutter is to be held by the handle and tweezers to hold the alcohol wipe, clean the exposed blade then turn the cutter over and repeat the process. The handle then can be cleaned as required.

10.4 Sharpening of Ligature CuttersAs an important safety device that depends on its sharpness the cutter must be sharpened after each use. It is the responsibility of the ADON and CNC to ensure the cutter remains sharp and fit for purpose. Ligature cutters that have been used and are no longer needed to be retained for forensic evidence are to be sent for sharpening to Canberra Hospital Sterilising Services. The ligature cutter should be cleaned of any body fluids and debris prior to being sent for sharpening.




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Implementation

This procedure is to be implemented in combination with the Operational Procedure for Ligature Risk Management for Mental Health, Justice Health and Alcohol and Drug Services’ Inpatient Mental Health Units.

The ADON and CNC in each mental health inpatient unit are responsible for implementing this procedure and for ensuring it is communicated to all staff and for new staff during their unit based local orientation to the clinical work area.


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 ACT Health Policy Work Health and Safety ACT Health Policy Incident Management ACT Health Procedure Incident Management Canberra Hospital and Health Services Clinical Procedure-Ligature Risk Management for

Mental Health, Justice Health and Alcohol and Drug Services’ Inpatient Mental Health Units.



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Canberra Hospital and Health Services Operational Procedure: Ligature Risk Management for Mental Health, Justice Health and Alcohol & Drug Services Inpatient Mental Health Units

Canberra Hospital and Health Services Adult Mental Health Unit Operational Procedures Adult Mental Health Unit

Canberra Hospital and Health Services BHRC Code Blue – Medical Emergency Response for Brian Hennessy Rehabilitation Centre

Canberra Hospital and Health Services MHJHADS Standard Operating Procedure – Clinical Handover

Canberra Hospital and Health Services Operational Procedure - Clinical Handover – Mental Health, Justice Health and Alcohol & Drug Services (MHJHADS)

Canberra Hospital and Health Services Clinical Procedure- Care of Adult Patients with Potential Spinal Injury

Canberra Hospital and Health Services Dhulwa Mental Health Unit (DMHU) Consumer Observation

Canberra Hospital and Health Services Dhulwa Mental Health Unit; Prohibited and Restricted Items and Items Requiring Approval

Canberra Hospital and Health Services Clinical Policy Dhulwa Mental Health Unit (DMHU) - Use of Force by Authorised Health Practitioners, Security Officers, Court Security Officers and Escort Officers

Canberra Hospital and Health Services Clinical Procedure Dhulwa Mental Health Unit (DMHU) - Use of Force by Authorised Health Practitioners, Security Officers, Court Security Officers and Escort Officers

Canberra Hospital and Health Services Dhulwa Mental Health Unit: Security Policy and Procedures

Canberra Hospital and Health Services Operational Procedure -Justice Health Services (JHS): Duress Alarm and Emergency Response

Canberra Hospital and Health Services -Emergency Department and Mental Health Interface

Canberra Hospital and Health Services Procedure - Emergency Response Plans – Code Blue Medical Emergency

Canberra Hospital and Health Services 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)

Canberra Hospital and Health Services -Initial Management, Assessment and Intervention for People Vulnerable to Suicide

Canberra Hospital and Health Services Operational Procedure- Mental Health Act 2015- Notification and Consultation Responsibilities in relation to the Public Advocate of the ACT

Canberra Hospital and Health Services Clinical Policy - Patient Identification and Procedure Matching

Canberra Hospital and Health Services Policy - Restraint of a Person – Adults Only Canberra Hospital and Health Services Operational Procedure - Risk Escalation and Closure Canberra Hospital and Health Services - Searching during Admission to MHJHADS Bed

Based Services



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Canberra Hospital and Health Services Clinical Procedure - Seclusion of Persons with Mental Illness or Mental Disorder Detained under the Mental Health Act 2015

Canberra Hospital and Health Services Operational Procedure - Searching on Admission to Brian Hennessy Rehabilitation Centre

Canberra Hospital and Health Services 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

Canberra Hospital and Health Services Operational Procedure - When Death Occurs


References

1. NHS Northamptonshire Foundation Trust – Procedure for the safe use of Ligature Cutters April 2017

2. NHS South Staffordshire and Shropshire – Ligature Risk Assessment Standard Operating Procedure April 2017

3. NHS West London Mental Health Ligature Risk Reduction Policy and Procedure November 2015


Definition of Terms

Ligature CutterA multi patient use device issued by MHJHADS which is a purpose specific implement used to cut ligatures that must not be used for any other purpose than responding a code blue medical emergency situation.

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.

It must be noted that the following list of examples is not exhaustive and some of these items can be readily repurposed by a person as a means to effect self-harm and suicide.



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Examples include: Clothing accessories - belts, braces, laces, stockings, pantyhose, tights, bras, garment

elastic, neck ties, scarves, hair ties Medical products - theraband, compression stockings, bandages, tubing Plastic bags – carrier bags, rubbish bags, clinical waste bags. Cords – curtain pull cords, cord from curtains, draw cord on linen bags, vertical/venetian

blind pull cords or chains, draw cords on gown cords, hoodies, tracksuit pants and dressing gowns.

Clothing – shirts, blouses, t-shirts, trousers, leisure wear, Jewelry - necklaces, rings, bracelets Curtains – shower curtains, window curtains, cubicle curtains. Vinyl bed covers Linen – torn sheets, pillow cases, blankets, towels Electrical leads (washers, dryers), telephone flex, mobile phone charger leads, head phone

leads, hair dryers, electric bed control cables Rubber strips from fire doors, rubber dust strips Coat hangers, cable ties, masking tape, duct tape, string, wool Shoe and boot laces Garden hose Tumble drier ducting

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.

It must be noted that the following list of examples is not an exhaustive of the things that can be used for the purposes of self-harm and suicide.

Examples 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 (this has been used with wardrobe doors); using door self-closing mechanisms.

Door hinges – either from the hinges themselves or from the part of the hinge that protrudes from the door

Handles/ hand rails – bedroom door handles, ensuite door handles, wardrobe door handles, toilet, shower and bathroom door handles, towel rails, disability rails / grab bars, stair rails

Ceiling fittings –false ceilings, lights, air vents, diffusers, smoke detectors, extractor grills Ceiling/wall - maintenance access hatch / panel



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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, key cabinets, wall mounted TV’s, 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 can 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 Walking sticks

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.


Search Terms

Ligature, ligature audit, ligature management, ligature points, self-harm, self-strangulation, suicide, hanging


Attachments

Attachment 1 – Guide to Ligature Cutter Use



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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.

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 Guide To Ligature Cutter Use

Opening The Ligature Cutter And Preparing For UseTo prepare the ligature cutter for use, take it out of its pouch when required and hold the handle firmly in one hand and then follow the procedures outlined below. With the free hand, grip the accessible part of the metal blade between your fingers and

gently pull this away from the handle until the blade clicks into place, fully extended. In this position, the ligature cutter is ready to be used. Under no circumstances should the cutting edge be touched. To minimise risk of injury to staff/others, the period of time that the Ligature Cutter is in

an open and ready to use position must be kept to a minimum.

Closing The Ligature Cutter After UseTo close the ligature cutter after it has been used the following procedures should be followed. Push/squeeze the release-point with one hand, whilst the other hand gently pushes the

blunt edge of the blade forward for a centimetre. This unlocks the ligature cutter from its fully extended position.

Next, ensure the hand/fingers holding the ligature cutter are doing so around the top/bottom of the cutter next to the release-point.

Check that no fingers of this hand are at the side of the ligature cutter where the cutting blade is to be folded.

Once this has been confirmed, push the cutting blade back to its ‘closed’ position. Ensure that the ligature cutter and ligature are retained for possible forensic analysis.

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ligature use in inpatient mental health units: …€¦ · web viewchhs18/187 doc number version...

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