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SOP Title The Use of Ligature Cutters in Mental Health and Learning

Disabilities

NAME TITLE SIGNATURE DATE

Author Rachel Coltart/ Tracy Hammond

Medical Devices and Clinic Lead RC & TH 18th

August 2015

Reviewer

Authoriser

Effective Date:

Review Date:

1. PURPOSE

The purpose of this document is to provide clear guidance on the correct procedures surrounding the use of ligature cutters. This document incorporates the storage, usage and replacement of the cutters.

2. INTRODUCTION

The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (2014) found that Hanging remains the commonest method of suicide in both the general and patient populations. Figures show that deaths by hanging continue to rise. In 2012 there were 2,994 suicides by hanging in the UK, 813 in mental health patients.

3. SCOPE

This procedure applies to all clinical staff in Mental Health and Learning Disabilities who may need to cut or remove a ligature.

4. TRAINING

Staff will receive information and training regarding the use of ligature cutters. Refer to Policy SH CP 150: Assessment and Management of Ligature Care, section 14. Further in-house training will be made available to clinical staff, to practice how to use the entire ligature cutting equipment safely. Training will be received as part of the local area induction package. All staff must familiarise themselves with local arrangements. This is an ongoing professional responsibility regarding access, storage, and replacement.

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5. RESPONSIBILITIES

It is the responsibility of all clinical staff to ensure that they have read the Policy SH CP 150: Assessment and Management of Ligature Care and have completed the on line training and assessment on Ligature Care. The appropriate Service Lead (Clinical Ward Manager/Modern Matron) is responsible for ensuring that all staff have had an opportunity to practice using the ligature equipment. The Clinical Competency Form (Appendix 1) is to be completed and held in the staff members file. It is the responsibility of the Service Lead to ensure that all clinical staff working in their area is aware of the availability, location and have access to the ligature cutters. Agency staff are to be shown how to use the cutters, location of the ligature equipment and how to access the ligature equipment by the Nurse in Charge, as part of their local induction.

6. SPECIFIC PROCEDURE

Ligature cutters are only to be used for ligature purposes or in an emergency situation such as removal of clothing due to a medical emergency. Ligature cutters are specially designed to offer an effective and safe method of cutting a ligature attached to a person.

7. LIGATURE EQUIPMENT

The Trust acknowledges that incidents involving the tying of ligatures may occur despite preventative strategies being in place. Therefore, all wards will have a ligature cutter pack. Procurement information can be found in Appendix 2. The design of the equipment allows for the speedy and relatively safe insertion under the ligature, whilst minimising the risk of secondary injury to the person or staff. The packs should be securely stored in the clinic room on each ward. The packs must be easily accessible with a laminated ligature information sign (Appendix 3) and A6 picture details of the equipment (Appendix 4). The ligature cutters must not be placed in cupboards or drawers, it is important that staff have quick and easy access to the ligature cutters. The ligature equipment (pack) will be held together in a yellow pouch on each. Each ligature pack will contain the following:

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ResQHook: Used for Webbing, Rope, Nylon line, Leather, Electrical flex & Clothing

Tuff Cut Scissors: Used for Used for Clothing, Seat Belts, Leather & Denim

Shark Safety Knife: Used for Strapping, Bubble Wrap, Tape, Rope & Shrink Wrap

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Cable and Wire Cutter: Used for Copper Wire, Brass Wire, Iron wire, Aluminium wire & Steel wire.

Community bases will be issued with a yellow shark safety knife.

8. CHECKS The ligature cutters must be checked in accordance with the frequency of security checks each shift. The checks are to ensure that the seal on the red scissors is in situ and that the pouch contains all four tools. If the seal or any of the tools are missing they must be replaced immediately. Spare seals and tools are to be stored in a place that is accessible to staff, to ensure that the cutters are always available.

9. THE USE OF LIGATURE CUTTERS IN PRACTICE Whilst this guidance cannot replace the need for appropriate staff training relating to ligature cutters, it is important that staff remember the fundamental points for effective response and use. It is essential that staff always retain the cut ligature for later inspection in order to preserve incident evidence e.g. Forensic evidence in the event of a police investigation. The police may request to keep any of the tools after an incident. They will advise if they wish for the tool to be decontaminated or not, due to preservation of evidence. If you find a person with a ligature in-situ, immediately call for assistance by activating your pinpoint alarm, and request the ligature pack and emergency bag. If you find a person with a ligature in-situ and they are in possession of a weapon you must assess whether it is safe to approach the person or not. Further guidance surrounding weapons can be found in the Security and Management of Violence and Aggression Policy and the Management of Violence and Aggression Procedure.

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It is also important to check the area for any hazards such as glass, water or electricity if the person has used a power cord as a ligature and make the area safe before the person is approached. Do not cut through a power cord if it is plugged into a socket.

10. RESPONSE TO FINDING SOMEONE WITH A LIGATURE Call for assistance immediately and if required, request for an ambulance to attend. Support the person’s body weight (if safe to do so) as soon as possible, to release the tension on the ligature. A person does not need to be suspended or clear of the floor to be using a ligature. Keep the body weight supported and/or the tension off the ligature until the ligature has been cut. Always attempt resuscitation in line with Trust Policy SH CP 30 - Medical Emergencies and Resuscitation Policy. In situations where the person resists staff attempts to remove the ligature, it may be necessary for staff to use appropriate physical intervention. It is expected that staff will employ techniques to help ensure the safe removal of the ligature. Every incident involving the use of a ligature cutter should be recorded on RiO and an incident form completed. The nature of an incident of this type should prompt staff to comply with other Trust polices and guidelines as appropriate e.g. The Immediate Management Report and requirement of Critical Incident Stress Management de-brief. Staff must complete Appendix 5 and ensure that all appropriate procedures have been followed and completed.

11. AFTER USE Staff must make immediate arrangements for replacement. The used ligature cutter must be returned to the Medical Device Lead or Clinical Lead in a safe manner, if it is not required by the Police, for checking and/ or disposal of. In the event that the blade is contaminated during use staff must check with the Nurse in Charge or Police first, before it is decontaminated.

12. PRESERVING FORENSIC EVIDENCE

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If the person is subsequently pronounced dead - Southern Health Foundation Trust SH CP 146: Care of a Patient after their Death Procedure, must be followed. The police will treat any such death as ‘unexplained’ and potentially a crime scene until proved otherwise. Do not touch or disturb the area or other evidence until the police give permission (apart from essential actions required to make the area immediately safe for service users). Do not cut or untie the other end attached to the ligature point, to preserve forensic evidence. Make accurate written records and witness statements as soon as possible after the event.

13. INTERNAL AND EXTERNAL REFERENCES

13.1 Internal References/Further Reading

SH CP 30 - Medical Emergencies and Resuscitation Policy SH CP 145 - Care of a Patient after their Death Policy SH CP 146 - Care of a Patient after their Death Procedure SH CP 150 - Assessment and Management of Ligature Points Policy SH CP 151 - Assessment and management of Ligature Points Procedure SH NCP 22 - Security and Management of Violence and Aggression Policy SH NCP 23 - Management of Violence and Aggression Procedure

13.2 External References The University of Manchester (2014) The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness Annual Report, University of Manchester, Manchester.

14. CHANGE HISTORY

SOP no. Effective

Date Significant Changes

Changes made by

Through-out

17/08/2015 Procedure reviewed and updated throughout. Rachel Coltart

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Appendix One

Clinical Competency for MEDICAL DEVICES

Name

Role:

Base:

Date initial training completed:

Medical Device Document Relates To

(this document can also be completed as a training guide and template) Competency Statement: The participant must perform this activity without assistance and/or direct supervision (level 3) for level descriptors see end. This document is a self-assessment for registered practitioners. Non registered staff should be signed off by a registered practitioner competent to Level 4. Line managers must have final sign off for all staff.

Performance Criteria Assessment Method

Level achieved

Date Assessor/self assessed

The Participant will be able to: Verbal Questioning /

Demonstration

1. Understand what the device is

to be used.

2. Has read and / or viewed any manufacturers materials relating to the medical device

3. Demonstrates an understanding of the specifications of the device

4. Shows understanding and competency in setting up the device correctly

5. Understands any safety features on the device and the rationale for them being there.

6. Understands the difference between models and the effects this may have on safety and function of the device

7. How to set the controls on the device appropriately

8. Recognise and malfunction or error from the device and take appropriate action

9. An awareness of the reliance that should be placed on the device to perform it’s required task.

10) An understanding of how the device produces results and the reliance that should be placed

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Performance Criteria Assessment Method

Level achieved

Date Assessor/self assessed

on these.

11) An understanding of the safety features available on the device and the level of reliance that should be placed on them.

12) Demonstrates safe practice by ensuring they double check both the patient and the device.

13) Demonstrates and understanding of and appropriately sets and uses any alarms.

14) Able to discuss any potential problems that may arise from the device as well as any likely /potential causes of failure

15) Able to monitor and check safe functioning of the device as per manufacturers guidance

16) Able to recognise when the device has failed

17) Able to recognise any common faults in the use of the device

18) Appropriately consults manufacturer’s instructions or seeks guidance when required

19) Is able to dissemble and reassemble (including accessories) for safe decontamination of the device

20) Is able to decontaminate / clean the device as appropriate

21) Demonstrates understanding of optimal storage of the device

22) Able to report any concerns relating to the use of the device

23) When and how to obtain assistance or advice

Date all elements of Competency Tool completed to level 3 ________

I confirm that I am competent to use this named piece of equipment Name ______________Signature ______________Status___________ Date _______

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I confirm that I have assessed the above named person and can verify that he/she demonstrates competency in using the named medical device Verifier / Manager ____________________________Signature _____________________ Status________________________________ Date _______________________

Levels of competency Rating Scale

Level of achievement Level Novice Cannot perform this activity satisfactorily to the level required in

order to participate in the clinical environment 0

Can perform this activity but not without constant supervision and assistance

1

Can perform this activity with a basic understanding of theory and practice principles, but requires some supervision and assistance

2

Competent Practitioner

Can perform this activity with understanding of theory and practice principles without assistance and/or direct supervision

3

Can perform this activity with understanding of theory and practice principles without assistance and/or direct supervision, at an appropriate pace and adhering to evidence based practice At this level competence will have been maintained for at least 6 months and/or is used frequently (2-3 times /week) The practitioner will demonstrate confidence and proficiency and show fluency and dexterity in practice This is the minimum level required to be able to assess practitioners as competent

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Can perform this activity with understanding of theory and practice principles without assistance and/or direct supervision, at an appropriate pace and adhering to evidence based practice. At this level the practitioner will be able to adapt knowledge and skill to special/ novel situations where there may be increased levels of complexity and/or risk

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Expert Can perform this activity with understanding of theory and practice principles without assistance and/or direct supervision, at an appropriate pace and adhering to evidence based practice. Demonstrate initiative and adaptability to special problem

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Review

Dates:

Competent

Yes / No

Registered

Nurse Signature

Verifier signature Comments

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situations, and can lead others in performing this activity At this level the practitioner is able to co-ordinate, lead and assess others who are assessing competence. Ideally they will have a teaching and /or mentor qualification

Adapted from: Herman GD, Kenyon RJ (1987) Competency-Based Vocational Education. A Case Study,

Shaftsbury, FEU, Blackmore Press, cited in Fearon, M. (1998) Assessment and measurement of competence in practice, Nursing Standard 12(22), pp43-47

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Appendix Two – Procurement information for Inpatient Units

Items in the ligature packs are to be ordered through Oracle. All of the items

required have been added to the catalogue to make ordering easier.

Item Description Search Term Price Yellow Storage Pouch Pouches £4.95

7.5” Utility Scissors Utility £7.50 Seals for Scissors Spring-lok £16.95

Spare blades for Shark Knife

Shark £3.00

Black Shark Safety Knife Black Shark £7.30

Res’Q’Hook Knife Resqhook £44.95 Cable/Wire Cutters 68891 £10.84

The search term has been included to make it easier to find the equipment you

wish to purchase. The prices are correct at the time of writing (February 2015).

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Appendix Two (cont) – Procurement information for Community Bases

It has been agreed that Community Bases will each have a yellow

‘tamperproof’ Shark Safety Knife.

Item Description Search Term Price Shark Safety Knife Yellow shark £8.00

The Yellow Safety Knife is single use only and is to be disposed of appropriately

when used.

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Appendix Three –

LIGATURE CUTTERS

EMERGENCY USE

ONLY

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Appendix Four –

ResQHook: Used for Webbing,

Rope, Nylon line, Leather, Electrical flex & Clothing

Tuff Cut Scissors: Used for Used for

Clothing, Seat Belts, Leather & Denim

Shark Safety Knife: Used for

Strapping, Bubble Wrap, Tape, Rope & Shrink Wrap

Cable and Wire Cutter: Used for

Copper Wire, Brass Wire, Iron wire, Aluminium wire & Steel wire.

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Appendix Five

LIGATURE PROCEDURE CHECKLIST

Name: Date:

Date of Birth

NHS Number: RiO Number:

Date of Ligature Incident:

Completed Date Time Signature and Designation

In the Event of a Medical Emergency ie Patient not Responding, Presenting Unconscious, Not Breathing, No Pulse Detected (this is not an exhaustive list) Emergency Services to be Contacted: Ambulance. Always Attempt Resuscitation in line with Trust Policy SH CP 30 - Medical Emergencies and Resuscitation Policy

If the Patient is Subsequently Pronounced Dead by an Approved Doctor / Paramedic: Southern Health Foundation Trust SH CP 146: Care of a Patient after their Death Procedure, must be followed and Forensic Evidence is Preserved

Physical Observations Taken

Incident Form Completed (Grading of incident to be discussed with Nurse in

Charge) Ref no –

Parents / Nearest Relative Informed

Incident and physical observations

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documented on RiO

Ligature Site / Area Assessed and treated (if required)

Doctor informed (if necessary)

Nurse In Charge Notified

Senior Nurse On Call Informed (if necessary) Out of Hours

Level of Risk Assessed and Recorded on RiO

Risk Assessment Updated

Ligature Care Plan Implemented and / or Updated

Observation Levels Reviewed and Recorded on RiO

Consideration of change of Room / Location

Debrief Provided to Patient and Recorded on RiO

Debrief Provided to Staff Involved in the Incident

Used Ligature Cutters Replaced with a New Set

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Appendix Six – Ligature Flowchart