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{{org_field_name}}

Registration Number: {{org_field_registration_no}}

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Preventing Suicide by Hanging and Strangulation Policy

1. Purpose

The purpose of this policy is to ensure that {{org_field_name}} adopts a proactive, preventative, person-centred and safeguarding-focused approach to identifying, assessing, managing and reducing the risk of suicide, self-harm, hanging and strangulation among people living at the care home.

{{org_field_name}} recognises that ligature-related harm may involve everyday personal possessions, furniture, fixtures, fittings, equipment or other features within the care home environment. The service will take all reasonably practicable steps to identify and reduce foreseeable risks while respecting each person’s dignity, autonomy, rights, preferences and individual circumstances.

Risk management under this policy must be based on individual assessment and must not involve blanket restrictions. Any restriction must have a clear and documented rationale, must be necessary and proportionate to the identified risk and must be the least restrictive practicable option.

This policy supports compliance with:

• the Health and Social Care Act 2008;
• the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, including:
  • Regulation 9 – Person-centred care;
  • Regulation 11 – Need for consent;
  • Regulation 12 – Safe care and treatment;
  • Regulation 13 – Safeguarding service users from abuse and improper treatment;
  • Regulation 17 – Good governance;
  • Regulation 18 – Staffing; and
  • Regulation 20 – Duty of candour;
• the Care Quality Commission (Registration) Regulations 2009, including statutory notification requirements;
• the Mental Capacity Act 2005, including the Deprivation of Liberty Safeguards where applicable;
• the Mental Health Act 1983 where applicable; and
• applicable safeguarding duties under the Care Act 2014.

2. Scope

This policy applies to all employees, agency workers, bank staff, volunteers and managers who provide, manage or support the delivery of care at {{org_field_name}}.

It applies to all people living at the care home where there is an identified, suspected or emerging risk of suicide, self-harm, hanging or strangulation, including where a ligature or ligature anchor point may present a foreseeable risk.

The policy covers:

• identification of individual risk factors and warning signs;
• assessment and management of environmental ligature risks within the care home;
• person-centred risk assessment and safety planning;
• consent and mental capacity;
• proportionate and lawful use of restrictive measures where these are necessary to prevent harm;
• staff competence and emergency response;
• recording, reporting and escalation of concerns;
• liaison with health, mental health and safeguarding professionals;
• review following incidents or significant changes in risk; and
• statutory notifications and organisational learning.

Risk assessment and care planning must be individualised. A diagnosis, disability, mental health condition or previous behaviour must not, by itself, result in automatic or blanket restrictions.

3. Related Policies

• CH07 – Person-Centred Care Policy
• CH13 – Safeguarding Adults from Abuse and Improper Treatment Policy
• CH18 – Risk Management and Assessment Policy
• CH19 – Emergency and Business Continuity Plan
• CH27 – Staff Supervision, Training, and Development Policy
• CH39 – Mental Capacity and Deprivation of Liberty Safeguards Policy
• CH40 – Assisting with Personal Care Policy

4. Identifying Risk Factors

Staff must be trained to recognise risk factors associated with suicide by hanging or strangulation. These include a history of self-harm, previous suicide attempts, mental illness (such as depression, psychosis, personality disorder), substance misuse, bereavement, isolation, or trauma. Environmental risks may include access to belts, cords, curtain ties, dressing gown ropes, shower hoses, or stair railings. Emotional or behavioural signs such as withdrawal, hopelessness, mood changes, giving away possessions, or verbal expressions of suicidal ideation must be taken seriously. A person-centred risk assessment must be completed at the outset of support and reviewed regularly or following any trigger event.

5. Risk Assessment and Individual Safety Planning

Where suicide, self-harm, hanging or strangulation risk is identified or reasonably suspected, an individual and documented risk assessment must be completed by a suitably competent person.

The assessment must consider, where relevant:

• previous self-harm or suicide attempts;
• current or previous suicidal thoughts, plans or expressed intentions;
• recent changes in mental state, behaviour or circumstances;
• known triggers and protective factors;
• relevant physical and mental health conditions;
• alcohol or substance misuse;
• recent bereavement, trauma, loss, distress or significant life events;
• access to potential ligatures;
• access to potential ligature anchor points;
• risks associated with the person’s bedroom, bathroom, toilet and other areas where privacy is normally expected;
• clothing, personal possessions, mobility equipment, beds and other equipment where relevant;
• the person’s communication needs;
• the person’s wishes and preferences;
• the level of observation, engagement or support required; and
• information received from relevant health professionals, family members, representatives or other agencies where it is lawful and appropriate to consider that information.

Where a significant risk is identified, a personalised safety and risk-management plan must be developed and incorporated into the person’s care plan. The plan must identify:

• known triggers and warning signs;
• agreed coping and safety strategies;
• action staff must take if risk increases;
• environmental measures required;
• appropriate levels of support, observation or engagement;
• emergency contact arrangements;
• relevant health and mental health professionals;
• arrangements for escalation and urgent review; and
• any restriction that has been assessed as necessary.

Any proposed restriction, including removal or controlled access to personal possessions, increased observation, limits on access to particular areas or other measures restricting the person’s freedom, must be individually justified. Staff must obtain valid consent where the person has capacity to make the relevant decision.

Where there is reason to doubt the person’s capacity to make a specific decision, capacity must be assessed in accordance with the Mental Capacity Act 2005. If the person lacks capacity for that particular decision, any action taken on their behalf must be in their best interests and must be the least restrictive practicable option.

Risk assessments and safety plans must be reviewed whenever there is a change in the person’s needs, mental state, behaviour, circumstances or level of risk, following an incident or attempted self-harm, following relevant hospital treatment or discharge, and whenever information is received that may materially affect the assessment.

All assessments, decisions, consultations, actions, reviews and reasons for restrictive measures must be recorded accurately and contemporaneously in accordance with Regulation 17.

6. Care Home Environment and Ligature Risk Management

{{org_field_name}} must assess and manage foreseeable environmental risks associated with hanging and strangulation within the care home. Environmental risk assessment must be proportionate to the needs and characteristics of the people using the service and must be reviewed where individual or environmental risks change.

Potential risks may include, but are not limited to:

• cords, cables and flexible tubing;
• window blind or curtain cords;
• belts, dressing gown cords, scarves and similar personal items;
• shower hoses;
• bed frames and specialist or profiling beds;
• grab rails, handles and rails;
• doors, door furniture and door closers;
• windows and window furniture;
• hooks, brackets and suspended fixtures;
• furniture and fittings;
• mobility or clinical equipment; and
• other objects or structures capable of acting as a ligature or ligature anchor point.

Particular attention must be given to areas where a person may spend time in private, including bedrooms, en-suite facilities, bathrooms and toilets, where this is relevant to the assessed risk.

Environmental assessment does not replace individual risk assessment. The presence of a potential ligature point does not automatically require its removal, and blanket restrictions must not be imposed solely because a possible risk exists. Measures must be based upon the actual and reasonably foreseeable risk to individual people.

Where action is necessary, measures may include:

• removing or modifying an identified environmental hazard;
• replacing an item with a safer alternative;
• modifying fixtures or fittings;
• restricting access to particular items where lawfully justified;
• increasing therapeutic engagement, observation or supervision;
• seeking specialist clinical or mental health advice; or
• using other measures identified through individual risk assessment.

Where the person has capacity to decide about a proposed measure affecting their care, possessions or freedom, their valid consent must be sought.

Where there is reason to doubt capacity, staff must assess capacity in relation to the specific decision in accordance with the Mental Capacity Act 2005. A person must not be treated as lacking capacity merely because they have a mental health condition, have previously self-harmed, make a decision that staff consider unwise or are considered to be at risk.

Where the person lacks capacity for the relevant decision, any action taken must be in their best interests and must be the least restrictive practicable option. Any restraint must be reasonably believed to be necessary to prevent harm and must be a proportionate response to the likelihood and seriousness of that harm.

Staff must not remove, withhold or control a person’s possessions merely because this is considered convenient or precautionary. Any restriction must have a documented, individual rationale and be subject to regular review.

In a genuine emergency where immediate action is required to prevent death or serious harm, staff must take only the minimum intervention reasonably necessary to protect the person and others, seek emergency assistance as required and ensure that the intervention and its justification are documented and promptly reviewed.

Where the overall care arrangements may amount to a deprivation of liberty, the Registered Manager must ensure that the circumstances are considered in accordance with the Mental Capacity Act 2005, Article 5 of the European Convention on Human Rights and current case law. Following the Supreme Court judgment of 2 June 2026, the assessment of whether arrangements amount to a deprivation of liberty must be made on an individual, multifactorial basis, considering the nature, duration, effects and manner of implementation of the restrictions and the person’s wishes, feelings and any objection.

Where there is doubt as to whether arrangements amount to a deprivation of liberty, or whether lawful authority is required, the Registered Manager must seek appropriate advice and make a referral to the local authority for consideration under the Deprivation of Liberty Safeguards where applicable. Any deprivation of liberty must have lawful authority.

7. Staff Training and Awareness

Staff must receive training, supervision and support appropriate to their role so that they can identify and respond safely to suicide, self-harm, hanging and strangulation risks.

Training relevant to staff responsibilities must include:

• recognition and escalation of suicide and self-harm risk;
• ligature and strangulation risk awareness;
• environmental risk identification;
• person-centred risk assessment and safety planning;
• safeguarding;
• emergency response and first aid appropriate to the staff member’s role;
• de-escalation and supportive communication;
• consent and the Mental Capacity Act 2005;
• lawful and proportionate use of restrictive practices;
• recognition of circumstances that may amount to a deprivation of liberty;
• the current legal approach to deprivation of liberty, including the effect of the Supreme Court judgment of 2 June 2026; and
• recording and reporting requirements.

Managers must ensure that staff competence is assessed and that additional training, supervision or support is provided where gaps in knowledge or competence are identified.

Staff must understand that restrictive measures must not be used as a substitute for appropriate staffing, person-centred care, therapeutic engagement or effective risk assessment.

Training records, competency assessments and relevant supervision records must be maintained.

8. Monitoring Mental Health and Wellbeing

Staff must monitor the emotional wellbeing of people we support and respond sensitively to changes in mood, behaviour, or mental state. All observations and concerns must be recorded clearly in care notes and reported to the Registered Manager or Safeguarding Lead immediately. Staff should initiate wellbeing conversations routinely and encourage individuals to share their feelings. We also promote access to mental health professionals, counselling services, and crisis helplines. Where appropriate, staff assist with appointments, medication adherence, or referrals to local services. Documentation must include all efforts made to support emotional and psychological wellbeing.

9. Multi-Agency Working and Safeguarding

Suicide prevention and the management of serious self-harm risk may require coordinated working between {{org_field_name}} and relevant health, mental health, emergency and safeguarding services.

Depending on the individual circumstances, relevant agencies and professionals may include:

• the person’s GP;
• Community Mental Health Teams;
• crisis resolution or home treatment teams;
• local NHS mental health services;
• the local authority adult safeguarding service, where safeguarding criteria are met;
• Approved Mental Health Professionals;
• ambulance services;
• police, where their involvement is necessary;
• hospital services; and
• other relevant professionals involved in the person’s care.

Where there is an immediate or life-threatening risk, staff must not wait for routine referrals or safeguarding processes before seeking emergency assistance. Emergency services must be contacted where required.

Where there are concerns that the person is experiencing or is at risk of abuse, neglect or improper treatment, these must be reported and acted upon in accordance with CH13 – Safeguarding Adults from Abuse and Improper Treatment Policy and applicable safeguarding duties.

A person’s lack of mental capacity does not, by itself, provide grounds for detention or assessment under the Mental Health Act 1983. Where staff believe that an urgent mental health assessment may be required because of the person’s mental disorder, presentation and level of risk, appropriate mental health professionals or emergency services must be contacted so that the need for assessment under the Mental Health Act 1983 can be considered by those with the relevant statutory functions.

Mental Capacity Act 2005 processes and Mental Health Act 1983 processes must be applied according to their respective legal requirements and must not be treated as interchangeable.

All referrals, professional advice, decisions, actions and outcomes must be accurately documented in the person’s records.

10. Incident Response and Emergency Action

If a staff member finds a person who is attempting, or appears to have attempted, hanging or strangulation, or who is otherwise experiencing a life-threatening self-harm emergency, the staff member must respond immediately.

Staff must:

• call 999 without delay where there is an immediate threat to life or serious injury;
• take immediate action within the limits of their training and competence to remove or reduce the immediate danger;
• release the person from a ligature where this can be done safely;
• commence and continue appropriate first aid or resuscitation in accordance with their training until emergency services take over;
• ensure that the person is not left alone where there remains an immediate risk of further serious harm, unless remaining would place the staff member or others at serious risk;
• follow instructions given by emergency services;
• inform the Registered Manager or the most senior manager available as soon as practicable;
• preserve relevant information and evidence following a serious incident where this can be done without interfering with emergency care;
• make a factual, accurate and contemporaneous record of the incident and the actions taken; and
• ensure that relevant care plans and risk assessments are urgently reviewed.

Following an incident, the Registered Manager must determine what notifications and referrals are legally required.

Where a person using the service dies in circumstances falling within Regulation 16 of the Care Quality Commission (Registration) Regulations 2009, the Care Quality Commission must be notified without delay using the required notification process.

Where an injury or other incident meets the criteria in Regulation 18 of the Care Quality Commission (Registration) Regulations 2009, the Care Quality Commission must be notified without delay as required by that regulation.

Any required safeguarding referral must also be made, and other relevant agencies must be informed where there is a legal or safeguarding requirement to do so.

The person’s family, representative or relevant person must be informed where this is appropriate and lawful, taking account of the person’s consent, confidentiality, mental capacity, any applicable legal authority and any safeguarding risk.

Following the immediate response, {{org_field_name}} must review the incident to identify:

• whether known risks had been appropriately assessed;
• whether care plans and risk controls were being followed;
• whether environmental risks contributed;
• whether staffing, communication or training issues contributed;
• whether professional advice or escalation was appropriate;
• whether further protective measures are required; and
• what learning and improvement actions are necessary.

Actions arising from the review must be recorded, allocated and monitored to completion.

11. Family, Representative and Carer Involvement

Where the person has capacity to decide whether information about their care and risks may be shared with family members or carers, the person’s wishes and valid consent must be respected, subject to any lawful exception to confidentiality.

Where consent is given, family members, carers or other people chosen by the person should, where appropriate, be involved in safety planning and provided with information relevant to their role, including:

• warning signs or changes that should be reported;
• agreed actions to reduce risk;
• how to obtain urgent or emergency assistance; and
• relevant professional or support contacts.

Where there is reason to doubt the person’s capacity to make a specific decision about care, information sharing or involvement of others, capacity must be assessed in accordance with the Mental Capacity Act 2005.

Where the person lacks capacity for the particular decision, decisions must be made in accordance with the Mental Capacity Act 2005 and in the person’s best interests. So far as practicable and appropriate, those making a best-interests decision must take account of the person’s past and present wishes and feelings, beliefs and values and consult appropriate people identified by, caring for, or interested in the person’s welfare.

A family member or carer must not be treated as having legal authority to consent on behalf of an adult solely because of their relationship with the person. Where a person holds a relevant health and welfare Lasting Power of Attorney or has been appointed as a deputy by the Court of Protection, staff must establish the scope of that person’s legal authority before relying on their decision.

All significant discussions, consent decisions, capacity assessments, best-interests decisions and information-sharing decisions must be documented.

12. Duty of Candour and Learning from Incidents

{{org_field_name}} will act in an open and transparent manner with people using the service and relevant persons in relation to care and treatment, in accordance with Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Following an incident, the Registered Manager must consider whether the circumstances meet the statutory definition of a notifiable safety incident under Regulation 20.

Where an incident meets the statutory definition of a notifiable safety incident, {{org_field_name}} must follow the Duty of Candour procedure required by Regulation 20. This includes:

• notifying the relevant person as soon as reasonably practicable;
• providing a truthful account of all facts known at that time;
• explaining what further enquiries or investigations are considered appropriate;
• providing reasonable support to the relevant person;
• offering an apology;
• providing the required notification in writing;
• providing the results of further enquiries where required; and
• keeping the required records and copies of correspondence.

The Duty of Candour requirements are separate from the duty to submit statutory notifications to the Care Quality Commission. The Registered Manager must therefore consider both requirements independently.

A near miss does not automatically constitute a notifiable safety incident for the purposes of Regulation 20. However, near misses and other incidents must still be reviewed where they identify a risk to safety or an opportunity to improve care.

Following any suicide, suicide attempt, ligature incident or significant near miss, the service must review relevant systems and practice. This must include, where appropriate:

• the person’s care plan and risk assessments;
• environmental risk assessments;
• staff actions and escalation;
• staffing and competency;
• communication between professionals and agencies;
• the effectiveness of existing risk controls; and
• whether organisational changes are required.

Learning and improvement actions must be documented, communicated to relevant staff and monitored to ensure they are implemented.

13. Efficient Risk Management at {{org_field_name}}

{{org_field_name}} prevents suicide risks through:

• Thorough individual and environmental risk assessments
• Robust multidisciplinary communication and safeguarding escalation
• Routine supervision and staff mental health briefings
• Partnership with mental health services and crisis teams
• Real-time monitoring and follow-up after hospital discharges or critical events
• Assigning a named mental health liaison within the service

Our approach ensures we are always aware, always alert, and always responsive to emerging risks.

14. Policy Review

This policy will be reviewed at least annually and sooner where required following:

• a serious incident, suicide, suicide attempt or significant near miss;
• an identified failure or weakness in existing risk controls;
• a safeguarding incident or significant safeguarding learning;
• changes to legislation or regulations;
• relevant changes in case law;
• updated CQC requirements or guidance;
• updated national guidance relevant to suicide, self-harm or ligature risk; or
• organisational learning indicating that the policy or associated procedures require amendment.

The Registered Manager is responsible for ensuring that changes affecting legal or regulatory requirements are incorporated into this policy and communicated to relevant staff without unnecessary delay.

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Responsible Person: {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}
Reviewed on: {{last_update_date}}
Next Review Date: {{next_review_date}}
Copyright © {{current_year}} – {{org_field_name}}. All rights reserved.