D267. Safeguarding People Using a Care Service from Suicide by Hanging/Strangulation

Introduction

Most people who kill themselves as in-patients in psychiatric settings do so by hanging, with death in most instances caused by lack of oxygen to the brain (asphyxiation) from strangulation. Men are more likely to use hanging as their suicide method than women. People can also strangle themselves without resorting to hanging. The two strategies are referred to as suspensory or non-suspensory strangulation.

The risks of suicide or attempted suicide by hanging or non-suspensory strangulation are sufficiently high in psychiatric hospitals and related institutions to require detailed policies and procedures to prevent and address the risks of patients killing themselves by hanging / strangulation, which include comprehensive risk assessments of individuals and of their environments, which supply the means by which suicide can be attempted, with risk management plans for those assessed as being at risk.

Most policies issued by NHS and other health care providers go under the titles of “ligature risk prevention”, “ligature risk assessment and management”, or similar.

A “ligature” is the material used to effect self-strangulation such as rope, flex, belt, or anything that can be used to tighten around the throat to restrict the flow of blood and oxygen to the brain.

In suspensory strangulation, to enable throttling, the ligature must be pulled taut by being attached to a weight-bearing device such as a hook placed to allow the body to suspend with the removal of something like a supporting chair or to swing freely. These means are known as “ligature anchor points” and to be effective they do not need to be above head height or waist height, which broadens the scope of the risk assessment.

Suicide or attempted suicide by hanging or non-suspensory strangulation is, of course, not confined to psychiatric settings and can occur anywhere and in different circumstances. Social care providers, including those running care homes for all age groups and service types, supported living and domiciliary care services should also be aware of the possibility and know how to act where there are evident risks of someone killing themself in this way and in any unexpected event.

Aims and Scope of a Policy for Social Care Providers

A “Safeguarding people using a care service from killing themselves by hanging/strangulation” policy therefore potentially applies to all social care services to be implemented where and when there is a need to exercise a duty of care to prevent a person using {{org_field_name}} from harming themself in this way and to act appropriately if one does; taking into account that not all suicides can be prevented. It will clearly be important for social care services for people with or recovering from mental ill-health, where there are clear risks.

The principles used in this policy also reflect the guidance issued by the National Institute for Health and Care Excellence (NICE) with its quality standard QS34 “Self – Harm” (NICE 2013).

The Care Quality Commission has produced guidance (2015, 2018) on inspecting ligature risks for mental health in – patient units and substance abuse services respectively, which suggests that a mental health hospital or special unit provider that does not engage adequately in ligature management processes could be found in breach of Regulations 12 “Safe Care and Treatment”, 15 “Premises and Equipment” (where applicable) and 17 “Good Governance”. There is no statutory requirements for ligature prevention and assessment policies outside these specialist high risk settings.

Nevertheless, the guidance for residential and community substance – abuse services (2018) found on p2 can be applied and is adopted for the purpose of this policy to all social care provision; particularly services for people with past or current mental ill – health or who are recovering from it, and who remain vulnerable to re-occurrence. In brief:

there should be a proportionate response to ligature risks
the response should be based on an assessment of risks for self – harming and suicidal tendencies in general, with particular reference to the risk of attempting suicide by hanging / strangulation
from this assessment and identification of any risk of attempted suicide by hanging / strangulation there should be a comprehensive risk assessment of the person at risk’s environment using ligature risk assessment tools
the result should be a risk assessment plan to keep the person safe
{{org_field_name}} should seek help for the person from mental health services if that help is not already available
there should be an alert made to the local safeguarding team.

Policy Statement

Assessing Risks to People Using {{org_field_name}}

{{org_field_name}} adopts the above principles to assess and manage the risks posed by people who are thought likely or might hang themselves, though it is recognised that not everyone who hangs themself could have been identified as a risk.

The risks will be identified and assessed as part of the comprehensive risk assessments that are carried out with all people using {{org_field_name}}, which will include identifying risks of self-harming in general and the particular methods, which a person using {{org_field_name}} might adopt.

It is recognised that it is difficult to know exactly if and when someone might attempt suicide by hanging as distinct from some other method such as taking a drugs’ overdose, but {{org_field_name}} will take all reasonable steps to discover a person’s intention of adopting this course of action and take the necessary measure to anticipate and prevent it.

The assessment will consider:

the person’s background and any history of self -harming, suicide or mental illness in the family
previous interest in or use of ligatures for self-harming
past and current mental health and well – being
current behaviour including such as (but not exclusively):

having morbid or suicidal thoughts and conversations
expressing hopelessness and without having reason to live
feeling that everyone else would be better off without the person
making suicidal plans, including searching online for possible means and support (and in this context specifically in relation to methods using ligatures)
being in a continuous state of emotional distress: anxiety, anger and/or guilt
drinking too heavily and/or taking drugs
misusing alcohol or drugs
not taking or taking inconsistently prescribed medicines
becoming increasingly withdrawn
being increasingly erratic in daily living – eating, sleeping etc
inability to cope with significant life events such as anniversaries of loved one’s deaths
making preparations for dying, eg, giving away possessions, saying good-byes and making a will.

Risk assessments for people using {{org_field_name}} with the above indicators will be developed with mental health professionals or referred to mental health services if this has not been done already.

The outcome of the risk assessment will be a risk management plan to reduce the likelihood of suicide attempts and specifically with a corresponding environmental risk assessment to make suicide attempts using ligatures less likely.

The risk management plan should include strategies to prevent use of or access to materials, wherever practical or legitimate, that can easily be used as ligatures such as:

belts and braces
boot and shoe laces
strips of clothing, bedding or towels made into potential ligatures
electrical cable flex and leads, including computer cables and mobile chargers
ties, scarves and sarabands
underwear including bra straps
rubber strips from door seals or window surrounds
durable plastic bags such as bin-liners.

It is recognised that in a community setting it might be difficult to control access to such items without a potential breach of people’s human rights. Therefore:

all plans should operate on the least restrictive principle in line with the risk factors involved
made with as much involvement of the person as possible
with contingency plans for intervention of the mental health services if the suicide risks evidently escalate.

Assessing Environmental Risks

{{org_field_name}} sees the purpose of environmental risk assessments and subsequent actions is to reduce the opportunities for a person to hang or strangle themselves by restricting access to usable ligatures and ligature anchor points from which the person can hang.

In line with the principle of proportionality, ligature risk assessments will be carried out only for individuals who are already assessed as being a suicide risk; taking then into account the evidence that death by ligature is a likely method, though other means might also be used, which might need to be similarly assessed.

In a social care setting such as a care home, supported living scheme , in which the person has tenancy rights, and who is being provided with care and support as if in their own home, or someone who is receiving a domiciliary care service, it must be recognised that it will be difficult to apply all the risk assessment and control measures that are recommended or required for specialist mental health institutional environments.

The following list, which is not exhaustive, will typically be made subject to a ligature risk environmental assessment with the exact items depending on the individual circumstances.

Doors including handles, hinges and closures, and windows
Curtain tracks/rails and showers and shower rails, picture rails and hooks
Light fittings and smoke detectors
Bed frames and clothing, and furniture, eg, wardrobes
Trailing cable lamps such as reading or bedside lamps and computer cables
Removable tiles and access to ceilings and walls that might provide ligature anchor points
Sinks, taps and air vents
Pull cords and toilet flushes
Notice boards and pictures
Exposed piping and cabling
Garden areas with trees, alarms, window ledges etc.

All items identified from this list and others that are unlisted could act as ligature anchor points in relation to their potential use by the person at risk.

Wherever possible and practical {{org_field_name}} will consider installing or encouraging the person to have installed recognised “anti – ligature” furnishings and fittings, which will reduce the risks of inappropriate use by, for example, replacing weight-bearing items with non-weight bearing equivalents.

All areas of risk will be assessed, reviewed and modified in the context of an individual’s care and support and risk management plan.

Intrinsic risks in the care environment and service culture that might pose risks to a proportion of the population of people using the service as opposed to the occasional individual will be systematically and regularly assessed with the risk assessments subject to scheduled auditing, from which plans to develop a total service environment that is as risk free as possible for all susceptible people using {{org_field_name}}.

Procedures in the Event of an Incident

{{org_field_name}} recognises that it might have to deal with an event of a person hanging or strangling themselves. This could be an unexpected event, which has occurred without there being any evidence of risk, or because the person has carried out their intentions despite preventive measures having been taken.

Where and when the incident takes place could vary, for example, it could be outside {{org_field_name}} setting. If it takes place within, say the person’s accommodation or in one of {{org_field_name}}’s facilities, it is likely that care service staff will be the first responders, either because they have been alerted by someone or discovered it themselves. In this case the following procedures might apply, though because of the nature of the situation, it is difficult to be entirely prescriptive, and much will depend on the training, confidence and competence in emergency situation handling of the people involved.

Where there is a clear known risk, a lone care worker should always have help available, and where possible there should be a co-worker. There should be the means to summon help immediately using a call system or mobile phone.
{{org_field_name}} should also make available emergency equipment, which can be carried or quickly accessed such as suitable cutting equipment to sever a hanging ligature and a ligature knife that can be used (with training) to remove the ligature from around the neck of part of the body which it is strangling.
Confronted with the sight of a person having hanged or strangled themselves, the care worker (or workers) will (taking into account the shock and the struggle to stay calm and professional) need to make a brief immediate assessment.

a. Is the person hanging or is it strangulation without hanging?
b. In either case, is the person obviously dead showing no vital signs and indications that the person might have been dead for some time? If that is the case there will be no point in doing anything other than calling for help from the duty manager and/or the emergency services to deal with the situation.
c. Is the person still alive and conscious or evidently or possibly still alive but unconscious? Whichever state the person is in time will be of the essence and there might not be enough time to wait for the arrival of the emergency services and the following actions might be taken.

Use if possible any remote advice and guidance from the emergency services by having one’s mobile phone on speaker.
If safe to do so without causing further injury to the person or self, (bearing in mind safe manual handling rules), a person found hanging might be cut down using a suitable cutting instrument, aiming at a point about half way between the anchor point and the head. (Do not attempt this of course if the ligature is a live electric wire). If it is impractical to cut the person down, consider how to support the person’s weight with furniture or even holding them up.
Lie the person on the floor, keeping them still (using suitable methods of restraint if necessary), and if competent from training and confident to do so, use the ligature cutter as instructed to remove the ligature from the neck or elsewhere, making sure that you keep the knot intact as this might be needed for examination by the police. (These manoeuvres would also apply to a non-suspensory strangulation).
In some situations it might be possible to ease the blocked airways by loosening the ligature manually.
Following this, with a person still conscious, keep the person as calm as possible and wait for further help. If the person is unconscious, and while awaiting the emergency services, it is permissible to begin CPR in line with {{org_field_name}}’s first-aid and basic life support protocols. Use any remote advice from the emergency services that can be provided.

After the Event

{{org_field_name}} will ensure that the incident is fully reported and all relevant organisations notified, including the CQC and the local safeguarding authority so that a full investigation can take place to identify what lessons might be learned.

{{org_field_name}} will also ensure that staff who were directly involved and others affected by the event, including people using {{org_field_name}}, receive the appropriate support and counselling opportunities.

Training

In a service where there are evident risks of service-users self-harming to the point to of killing themselves it is considered essential to train staff to deal with all eventualities, including possible suicide by hanging and strangulation.

In respect of this form of self – harming and destruction, staff will be trained in the following aspects, which are reflected in this policy and procedures.

Signs and symptoms of people at risk of committing suicide by hanging, strangulation and other means
Observing and reporting of concerning behaviour, and how to deal appropriately with it
Risk assessments and management planning
Emergency procedures as reflected above, including making on – the spot assessment, and staying calm, and the correct use of emergency tools such as ligature cutters
How to deal with post – traumatic stress arising from the experiencing of disturbing events.

{{org_field_name}} will use or commission active learning methods such as role play and simulation to rehearse the different scenarios with which staff might be confronted and thorough practise in the use of such as ligature cutters.

References

Care Quality Commission Ligature Points Brief Guide for Inspection Teams (2015)

Care Quality Commission Ligature Points Brief Guide for Substance Abuse Services (2018)

Responsible Person: {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}

Reviewed on: {{last_update_date}}

Next review date: this policy is reviewed annually (every 12 months). When needed, this policy is also updated in response to changes in legislation, regulation, best practices, or organisational changes.

D267. Safeguarding People Using a Care Service from Suicide by Hanging/Strangulation