Rotherham Doncaster and South Humber NHS Foundation Trust policy for ligature risk reduction (superseding the previous suicide prevention policy).
The purpose of this policy is to outline the responsibility and arrangements that the trust undertakes to control the presence of ligatures and anchor points across all inpatient and community facilities under the control of the trust, accessed by mental health, learning disability, section 136 suite, older persons and other patients.
There are other areas that are not covered by this policy such as physical rehabilitation wards and the hospice. These areas should undertake annual health and safety inspections as part of the on-going management of health and safety. There will be occasions where a person is admitted who has mental health needs but whose physical health needs outweigh their mental health needs. In these circumstances, these services should consider using observations in line with the supportive therapeutic observation policy.
For those patients who are part of the residential drug and alcohol service, their ligature risk assessments will be done in line with the Care Quality Commission (CQC) 2016 guidance on ligature risks in substance misuse services.
To access or download this policy please follow the link. This link is only accessible to trust staff:
To access the equality impact assessment for this policy, please email rdash.equalityanddiversity@nhs.net to request the document.
This policy should be used in conjunction with the suicide prevention strategy.
Page last reviewed: April 30, 2024
Next review due: April 30, 2025