The UK’s ‘obsession’ with ligature risk in psychiatric facilities was again highlighted as speakers at this year’s Design in Mental Health Annual Conference called for a fresh approach to safety which focuses more on creating therapeutic healing environments.

While ligature risk is still a major driver in the design of mental health facilities; architects, trust managers, and service users themselves were united in their belief that a better balance could be struck between protecting people in crisis and creating more-supportive facilities in which to deliver care.

Are you OK?

The conference heard from James Leadbitter, the creator of Madlove: A Designer Asylum, a long-term project that blends research, design, building, and exhibitions to reimagine mental health support and the environments this support happens in.

What we need are human beings, not doors, cameras and safety glass. It’s someone to ask if you’re OK

His team recently created a temporary mental health space in the heart of Liverpool, which was purposely designed with no anti-ligature products.

Leadbitter said: “Whatever we do we are not going to design self-harm out of mental health settings, so we believe it is more important to ask someone ‘are you OK?’

“We are not going to design out all risk. It will always be there.

“We need to start talking about safety in terms of feelings and we need to be smart about where we are directing resources. What we need are human beings, not doors and cameras and safety glass. It’s someone to ask if you’re OK.”

And the message, it seems, is getting through, with a number of forward-thinking trusts beginning to reconsider the widespread use of anti-ligature products.

The Dorset Approach

Among these is Dorset HealthCare University NHS Foundation Trust, which has adapted the commonly-used Manchester Ligature Audit Tool in what they call The Dorset Approach.

Steve Harper, the trust’s head of health and safety, said: “Due to human ingenuity, or the lack of a technical solution, it might not always be possible for every ligature point to be removed.

“Instead, we identify all likely points through a process of environmental risk assessments, then provide an opinion about the likelihood of the item being utilised as a ligature point.”

But he admitted that ligature management and patient safety still ‘keeps me up at night’.

Under its innovative risk assessment process, the trust allocates a red, amber, green (RAG) warning to each area within a building. It also looks at all recorded incidents by room type.

These documents are accessible to all and are not solely focused on inpatient mental health wards, but also community assets.

“The Dorset Approach incorporates good health and safety to identify hazards room by room,” explained Harper.

Due to human ingenuity, or the lack of a technical solution, it might not always be possible for every ligature point to be removed

“We have signs on doors showing if areas are off limits, semi-private, or freely accessible; and we do room checks and encourage our staff to report anything they see, such as damage to the environment.

“We take photographs looking for areas that may have been targeted and we train our domestic staff, so we are taking some of this work away from clinicians.

“And we include ligature training in our staff inductions.”

A home from home

By taking this approach, he said, the need for so many anti-ligature fixtures and fittings can be reduced, and environments made more homely.

The trust’s capital projects manager, Kerri Howlett, added: “We have been able to standardise a lot of our reduced-ligature fixtures and now have a standard components schedule of preferred products that we have developed in collaboration with health and safety, infection prevention and control, and other teams.

“I also share this with design teams at very-earliest stage of a project.

“By doing this, from the very start we know what products we will specify.”

And the approach has led to the trust partnering with manufacturers.

“Collaboration with suppliers is very important,” Howlett told the conference.

“We have built good working relationships and a lot of companies will work with us if we identify risks and go on to implement that in their product development.

We have built good working relationships and a lot of companies will work with us if we identify risks and go on to implement that in their product development

“But we have got to continue researching new products and making sure we remain at the forefront of innovation.

“While we do have a standard schedule, we are always looking for new ways to manage ligature risk and more, and better, products.

“Many suppliers make it very easy, but also we take on a lot from our design team and architects might propose to use something from other projects they have done.

“We make sure they come to site and we get everyone to review samples before we specify anything.”

Satisfying the regulators

But she warned that there is never enough funding to address every risk.

“Priority decisions need to be made,” she admitted.

“Each year we decide which items on our wards need changing, but then something else will happen which we need to fund

“Procurement is another restraint. We see all these things we like and know are safe, but procurement does not like us naming one item or supplier, so we have a bit of a battle .

“There are also considerations over maintenance and availability of supplies.

“Ligature reduction is at the forefront of design, so we need to ensure anything being specified is easily accessible.”

And the trust’s director of nursing, Dawn Dawson, said: “As a trust it’s about making sure safety is everybody’s business and empowering people to make changes.

“Also, it’s making sure environments are therapeutic and we are mitigating risks to our patient groups.”

While there is this ongoing debate over the balance between ligature risk and creating environments that are homely and non-institutional, the Care Quality Commission (CQC) still puts ligature risk high on its list of priorities when making inspections which determine if services can continue to operate.

Some ligature restrictions can antagonise patients by increasing the ligature appetite, so it’s about looking at what can designers and architects can do to balance that

This focus comes as figures show an 11% increase in ligature incidents in 2019 compared to 2018 and a further 13% increase between 2019-2020.

But, speaking at the conference, Jane Ray, head of hospital inspections for mental health and community health services at the CQC, told delegates: “First we need to remember the environment needs to be therapeutic, and if we did that right it will be much safer by default.

Getting creative

“It is important to keep restrictions as minimal as we can and that’s something we have worked very hard on.

“Some ligature restrictions can antagonise patients by increasing the ligature appetite, so it’s about looking at what can designers and architects can do to balance that.

“I think that’s what is happening is with the focus on ligature reduction, people are getting more creative.

“We do want to know trusts have thought about ligature safety and have come up with solutions, but we certainly do not want to be really prescriptive,

“We need providers to show they have thought about it in the context of who they are supporting.”