Safety recommendation
HSSIB recommends that NHS England, working with other relevant national bodies, develops guidance on how to reduce and respond to non-anchored ligature risks. This will help staff to support people who attempt to hurt themselves with non-anchored ligatures and improve patient safety whilst maintaining a therapeutic environment.
Response:
NHS England Mental Health, Learning Disability and Autism Programme welcomes the recommendations of the HSSIB investigations ‘Mental health inpatient settings: Creating conditions for learning from deaths in mental health inpatient services and when patients die within 30 days of discharge’. The outcomes of the investigations support our work focused on improving patient safety across the Mental healthcare system by reducing restrictive practices and least coercive care. We recognise the importance of approaching this sensitively and compassionately given the experiences of both staff and patients and the complex decision making that is required to consider people’s human rights, least coercive care and safety. Guidance on how to reduce and respond to non-anchored ligature risks will help staff to support people who hurt themselves with non-anchored ligatures and improve patient safety whilst maintaining a therapeutic environment.
Actions planned to deliver safety recommendation:
- Establish a working group with key stakeholders to collate existing evidence base and agree key inclusion points for the guidance document, by September 2025. Organisation lead: MHLDA Quality Transformation Team. Resources in place to deliver actions: Time protected within existing team to undertake this work. Other dependencies identified: NCISH have been identified as a key stakeholder for this work. Availability and capacity of key stakeholders. Additional comments: All actions and subsequent timelines are subject to change due to the NHSE restructure. All stakeholder engagement will include lived experience representation.
- Create and publish guidance for staff on how to reduce and respond to non-anchored ligature risks in line with personalised safety planning a least coercive care, by December 2025 to start NHSE publication process. Organisation lead: MHLDA Quality Transformation Team. Resources in place to deliver actions: Time protected within existing team to undertake this work. Other dependencies identified: Availability and capacity of key stakeholders. NHSE publications process. Additional comments: All actions and subsequent timelines are subject to change due to the NHSE restructure.
Response received on 28 April 2025.