Ligature Response: How to Identify and Respond to Warning Signs

Ligature Response: How to Identify and Respond to Warning Signs

Estimated reading time: 6 minutes

Ligature response is a critical aspect of patient safety in mental health facilities. It involves identifying warning signs of potential self-harm or suicide attempts and responding appropriately to prevent harm.

This guide aims to provide practical tips and strategies for healthcare professionals to ensure the safety of their patients. In this guide we’ll use the term “patient”, but you may use “service user” or other terms in your establishment. We also use the term “casualty” where a patient has placed a ligature around their neck.

Understanding Ligature Risks and Warning Signs.

The term “ligature risks” refers to the potential for a patient to harm themselves using a ligature, such as a belt, shoelace, or bed sheet.

It is important for healthcare professionals, family members and others to be aware of the warning signs of potential ligature risks. These include patients expressing suicidal thoughts or behaviours, exhibiting self-harm behaviours, or attempting to access items that could be used as a ligature. By understanding these risks and warning signs, everyone can take proactive steps to prevent harm and ensure patient safety.

Image of a black leather belt on light blue denim cloth.


A ligature is any item that can be bound or tied around the neck that acts as a tie or noose for the purpose of hanging, strangulation or suffocation.

A ligature point is any load bearing point above or below head height, where a ligature can be secured for the purpose of self strangulation or hanging.

Note that the Office for National Statistics group the World Health Organisations’ ICD-11 categories into various subsets, including one subset of “Hanging, strangulation and suffocation”. As such we must take suffocation into account when undertaking a ligature risk assessment.

Training Staff on Ligature Response.

Proper training of healthcare staff and affected family members is crucial in identifying and responding to ligature risks.

Staff and family members should be trained on how to identify warning signs, how to communicate with patients about their mental health and critically, how to respond appropriately in the event of a ligature risk. To avoid skills fade, this training should be ongoing and updated regularly to ensure that staff are equipped with the latest information and strategies for preventing harm and ensuring patient safety.

Additionally, everyone involved should be empowered and encouraged to report any potential ligature risks or concerns to their supervisors or designated safety officers.

Developing a Ligature Response Plan.

Developing a ligature response plan is an essential step in ensuring patient safety. The plan should include clear guidelines for identifying and responding to ligature risks, as well as strategies for preventing harm and ensuring patient safety.

It should also outline the roles and responsibilities of staff members, including who is responsible for monitoring patients and responding to ligature risks.

Regular training and updates to the plan are crucial to ensure that staff members are equipped with the latest information and strategies for preventing harm and ensuring patient safety.

Ligature risk assessments

Ligature risk assessments should be undertaken annually in all areas as well as following or building works or a “significant event”. They should ideally be undertaken by a trained assessor as spotting a ligature attachment point or material for use as a ligature can be challenging, even for those with some level of experience.

Where a patient who is at risk of self-harm and has a care plan, this should always be taken into consideration. Once completed, the ligature risk assessment will help to inform the decision making process regarding the required level of patient observations needed.

It’s critical that the patient always be involved in any decision making process regarding their safety. This should be documented in the individuals risk assessment and response plan. Where the patient declines this or lacks capacity, engagement with any relevant stakeholders must be then undertaken with this being clearly documented and reviewed regularly.

Image of a closed first aid box

Responding to Ligature Incidents.

When a ligature incident occurs, it is important to respond quickly and appropriately to prevent harm to the patient.

Each affected premises will have it’s own bespoke ligature incident procedure. Naturally we cannot go into much detail here, as this could be used as a resource by those looking to use a ligature on themselves. However, most procedures tend to follow a similar pattern as described in the following paragraphs.

Initially, undertake a quick dynamic risk assessment, being aware that those looking to end their lives typically look to defend their actions. Obstructions and weapons are common.

The next step is to remove the tension on the ligature as quickly as possible, before moving on to removing the ligature itself. If the patient is unconscious or unresponsive, call for emergency medical assistance immediately. Movement of the casualty should be minimised to limit any further harm to the casualties neck.

Be aware that the ligature incident may not be as simple as it first appears and police investigation may be required following the incident. Staff members should also document the incident and report it to their supervisor or designated safety officer. It is important to review the incident and identify any areas for improvement in the ligature response plan to prevent future incidents.


Proper training is essential for those with a duty of care or a duty to respond to ligature incidents. As part of our ligature response training courses we take an in-depth look at ligature risk assessments, managing ligature incidents, as well as hands-on rescue and medical procedures for those responding to incidents.

Our courses run monthly at our training centre in Cheshire with the option to hold private courses for your colleagues at your venues, nationwide. Please get in touch if you have a specific requirement not listed on our course page and we will do all we can to accommodate your requirements.  

Ligature Response: How to Identify and Respond to Warning Signs

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