Common Terminology    
 

Ligature
The Oxford Dictionary defines a ligature, as a thing used for tying or binding something tightly.  This could be a cord, rope, thread, item of clothing, or a piece of bedding.

Ligatures pose significant risks in mental health environments, due to their potential to be used for the purpose of self-harm, by hanging or strangulation.

Facility managers and carers must therefore ensure, that reasonable steps are taken to reduce the accessibility of unnecessary ligatures to at-risk patients, and that these patients are properly monitored and supervised.


Ligature Point
A ligature point is any load bearing location, where a ligature can be attached, or secured.  This could be a part of the building architecture, a piece of furniture, a wall fitting, or other physical objects.

Ligature points increase the risks of self-harm in mental health environments and are therefore a key consideration in facility design.

In Australia, the Australasian Health Facilities Guidelines (AusHFG) states that design documentation will need to consider anti-ligature design in specifications and design details. The guidelines also emphasise the need to minimise ligature risks in healthcare facilities, particularly those catering to mental health patients.

In the United Kingdom (UK), the National Health Service’s (NHS) Health Building Note (HBN) 03-01 - Adult Acute Mental Health Units, state that spaces where service users may not be continually supervised by staff (for example in bedrooms and toilets), should be designed, constructed and furnished to make self-harm or ligature as difficult as possible, and that all fixtures and fittings should be anti-ligature.

In the United States of America (USA), the Joint Commission says that when ligature points exist, that the facility must have appropriate mitigation plans and safety precautions in place.


Ligature Resistant and Anti-Ligature
The terms ligature resistant and anti-ligature have many varying definitions, and are often used interchangeably, especially in healthcare and behavioural health settings.

The terminology also varies across countries.  In Australia and the UK, the use of anti-ligature seems more common, whilst in the USA, ligature resistant appears more predominant. 
Ligature resistant and anti-ligature refer to the design features or modifications incorporated into products and spaces specifically aimed at minimising or preventing individuals from using a ligature to harm themselves, particularly through hanging or strangulation.

With products, this typically means designed to be without points where a cord, rope, or other material, can be looped or tied to create a point of attachment that could be used by vulnerable individuals for self-harm.

Australia’s AusHFG has a revised definition of anti-ligature design, noting that where the term is used in the document, it is expected that the product will be of a type specifically manufactured and marketed as anti-ligature / ligature resistant, has been tested prior to installation or has a proven track record, and is installed in accordance with the manufacturer’s instructions.

The NHS’s HBN on mental health states that all fixtures and fittings such as window and door furniture, door closers and hinges, taps, showerheads, toilet roll holders, and coat hooks should be anti-ligature, robust and able to withstand sustained attack, and meet national safety requirements. In general, all fixtures and fittings should be specified, manufactured, fitted and maintained to help prevent the possibility of accidents, misuse or use as weapons or to aid self-harm. Local risk assessment is necessary, with fitting according to manufacturers’ instructions.  Projections, level surfaces that could form hook points, and horizontal rails or similar are also to be avoided.

In the USA, the Joint Commission defines ligature resistant as without points where a cord, rope, bedsheet, or other fabric/material can be looped or tied to create sustainable point of attachment that may result in self-harm or loss of life.  They advise that organizations should conduct a risk assessment of the environment, determine which products to appropriately install (based on manufacturers’ instructions), and ensure that they are functioning properly.

It is important to note that whilst ligature resistant or anti-ligature products are designed to minimize the risk of ligature attachment, they may not eliminate it entirely.  Therefore, in high-risk environments, adequate monitoring and supervision of vulnerable individuals is required.

In the UK, the Design in Mental Health Network (DIMHN) and Building Research Establishment (BRE) Partnership’s Informed Choices Testing Guidance recognises that Zero Risk doesn’t exist.  They go on to say that the term anti-ligature is seen as too absolute, suggesting everything is safe or not, and it is thus too binary to suggest products are ligature free or not. More recent adoption of reduced ligature is equally dangerous; with a suggestion everything performs the same. The reality is there is a spectrum of risk level.

 

Ligature Resistant and Anti-Ligature Products
The selection of suitable products for use in health facilities is the responsibility of building designers, facility owners, facility managers, builders, and clinicians.

In Australia, currently there are no official standards for building designers or product manufacturers to refer to regarding ligature resistant and anti-ligature product design. 

In the UK, clinicians, designers and product manufacturers can use Informed Choices to assist.  Whilst Informed Choices is not a pass / fail test, it is a graded assessment of performance.  Ultimately however, decisions about use cases for different grades of product remain a clinical matter.

In the USA, there are some useful documents that designers can refer to assist in product selection, such as the Patients Safety Standards – Materials and Guidance Guidelines – 33rd edition rev.1, which is published by the New York State’s Office of Mental Health (NYS-OMH). 

The document offers guidance with respect to patient safety features in the inpatient psychiatric environments throughout New York State.  The purpose of the guidelines is to provide a selection of materials, fixtures, and hardware that the NYS-OMH has reviewed and supports for use within inpatient psychiatric units to further the agency’s goal of reducing the risk of harm to individuals in inpatient settings. Utilization of any of these products is not mandatory. 

The NYS-OMH state that evaluation of programmatic appropriateness and architectural detailing shall not be omitted from the product selection process.  It further notes that that whilst the items selected represent styles and properties of products that help lower patient risk while on an inpatient psychiatric unit, installation of these products will not eliminate all risks.
At Galvin Engineering, we incorporate anti-ligature elements like rounded edges, ligature-resistant fixtures, durable materials, concealed fittings, and anti-grip surfaces, to minimise the risk of individuals using ligatures to harm themselves. 

To ensure our products are best in class, our Research and Development team test our products inhouse, and rely on the knowledge and resources of our trusted supplier partners, like Wallgate in the UK (ISO 19712-3: 2022 Plastics — Decorative solid surfacing materials; Part 3: Determination of properties — Solid surface shapes).


Crocodile Role Resistant
Crocodile Roll Resistant (CRR), refers to features or products designed to prevent or resist the dangerous self-harming behaviour known as a "crocodile roll."

This behaviour involves using a ligature attachment, and twisting or rolling the body, to attempt self-strangulation.  In settings like mental health facilities, specific design elements such as rounded edges, concealed fittings, ligature-resistant mechanisms, and anti-grip surfaces are incorporated, to discourage ligature attachment and enhance safety.

 

 

Disclaimer
 

Galvin Engineering offers a range of ligature resistant and anti-ligature products designed to reduce the risk of self-harm or suicide, but we cannot offer any guarantee that this will not take place.  Therefore, it is important to understand that installation of these products will not eliminate all risks.

When we use the terms ligature resistant and/or anti-ligature about our products, it means that we have designed and tested these products to reduce the risk of that product being used as a ligature attachment point.  They will not protect or prevent injury when the risks where unknown to us at the time of the design of the products. They are not a replacement for professionals who are trained in the proper evaluation, management, and supervision of persons at risk of self-harm or suicide.

Galvin Engineering recommends that designers, installers, facility managers, and anyone intending to rely on or use any products displayed in our literature or on our website, satisfy themselves about the suitability of the products for their intended use in the building design, and ensure they are being installed, used, and maintained in accordance with our instructions.  Facility managers, clinicians, and carers need to ensure that reasonable steps are taken to reduce the accessibility of unnecessary ligatures to at-risk patients, confirm that adequate risk mitigation controls are in place, and make sure that applicable health, safety and patient care standards are being met.

Galvin Engineering makes no express or implied warranties regarding the ability of the product to prevent death or injury, or to resist all ligature attachment.  No responsibility is assumed by Galvin Engineering for any incidental or consequential damages resulting from the use of any products sold by Galvin Engineering.  To the fullest extent permitted by law, Galvin Engineering excludes all liability for damage or injury to any person, damage to any property, and any indirect consequential claims, loss or damage.

 

 

References
 

Australia

United Kingdom

Unites States of America