What do we do

Liverpool University Hospitals NHS Foundation Trust recognises its statutory duties under the Health and Safety at Work etc. Act 1974 and the Management of Health and Safety at Work Regulations 1999, and is committed to maintaining and improving a safe and secure environment for its staff, patients and visitors.

In accordance with the Care Quality Commission and Department of Health, Health Strategy for Suicide Prevention, the Ligature Risk Reduction Policy creates a requirement on all areas accessible to patients to undertake ligature risk reduction assessment and implement any control measures in order to reduce the risk of hanging and/or strangulation. This must be reviewed annually.

What do I need to do?

1. All areas accessible to patients must have this risk assessment in place, the assessment must be carried out by the person in charge of the area or delegated person. (It is important you assess multiple factors and not only use height as the sole determining factor in identifying a ligature point’s risk.) 
2. An action plan must be drawn up and reasonably practicable actions taken to reduce risk. (Ensure that all staff are aware of the identified ligature points and any risk management plans. Where possible, identified ligature points should be removed, and where agreed, any identified mitigation requirements must be in place.)
3. Store a copy of the risk assessment on the shared drive and share with staff. You must also upload a copy of your assessment here. 
4. The risk assessment should be reviewed every two years or following a change in the environment and following any incidents. 

What training do I need?

1. All managers and deputies responsible for clinical areas where patients are assessed, treated or admitted should undertake our ligature assessment training. This course is a two-hour session on risk assessments, ligature guidance and involves a practical risk assessment on a mock ward.
2. General staff across the Trust should access the awareness course provided by Merseycare.

Risk assessment template

• General Ward
• Outpatients and Therapy
• DMOPS
• Assessment and Emergency.

Managing hazardous substances in the workplace is a complex task. If a workplace uses a hazardous substance, it must legally have a COSHH risk assessment in place to demonstrate that the substance is being controlled and used safely.

The Trust currently has one distinct COSHH management systems in place.

This information sheet gives guidance on how the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 (RIDDOR) apply to the health and social care sector.

It is aimed at employers and others in health and social care, who have a duty to report under RIDDOR.

RIDDOR requires the ‘responsible person’ (usually an employer in relation to a worker) and those in control of premises to report deaths, ‘specified injuries’ to workers, certain occupational diseases and dangerous occurrences that ‘arise out of or in connection with work’.

Generally, this means incidents where the work activity, equipment or environment (including how work is carried out, organised or supervised) contributed in some way to the circumstances of the accident.

RIDDOR reports alert enforcing authorities (HSE or local authorities) to events and help them to decide whether to investigate serious incidents.

Reports also assist to identify where and how health and safety risks arise, reveal trends and help target activities. Some incidents are not reportable under RIDDOR but this does not mean that health and safety law (including the Health and Safety at Work etc.

Act 1974 (‘the HSW Act’)) do not apply. Depending on the circumstances, the enforcing authority may decide it is appropriate to investigate such incidents.

This is more likely to arise where serious management failures have contributed to, or had the potential to cause, death or serious injury.

What do you need to report? The following are reportable if they arise ‘out of or in connection with work’:

• The death of any person, whether or not they are at work (see ‘Section 1)
• Accidents which result in an employee sustaining a specified injury, being absent from work or unable to do
• Their normal duties for more than seven days (see Section 2)
• Accidents which result in a person not at work (e.g., a patient, service user, visitor) suffering an injury and being taken directly to a hospital for treatment, or if the accident happens at a hospital, if they suffer a specified injury (see Section 3)
• An employee or self-employed person is diagnosed with one of the specified occupational diseases (See section 2)
• An employee or self-employed person receives a diagnosis of cancer attributed to an occupational exposure to carcinogens (See section 2)
• An employee or self-employed person receives a diagnosis of a disease attributed to an occupational exposure to a biological agent (see Section 2)
• Specified dangerous occurrences, which may not result in a reportable injury, but have the potential to do significant harm (see Section 4).

For details on DSE, please click here.