From Audit To Action: Limerick University Hospital Psychiatric Unit

Ligature risk management in mental health settings is often well understood in principle, but harder to implement consistently across an organisation.

This case study from an acute mental health inpatient unit in Ireland shows how a structured ligature and environmental safety audit led to measurable changes in awareness, governance, and the physical environment.

Background

The service operates within a Community Healthcare Organisation (CHO) and is regulated as an Approved Centre under the Mental Health Act.

Before the audit, ligature risk assessments were primarily carried out by a senior nursing lead. While risks were identified and communicated, involvement from other departments was limited.

As described in the case study:

“Prior to this audit I operated as though I was the owner of the risks identified… The global awareness at all levels of the management structure simply was not there.”

The Audit Approach

The audit went beyond a standard checklist and introduced a broader way of working.

A key concept was collective capability, meaning that responsibility for identifying and managing risk is shared across multiple disciplines.

The process resulted in:

• A detailed review of environmental risks, including fixtures and fittings

• A post-audit report

• A Quality Improvement Plan (QIP) with actions assigned to relevant departments

The audit also highlighted that risk is not limited to obvious ligature points:

“The attention to detail beyond the obvious was eye-opening… fixtures and fittings… can contribute to risk.”

What Changed

1. Governance and Leadership Involvement

Following the audit, senior stakeholders including the Maintenance Manager, General Manager, and Registered Proprietor met specifically to address ligature risk.

Responsibility moved beyond the nursing team and became a wider organisational issue.

This aligned with national guidance published in December 2024, which requires Approved Centres to establish multidisciplinary Ligature Reduction Groups.

2. Environmental Improvements

The audit informed investment decisions and led to specific changes within the unit, including:

• Replacement of en-suite and bathroom doors with alarmed anti-barricade doors

• Installation of ligature-reduced windows in the High Observation Unit

• Introduction of ligature-reduced beds

• Installation of ligature-resistant dispensers and waste bins

• Replacement of screw-fixed items with safer alternatives

These changes were also standardised across multiple centres within the CHO.

3. Maintenance and Accountability

Including Maintenance in the audit process and assigning QIP actions to relevant teams changed how risks were managed.

Maintenance staff became more aware of ligature risks and more proactive in responding to infrastructure-related issues, such as doors, windows, and fixtures.

4. Multi-Disciplinary Working

Future audits are planned with representatives from:

• Risk

• Health & Safety

• Maintenance

• Clinical teams

Capital planning is also now discussed across all four Approved Centres in the CHO, allowing for more coordinated decision-making.

5. Staff Awareness and Training

Ligature risk is now a standing item in management meetings, and staff have received training on new systems such as alarmed anti-barricade doors and windows.

Awareness of shared responsibility is regularly reinforced across different governance groups.

Key Takeaways

The service identified several practical lessons for other organisations:

• Involve Estates, Maintenance, Risk, and Health & Safety teams from the outset

• Ensure stakeholders understand their role before the audit begins

• Use a QIP to assign clear responsibility for actions

• Develop a standardised, approved range of ligature-resistant products

• Engage with sector forums to stay informed on design and product developments

• Anticipate alignment with national requirements for ligature-reduced environments

Conclusion

This case study shows that a ligature and environmental safety audit can do more than identify risks.

In this instance, it led to:

• Greater organisational awareness

• Wider stakeholder involvement

• Defined accountability through a QIP

• Targeted environmental improvements

  
  

For services reviewing their current approach, the main shift demonstrated here is from individual ownership of risk to a shared, structured, and organisation-wide response.

If you're interested in finding out what we can do for your organisation, feel free to get in touch.

Download the case study