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Wardrobes used as ligature points | Signal

Reference number
1104 I
Issue date24 September 2009

This ‘Signal’ is about the risk of wardrobe handles/hinges being used as ligature points for self-harming patients in mental health trusts.


Extract from incident reported to the RLS:
 “…her bedroom door was locked, the room was entered, patient was suspended by a ligature (later noted to be two shoelaces tied together) secured around the top of a hinge on her wardrobe door… ligature was released and then cut free… she was not breathing and her pulse was very weak and thready, CPR was commenced”


While ligature points above head height are the most dangerous, it is possible to create fatal suspension from points at least high enough for the upper body weight to be suspended from the ligature.


As part of a wider review of serious self-harm incidents in mental health units, the National Reporting and Learning Service (NRLS) identified four deaths and four additional serious incidents (where the patient was cyanosed or required resuscitation) related to service users suspending ligatures from bedroom or bathroom cupboards or wardrobes.


Ligature points included wardrobe handles, wardrobe hinges, and the horizontal bar within the wardrobe used for hanging clothing. DH Estates have set very specific standards for bedroom doors in mental health units, aimed at ensuring that a ligature cannot be lodged between the door and the door frame, and that door hinges and door handles cannot be used as ligature points. However, no standards appear to apply to doors in furniture.


The NRLS is exploring this issue further with DH Estates.


We would like to hear from you – please contact us  with anonymised copies of local investigations or information about your initiatives to reduce risks in any of these areas. 

Signals are notifications of key risks emerging from review of serious incidents reported and shared by the NRLS







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Relevant to: mental health