We have progressed Phase 2 of the Ligature safety Initiative, building on the strong foundations of Phase 1 ‘Improving safety for consumers at risk of harm of ligature’, to reduce environmental ligature point risks in mental health and wellbeing settings through a consistent, evidence-based approach.
Adapted from the Care Quality Commission’s model in the United Kingdom, the Ligature Point Audit Tool (LPAT) was piloted across 4 Victorian and an interstate mental health and wellbeing services. The pilot confirmed its relevance and usability, while highlighting opportunities to refine the tool for local needs. Adaptation was guided by a literature scan, Plan Do Study Act (PDSA) cycles and co-design principles.
To drive this work, our Expert Working Group was expanded to include additional mental health and wellbeing services across Victoria and interstate – bringing together clinical, operational and consumer perspectives. Meeting weekly, the members provided expert input to refine the LPAT and create a supporting guidance document, resulting in a practical, sector-ready resource to help mental health and wellbeing services create safer environments for our consumers.
While the LPAT has been developed and tested within mental health and wellbeing settings, we intend to explore its use in other areas across health services. These areas will be reviewed after six months to see how the tool is being used, gather feedback, and decide whether to expand its use.
We encourage all mental health and wellbeing services to access the LPAT and guidance and embed them into organisational practice as part of your broader safety measures in identifying and mitigating ligature point risks.
This work reflects our commitment to co-designed, evidence-based solutions that make mental health care safer, more consistent and more responsive.
Key outcomes and next steps
Phase 2 delivers a standardised audit tool and supporting guidance that can be applied consistently across Victorian mental health and wellbeing services.
The tool aims to:
- identify and address ligature-related environmental risks
- strengthen governance
- improve safety for consumers receiving care.
The tool is currently recommended for use in the following types of settings:
- Community-based mental health and wellbeing services
- Inpatient mental health and wellbeing services
- Non-acute care settings, such as rehabilitation and extended care
- Residential mental health and wellbeing services
- Combined mental health and alcohol or drug support hubs (MHAOD)
- Psychiatric Assessment and Planning Units (PAPU)
- Forensic mental health services
The tool is currently not intended for use in the following settings:
- Alcohol and other drug services (both residential and community-based)
- Consultation liaison services
- Hospital emergency departments
- General medical and surgical inpatient wards.
These areas will be reviewed after six months to see how the tool is being used, gather feedback, and decide whether to expand its use.