DESIGN IN MENTAL HEALTH CONFERENCE 2019


boxers, ‘alongside a raft of anthropometric data’. This was used alongside body weight calculations and momentum to better understand what forces can be achieved. Philip Ross said: “During the workshops one of the other major things to emerge was the determination and time that people in mental healthcare settings have to plan and enact attacks on products with the goal of self-harm. A patient learning process has been built into the testing to capture when there are co-ordinated incidents to learn about staff procedures.”


The ‘size’ of the design challenges The workshops held in various locations in England and Scotland had highlighted the magnitude of the design challenges in mental health. Philip Ross explained: “Participants highlighted various conflicting requirements when looking both at specific products and the overall project – for example privacy versus safety, robustness versus ‘homely’, and ligature-resistance versus grip or slips, trips, and falls.” He added: “We recognise that improving the design of mental health spaces for safety and recovery is about encouraging innovation to overcome these conflicts long term.” In the meantime, he believed it should be possible – through the development of effective test standards – to help specifiers and clinical teams make good product choices, factoring in which risks can be managed through clinical observations, and which must be reduced through good product design. “Ultimately,” Philip Ross said, “until the perfect product comes along, it is about choosing the right place to compromise, and ensuring that the clinical risk management procedures can be suitably informed – with the decision different for each care pathway.”


‘Too binary’


To ‘make good decisions’, Philip Ross said the mental healthcare community needed a more comprehensive range of tests than were currently available, differentiating between simple and determined ligature attempts or physical attacks. Moving to discuss ‘the issue of ligature’, he said this was ‘an interesting topic’, but one that was currently ‘too binary’. He explained: “There is a wide range of products currently given the label ‘anti-ligature’. We’ve focused on using the medical data to give graded performance benchmarks, more accurately


capturing the spectrum of risk reduction, and hopefully banishing the term ‘anti- ligature’, which is too absolute when you factor in the determination and time that patients devote to thinking up innovative ways to self-harm, or, in the worst cases, to try to end their life.”


A range of tests needed


He continued: “Reduced ligature products behave in different ways, employing different risk management approaches, and we needed a range of tests to assess the function and ‘strategies’ of different product types. To give some examples, the first ‘type’ we have here (Philip Ross pointed to his slides) is fixed products, i.e. those that do not move, and the next ‘moveable fixed products’, such as doors and windows. The fact that they move creates additional risks, so it is important to assess those two factors differently. “Then,” he continued, “we have a range of load release products – and here again it is a question of a strategy to minimise the risk, and finally alarm systems on doors, which do not remove the ligature risk, but alert staff to it. Here what we are principally testing is the reliability of the alerting system.”


Considering all risks irrespective of height


Philip Ross explained that another recent Estates and Facilities Alert, Assessment of ligature points, (EFA/2018/005), issued last September, had highlighted the need to consider all ligature risks irrespective of height in unsupervised areas such as bedrooms and en suites. He said: “This needs to be a key consideration.” Explaining why, he said: “Commonly, we are just looking at loads applied from top down, but actually you need to start thinking about the full loading patterns; it’s not simply about attaching a ligature point and then pulling up or down. You have to think about how the attachment is made, the direction of load, and how it is then converted into ligature.” The joint DiMHN/ BRE team had also factored into the equation the ‘determination and time aspects’ of the testing, creating different grades of performance based on products’ ability to cope with ‘no planning’, i.e. an ‘impulse attempt’ ligature, ‘some planning’, and ‘a great deal of planning’. Philip Ross elaborated: “The latter would involve


An Estates and Facilities Alert (EFA/2017/002) issued in August 2017 related to push-button stops and other anti-barricade devices not working under active manipulation of pressure from within the room.


multiple attempts to capture the patient practice and learning process, allowing a total of 40 minutes to try to manipulate the device with commonly available tools – clothing, bedsheets, a broken CD, or just brute force.”


Consistent application


The DiMHN speaker said ‘the biggest step forward’ with assessing robust performance was the creation of testing processes that could be consistently applied, were repeatable, and could be carried out once. To overcome the problems with current testing, the joint team had looked at a wide range of testing regimes – largely from the security sector – and combined this with the team’s own experience of mental health, ‘factoring in superhuman strength’, and ensuring that all types of attacks on products were covered, using weapons, body force, or ‘stealth attacks’. Recognising that some products’ performance could be affected by the substrate they were fitted to, the team would in some cases be testing products with a range of construction details. One example of how the team had striven to make the testing reflect ‘real world’ conditions was via ‘body ramming’ a door – currently replicated by using a paving maul and hitting the door at all heights. Philip Ross illustrated – via a slide – how in this testing the door would be hit at a number of different points. He said: “In this particular testing among the areas we have looked at, using anthropometric data, are the scope of impact on the product – in this example from waist to shoulder height, and the size of the impact and its density,


There are a number of potential ligature points on an item such as a door to consider. Right: The many points at which a determined attacker might physically attack a door, with differing body force and impact, including via a punch and a full ‘body ram’.


THE NETWORK | JULY 2019 25


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