Improving quality and safety in healthcare: safety in mental health trusts


Case studies on how to protect service users and staff, by de-escalating violence, improving restraint and seclusion practices and minimising risks of suicide.

2gether NHS Foundation Trust

Case study: Reducing prone restraint, through better use of data, targeted training and other improvement initiatives PDF, 110.5 KB

Explores the roles of targeted training, the effective use of data and other improvement initiatives in phasing out prone restraint and replacing with supine restraint.

Oxleas NHS Foundation Trust

Case study: Reviewing ligature points in communal areas and developing area-specific ligature risk-assessment folders PDF, 180.2 KB

Minimising ligature risks through clinical review, including in communal areas, and raising staff awareness of the risks and what to do.

Avery ward: 2016 ligature audit PDF, 376.3 KB

Outlines ligature risks and the role of staff in identifying risks, and raising concerns.

As a learning organisation, we would be grateful for feedback, as well as suggestions of local good practice that could complement our case studies. Please email any feedback and examples through to using the subject line 'safety case studies'. 

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