The safe intervention for ligaturing assessment score (SILAS) was developed at Priory Hospital Cheadle Royal following analysis of the Woodlands Unit's intervention technique in the management of young people engaged in unsuspended ligaturing.

The Woodlands Unit at Priory Hospital Cheadle Royal is a low secure, therapeutic rehabilitation service for female adolescents, aged 13 - 18 years, with complex needs who require a longer-term therapeutic intervention within an inpatient setting.

The tool has been developed for use with patients with a primary diagnosis of borderline personality disorder.

The aim of the scoring system is to balance the need for support, whilst maintaining the safety of the young person and the staff, and encouraging individual responsibility.

SILAS considers three domains: circulation to monitor the physical health of the young person, engagement and co-operation to ensure physical safety of the staff team and to empower responsibility of the young person, and time limits to give support whilst encouraging the young person to regain control for themselves. Only once an agreed score has been reached, will physical intervention begin.

Twelve months of research was carried out looking at the interventions used by the nursing team at the hospital's Woodlands Unit prior to the implementation of the initiative. Staff received comprehensive training which is regularly updated, ensuring consistency and improved patient care for the young people. Jenine Gorman, Ward Manager and Louise McKenna, Clinical Nurse Lead said: "We found that the first response to incidents of unsuspended ligaturing was for staff to immediately intervene and to stop and take control of the incident. This frequently resulted in the young person becoming aggressive and staff having to initiate restraint, which places both staff and patient at risk.

"On analysing our interventions, we felt that we were giving the message that the behaviour was inappropriate and must be stopped. What was not happening was the individual being given the opportunity to communicate their distress or learning how to regain control, which denied the opportunity to develop new and safer coping strategies.

"There is no guidance or best practice available concerning the act of unsuspended ligaturing so we looked at developing our own assessment tool and protocol taking into account other self-harming behaviour guidelines from the National Institute for Health and Care Excellence (NICE).

"Since we started this initiative, the need for restraint following this form of self-harm has significantly reduced and consequently patient and staff injuries have also reduced."

The Care Quality Commission (CQC) is aware of SILAS and included in its report: "We are pleased to hear of the methods of supporting patients who are harming themselves using non-suspended ligatures. It is clear that the method currently in operation maintains patient safety and yet encourages autonomy and responsibility. It also avoids the potential for escalation."

The Quality Network for Inpatient CAMHS (QNIC) commented that "The unit has developed a new deliberate self-harm protocol which has reduced the number of staff injuries and has received positive feedback from parents and young people."

Lindsey Cree, Parents and Carers Support Group Coordinator, Priory Hospital Cheadle Royal said: "At present, it's clear there are no guidelines on how to enable the young person to learn new behaviours that enhance autonomy whilst engaging in this type of self-harm. SILAS offers the young person a safe, individual method for developing self-empowerment during a time of immense personal distress.

"As the parent of a young person who has a severe and enduring mental illness, I welcome this intervention. The fact I was asked to review this proposal shows me that carers' views are valuable to the author."

Two of the young people at Woodlands also endorsed the initiative: "In my other placement, they used to rush in and cut it off, no communication and leave you and go and have a de-brief, but when they came in they would frighten the living daylights out of you but here on Woodlands they come in and talk to you and try to help you take it off and after, they would talk to you and help you with what you are struggling with."

"On a previous placement, if I ligatured, the alarms would be pulled and a full team would come in and restrain me to take it off. The sound of the alarm made me feel more anxious. The full team all running in made me feel worse and when the team put hands on me it made me feel worse and reminded me of bad things. But now on Woodlands, if I ligature they persuade me to take it off myself, staff sit with me and give me reassurance, this makes me feel better and less anxious. Woodlands staff would only restrain me as a last resort or if my life was at risk. I think I ligatured more before because of the way it was dealt with; it gave me more attention, whereas on Woodlands the way they deal with it made me feel safer and was less of a big deal and more discreet from other patients."

SUCCESS RATES: since August 2010 (when the system was introduced) the number of staff who have been injured in restraint had noticeably decreased. The percentages of unsuspended ligatures requiring restraint have reduced from 71/8% (April 2010) to 18.9% (March 2012).