Ligature Resistance: Getting a Handle on Life Safety

May 3, 2021
Door hardware that’s aimed at helping to prevent suicide attempts continue to evolve.

Ligature-resistant door hardware is a relatively new phenomenon in the security industry, so new, in fact, that an ANSI/BHMA standard for such hardware didn’t even exist 10 years ago. Consequently, the evolution of the products has been fairly constant and continues to this day.

Although many locksmiths and security pros might not have to work with this type of hardware, that’s expected to change in the years ahead, and for those who have little experience, the landscape can be confusing.

The lock and the means of opening and closing a door take priority, but one must consider the entire door. Then, one must consider the entire room and then the entire building.

“It really is a package deal,” TownSteel President Dennis Ma says. “If you protect the door hardware but your hinge is not ligature-resistant, that becomes a soft target. If you want to totally protect [patients], all this needs to be addressed.”

Further, different rooms might require different solutions. A facility might want a ligature-resistant mortise lock that has keyless, keyed single-cylinder, keyed double-cylinder, deadbolt and even dummy options on the same floor.

The key, as is often the case, is to be responsive to the customer, says Mark Berger, president and chief product officer of Securitech.

“[The locksmith] has to get into the head of the facility manager as to what they’re trying to achieve,” he says. Different sites might have different demands, even though the goals might be the same. “So, it’s not important to present [a solution]. It’s more important to listen.”

Ligature Resistance 101

Before that, it’s important to have a basic understanding of the products themselves. Simply, ligature-resistant hardware is aimed at life safety, specifically the prevention of attempted suicide by hanging. A ligature is something used for tying or binding, and a knob or handle naturally provides a strong ligature point by protruding out from a door.

This is a primary consideration at behavioral-health facilities as well as prisons and other correctional institutions, where attempted suicides are a big risk.

Ligature-resistant hardware, thus, attempts to eliminate those possibilities by several means. The hardware uses sloped escutcheon and handle designs, so anything attached will slide off. Levers aren’t fixed but spin freely when locked or rotate enough to further resist having something tied to them staying on when enough weight is applied. Also, tolerances on the hardware itself have to be tight, so a person can’t jam something even as small as a paper clip into a crack to create a ligature.

The latest handle designs typically are a solid D shape, so nothing can be looped through it. These products are deemed five-point ligature-resistant, because they resist having something tied to them in five directions: up, down, left, right and straight out, says Bill Sporre, senior vice president of sales for Marks USA.

“That’s brand new,” he says of five-point ligature resistance. “When I say ‘brand new,’ it’s been out for a couple of years, but it’s the direction that a lot of hospitals are going.”

Rickey Green, director of sales for multihousing and institutional at TownSteel, agrees. This new design has been approved by The Joint Commission (known colloquially as JHACO), which oversees and licenses hospitals, including behavioral-health hospitals.

“Over the next couple of years, they’re migrating all psychiatric hospitals and anything that’s under The Joint Commission to a five-point ligature-resistant lock,” he says.

You’ll notice the use of the term ligature-resistant, rather than anti-ligature or, certainly, ligatureproof. That’s because no one can guarantee that any product eliminates all risk of self-injury. In fact, that acknowledgement led to the creation of the latest door handles, Berger says.

“Someone had the idea that patients are going to tie a sheet around the door and hang themselves that way,” he says. “Every facility that I’ve spoken with, not a one has ever told me that somebody has done that.” But because someone thought of it, it created a demand for a product that could prevent such a scenario.

Berger notes particularly the potential at Department of Veterans Affairs (VA) hospitals.

“We have people there who we have taught to extricate themselves from any situation,” he points out. “Now, design hardware against that so they don’t harm themselves.”

Setting the Standard

The Joint Commission makes no specific recommendation about ligature-resistant hardware, just that hospitals have it. Builders Hardware Manufacturers Association (BHMA) created a standard for bored and mortise locks that have ligature-resistant trim, A156.34-2019 being the most recent version, and manufacturers can test their locks against that.

As with other categories, locks might grade 1, 2 and 3 based on durability — a Grade 1 lock must hit 1 million cycles of opening and closing with a 10-pound axial load, for example. The standard also looks at the amount of force that can be applied to a ligature in any direction. A Grade 2 lock can’t exceed 11 pounds of force, for example.

The problem is that when you look at manufacturer spec sheets, you typically won’t find much mention of A156.34 but other BHMA standards, such as A156.13, which is for mortise locks.

You’re more likely to see mention of NY-OMH certification. That’s the imprimatur of the New York State Office of Mental Health (OMH), which publishes a large volume of guidelines for a broad range of products aimed at ensuring patient safety, including door hardware but also closet bars, showerheads and even thermostats. Although meant only as recommendations for New York facilities, the guidelines are referred to nationwide.

More important, they include recommendations for specific products, unlike The Joint Commission or BHMA, and manufacturers agree such recommendations are important for their products to have.

“It’s like the Good Housekeeping seal,” Berger says, referring to the magazine that approves of appliances it tests. “That’s because that’s the only independent group that tests” these products.

There’s more to OMH certification than just a seal of approval. In its guidelines, OMH notes three levels of risk: low, medium and high:

  • A low-risk area is one a patient won’t use or where patients are supervised constantly.
  • A medium-risk area is one where patient access is controlled or where patients are supervised without any solitary use.
  • A high-risk area is one where a patient will be unsupervised, such as their own room.

A facility typically will make the determination as to what to put where. Representatives are aware of The Joint Commission recommendations, and it can’t hurt to consult a local Authority Having Jurisdiction. When in doubt, however, go high, says Uriah Parker, project sales manager for the Midwest Region at Allegion.

“My personal recommendation would be to always err on the side of safety,” he advises. “The most important facet to consider is life safety.”

What’s Next

Ligature-resistant hardware is a niche product aimed at niche applications. However, Berger sees fallout from COVID leading to an uptick in demand for mental-health treatment, which, in turn, will lead to a wider recognition of the necessity to consider ligature-resistant hardware at community hospitals and even urgent-care centers.

Green agrees, noting that a hospital in Tennessee is retrofitting most of its doors with ligature-resistant hardware, but he suggests that at least some form of ligature resistance could spread beyond healthcare and corrections to the hospitality market (hotels) and universities (housing).

“We’ve already had some of those requests, so the market is only growing,” he says.

Manufacturers already are taking the appearance of their products more into consideration. A healing environment is better accomplished if a patient’s surroundings are more comfortable and less institutional. Berger likens it to staying at a Marriott instead of a hospital. The challenge, of course, is to make sure that aesthetics don’t trump safety.

Another feature that you can expect to see more of in ligature-resistant hardware down the road: electronics. Few manufacturers incorporate electronics in their ligature-resistant hardware, even as an option, for the simple reason that it isn’t deemed necessary for the most part. However, electronics bring several benefits to the table, says Christine Cicchetti, product manager – hinges for dormakaba, which makes electrified ligature-resistant locks under the BEST brand. She notes that electrified locks can monitor door position or latch and lock status.

“Healthcare professionals simply can’t be in multiple locations at one time,” she says. “Electrified locks and door-top monitoring paired with an access control or alarm system can alert a provider to an urgent patient safety need and direct immediate assistance within seconds.”

And, yes, in case you were wondering, manufacturers are considering ways to bring ligature-resistant hardware into an increasingly touchless world. In fact, Ma says TownSteel is working on a mortise lock that allows for automatic motorized latch retraction that it hopes to have out by the third quarter of 2021. The lock will be aimed at multiple applications but will be able to incorporate ligature-resistant trim.

“When you talk about electronics and touchless, those lend themselves very well to an environment where you have less ligature risk and more of a healing environment,” Parker says. “There’s great opportunity in the industry around electronics and touchless and how it fits into ligature resistance, and I’m excited to see where that goes.”

Below are a few products to consider in the meantime. All listed locksets come with a 2-3/4-inch backset standard for a 1-3/4-inch door.

Marks LifeSaver Series D-Lig slides

The latest addition to Marks’ venerable LifeSaver Series of ligature-resistant hardware features a five-point ligature-resistant slide trim handle. Sporre says the handle was a natural evolution of the company’s ligature-resistance hardware.

“There’s all these other little things that you have to think about besides being ligature-resistant,” he says. “You have to be able to grab the door and close it and open it.”

Both versions meet BHMA 156.34 for ligature resistance and are rated Grade 1 for cylindrical (195BH) and mortise (5BH) locking versions, respectively. The mortise version has several options, including a ligature-resistant thumbturn for privacy applications that adheres to Americans with Disabilities Act (ADA) guidelines. An antimicrobial coating is available.

Even though he calls five-point ligature resistance the best type of design from a life-safety standpoint, Sporre says Marks already is working on its next iteration, with details to come.

“We’re always trying to think of different new ways to make ligature-resistant hardware,” he says.

Keying: 6-pin Marks “C” keyway, interchangeable core and all OEM cylinder preps, Marks Hi-Security Cylinder available

More info:

Securitech SOLIS

The first thing anyone notices about the SOLIS, Securitech’s latest piece of ligature-resistant hardware, is that the white handle made of antimicrobial polycarbonate doesn’t look as though it belongs in an institutional setting.

That’s the idea, Berger says. It’s aimed at making the surroundings appear to be less intimidating. “That’s why it looks like an egg on the side of your door — so it’s not something that frightens you,” he says. The SOLIS has a profile of only 2-1/4 inches off the door.

But make no mistake: The SOLIS also has life safety firmly in mind by providing five-point ligature resistance in what Securitech calls a levered lockset. It’s available keyed or keyless in cylinder and mortise versions. The mortise version has a ligature-resistant thumbturn available for privacy applications as well as a deadbolt option.

Berger also notes that the handle requires less than 5 pounds of force to depress, which makes it comply with ADA regulations and ANSI 117.1. The SOLIS is available as a retrofit option to existing mortise locks, and Berger notes that the SOLIS can be used on just the inside of a door if budget concerns are an issue.

Keying: 6- or 7-pin small-format interchangeable core

More info:


The SPSL Series by dormakaba brand BEST comes in a variety of options for maximum applications, including privacy functionality for patient rooms.

The SPSL also has a number of features going for it besides its ligature-resistant design, Cicchetti says. The lever has only a 1-3/4-inch profile off the face of the door, and it’s free moving in both directions for additional safety. Also, the locksets comply with the spirit of ADA by eliminating “pinch and grasp” motions. The result provides “patients and staff with easy-to-operate hardware,” she says.

The SPSL comes in cylindrical or mortise versions, although the cylindrical version comes keyless only. However, the mortise version includes electrified options (SPSE) for fail-safe or fail-secure egress on one or both sides of a door, as well as request-to-exit, door-position monitoring and latch-position monitoring if connected to an access control system.

Keying: 7-pin small-format interchangeable core

More info:

Markar DSH1000

The hinge presents a prime location for a ligature, particularly when a door is open.

“I would say anything touching the door is important, because sometimes the patient has access to the entire opening,” says Betty Kay Ward, product manager of hinges for ASSA ABLOY’s door accessories group. “Danger can present itself anywhere a determined person is looking.”

To protect against that possibility, ASSA ABLOY brand Markar offers the DSH1000. The DSH1000 not only provides ligature resistance as a continuous hinge, but it also can be employed as part of an anti-barricade strategy, because it allows a door to swing in either direction up to 100 degrees. In fact, Ward says, combining the hinge with the Pemko Emergency Release Stop creates a complete anti-barricade solution.

As for the DSH1000, its pin-and-barrel design supports door weights of up to 600 pounds, and it has a hinge frame and door leaf offset of three-thirty-seconds of an inch, which helps to reduce ligature points at the top of the opening. It’s available in lengths of 84, 96 and 120 inches.

In addition, the DSH1000 has an optional electrified module that allows for easy access to wires without having to remove a door from the frame.

More info:

Schlage HSLR Series

The HSLR Series from Allegion brand Schlage, which features a D-shaped sliding handle in cylindrical and mortise versions, is a good example of OMH’s influence on the industry, Parker says. The design, which has been out for about a year, came as a direct result of the OMH guidelines.

Recent research found new ways to create ligature points off products previously rated at the top of the OMH scale, he says. “The HSLR brought us back to the top standard in the guideline and provide a safer product.” The HSLR even carries OMH’s newer paper clip rating, which indicates that it resists attempts to create a ligature through the use of a paper clip.

A variety of options are available for either lockset, including electrification. Schlage notes that the handle complies with ADA for no pinching or grabbing, and both locks are Grade 1 certified for their respective BHMA standards.

Keying: 6-pin patented Schlage Everest 29, additional options available

More info:

TownSteel MXR-A, CXR-A series

As with other manufacturers, TownSteel has advanced to five-point ligature-resistant hardware, in mortise (MXR-A) and cylinder (CXR-A) versions. That the locksets and handles achieve the highest standard for ligature resistance — OMH’s paper-clip standard — is because of two things: design and manufacturing, Ma says.

“These are all very tight tolerances,” he says of the machining on the locks. “We still have to do a lot of tests in the process to make sure that we don’t have a tolerance gap that’s larger than required. It’s a very high standard.”

Both versions are BHMA Grade 1 certified and come with multiple optional variations, including electrification (XMXR-A) and an auxillary deadlatch for the mortise version. The mortise version also has through-bolt mounting in addition to the temper-resistant mounting screws that come with the cylinder version. Both versions meet ADA standards.

Keying: 6-pin Schlage C keyway, other OEM interchangeable cores, 6-pin TownSteel L high-security keyway available

More info:

About the Author

Will Christensen | Senior Editor

Will Christensen is senior editor at Locksmith Ledger International. He has been an editor and reporter at magazines and newspapers for more than 30 years.