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Preventing Self-Harm: A Call for Strongwear Specific Guidelines

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About The Author

Jonathon Wright (Guest Contributor)

Jonathon read Law LLB (Hons) at Newcastle University. He was subsequently awarded a major Middle Temple Scholarship for the BPTC, which he undertook at Nottingham Law School, completing it in June 2014. Jonathon is currently a paralegal and writing an LLM at Nottingham Law School. Outside of law, Jonathon is a keen linguist, having taught himself several languages.

Credit: Patient Care Technician

From caring comes courage.

Lao Tzu

The National Institute for Health and Care Excellence (NICE) provides a raft of comprehensive guidance on a range of clinical practices. Such guidance has extended to 850 pieces to date, focused upon producing evidence-based advice and recommendations. The guidance prescribed by NICE is to orchestrate the best clinical practice; giving healthcare providers a marker on which to base their policies. However, despite the coverage of many clinical practices, there remains an absence of specific guidance relating to ‘strongwear’.

What is Strongwear?

In its simplest form, strongwear is a virtually untearable material that can replace general clothing and bedding. The primary purpose of strongwear is self-harm prevention. Therefore, it is readily used in secure units, chiefly for those detained under a section of the Mental Health Act 1983. Its preventative function inhibits patients using torn material as ligatures and its value in a secure setting for precluding self-harm or suicide is self-apparent.

The Current Practice

At present, the most relevant guidance NICE provides on issuing strongwear to detained patients refers to ‘self-harm’, ‘violence’, and ‘self-harm – longer term management’. While having this general self-harm guidance in place is helpful in that it ostensibly aids clinical decisions, it fails to address the specific issue of strongwear. Furthermore, it fails to prescribe principles on which to act.

To illustrate the lack of strongwear guidance, it is useful to contrast the current position on strongwear to that of observation levels. NICE currently prescribes observation guidelines on the following;

  • Who can increase or decrease observation levels;
  • In which situations the varying levels of observation are required;
  • Certain variables that may dictate the level of observation required;
  • How to carry out each level of observation;
  • Who to inform when observations have been altered.

The position on observations is unequivocally detailed and clear as to what the best practice is. Unfortunately, the guidance on issuing strongwear to patients fails to emulate such detail.

The Problem of Such Sparse Guidance

It was apparent from the inquest touching the death of Rebecca Overy at Nottingham Coroner’s Court that understanding of the relevant and best strongwear practice was blurred, with the problem unquestionably attributable to a lack of guidance from NICE. For example, ward staff had no form of direction on issuing strongwear to patients, and the lack of understanding extended to what variables constitute putting a patient in strongwear clothing, who could issue and remove the strongwear, and – more generally – the best way to operate a strongwear policy.  

Further, Overy had a history of self-harm and was considered a high self-harm risk. Specifically, she had a history of self-harming by ligating; using material from her clothing or bedding as an implement. It was confirmed that at the time Overy was found in her room having ligated, she had not been issued strongwear clothing despite forty incidents of self-harm in a three month period. As part of the conclusion, the jury found that the five-minute gap in her observation plan gave Overy the opportunity to ligate.

In light of this, it seems that the logical conclusion is – putting the observation levels aside – if clear guidance from NICE had been in place, a proper decision could have been made about placing her in strongwear clothing or not. This is not to say that had the guidance been in place, she would have been placed in strongwear. Instead, the point is that if the guidance was in place, it would have given staff a marker in making a decision knowing that such decision is grounded on the best practice principles. Unfortunately, such a marker was – and still is – absent from NICE’s guidance.

What Should Such Guidance Contain?

In order to provide sound guidance, the best practice that is endorsed by NICE must be one that is detailed. Indeed, given the extensive needs of patients, it must be applicable in a range of circumstances. What is more, the guidance needs to encourage medical staff to utilise their discretion to act based on circumstances that can readily fluctuate. For example, in secure units, by virtue of their nature, it is far from uncommon for patients to display rapid changes in mood and disposition. Therefore, it is recommended that the strongwear guidance is commensurate to the current practice guidelines for observation levels, both in detail and in scope.

The following is recommended as illustrations of what should be included in such strongwear guidance:

  • Who Can Place a Patient in Strongwear?

In line with the theme of the guidance on observations, any member of the ward staff – whether that be a Doctor, Nurse, or Healthcare Assistant  should be empowered to authorise to use of strongwear. Placing a patient in strongwear should occur if a staff member senses imminent self-harm or a certain trigger factor for the patient is present. The issuing of strongwear should then be retrospectively authorised by the Responsible Clinician.

The reason for this is twofold: firstly, staff must be able to respond immediately to the circumstances that present themselves and act in the patient’s best interests. Secondly, if the permission of a Responsible Clinician was to be obtained prior to placing a patient in strongwear, this increases the risk of self-harm due to the delay in waiting for permission. Understandably, this would not be in the patient’s best interests.

  • Who can Authorise the Removal of Strongwear?

Strongwear should only be removed with the prior consent of the Responsible Clinician. The reason for this is that removing the strongwear puts the patient at far greater risk. Therefore, the level of assessment must be commensurate with the risk involved in order to ensure the patient’s safety.

  • When Should Strongwear be Removed?

This point requires discretion, and a detailed assessment of the patient’s individual presentation. Referring back to the inquest regarding Rebecca Overy’s death, Overy’s individual presentation consisted of vigorous fluctuations in mood and demeanour. Therefore, the removal of strongwear in a case analogous to hers may have occurred when she presented well. However, the risk still remained that she could descend into a vulnerable state quickly. As such, a detailed assessment must be required in order to gauge the level of risk posed by the patient to themselves.   

  • What Trigger Factors Should Indicate That Strongwear is Desirable?

The trigger factors should replicate the current NICE guidance on observations. As non-exhaustive examples, regard should be had to: the patient’s history of self-harm; personal trigger factors; and the side effects of medications.

  • Strongwear’s Interplay with Observation Levels

The purpose of strongwear is harm prevention. Observation levels mirror this in serving such a purpose. Therefore, there is somewhat of an interaction between the two. Evidently, if strongwear is issued, the need for increased levels of observation subsides. In a similar vein, if observations are increased, the need for strongwear will be reduced, simply because the opportunity to self-harm is reduced. Therefore, the guidance needs to take account of the interplay between the two so as to ensure the safety of the patient whilst not creating an unnecessary overlap in resources. For example, there is little merit in prescribing one-to-one observations in touching distance and simultaneously issuing the patient

Therefore, the guidance needs to take account of the interplay between the two so as to ensure the safety of the patient whilst not creating an unnecessary overlap in resources. For example, there is little merit in prescribing one-to-one observations and simultaneously issuing the patient strongwear.

  • Balancing the Use of Strongwear with the Patient’s Dignity

It is ostensible that strongwear is visually unappealing and an unpopular item of clothing to be worn by patients. As such, there is a need to limit the time a patient is in strongwear to preserve their dignity. Indeed, NICE recognises such a requirement to preserve patient dignity. This point, however, cannot be taken in isolation. Instead, it has to be balanced in connection with preventing self-harm and acting in the patient’s best interests. To achieve such balance between safety and dignity is not an easy task. What is more, at its core, this balance hinges on the judgement of a Responsible Clinician. Thus, whilst provision in the guidance should be made for promoting patient dignity, the overriding concern should be the patient’s safety.


Detailed guidance from NICE is required. It is remarkable that there is an absence of NICE guidance specifically addressing this issue; especially given the wide-ranging guidance on a vast array of clinical practices. Such guidance is required to give medical staff treating patients a clear guide, but also allow them to act in the knowledge that their decisions are based on sound guidance. By having this, the overriding objective of ensuring patient safety and acting in the best interests of patients could be more effectively achieved in contrast to the measures current in place. 

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Tagged: Medical Law & Ethics

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