When it comes to service user safety in mental health settings, every second counts. That’s why Aspen Wood, Mersey Care NHS Foundation Trust’s new 40-bed low secure unit for people with learning disabilities, installed 67 full-door ligature alarm systems. These innovative systems transform the entire door into a weighing scale, detecting sustained loads and triggering an alert so staff can proactively intervene and save lives.
But frontline NHS teams soon identified a significant challenge: frequent false alarms. These alarms—though well-intentioned—were disruptive, desensitising, and a barrier to the calm, therapeutic environment essential for recovery.
We listened. Then we acted. Together with Mersey Care, we launched a Quality Improvement (QI) initiative to understand the root cause and create meaningful change.
The cost of constant alarms
Imagine being a nurse on a mental health ward, where a ligature alarm sounds 10–20 times a day. Each alert demands urgent attention, yet almost every time it’s a false alarm.
Understandably, staff began to experience alarm fatigue—a recognised clinical risk where repeated exposure leads to desensitisation, slower responses, or missed alerts. In mental health care, that delay can mean the difference between life and death.
A 2024 NIHR review warned that alarm fatigue related to surveillance technology can have fatal consequences. A tragic example occurred in Essex, where an 18-year-old was found unresponsive after staff failed to respond for over 52 minutes to a bathroom sensor. The inquest revealed staff had become desensitised to frequent alerts from their digital monitoring system.
Aspen Wood’s challenge: 600+ alarms a month
At Aspen Wood, alarm overload was quickly identified as a patient safety and operational issue. Mersey Care brought together a cross-functional working group: clinicians, Estates and patient safety leads, our product development team (Safehinge Primera), and Pinpoint (staff attack alarm system provider).
Their goal was clear: while zero alarms wasn’t realistic, significantly reducing the volume—ideally to one per day—was achievable with the right solutions.
When NHS teams tell us there’s a problem, we lean in. The improvements we made at Aspen Wood were the result of honest conversations, deep listening, and real action.
— Martin Izod, Chief Product Officer, Safehinge Primera
Smart changes with powerful results
Several key improvements emerged:
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Adjusted weight sensitivity: The original 7 kg threshold was overly sensitive compared to other room safety systems. Increasing it to 15 kg sharply reduced false positives while maintaining protection. This threshold can still be lowered for other service user groups, like those with eating disorders.
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Firmware enhancements: New updates improved battery life and introduced smarter data logging. These updates help staff understand common triggers (e.g., wedging the door or hanging items), reducing nuisance alarms and guiding better practices.
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Localised, silent alerting: Previously, one alert echoed hospital-wide. Now, alerts notify only the local ward—minimising disruption while preserving the ability to escalate in emergencies. Mersey Care had already adopted silent alarms to reduce distress for service users with learning disabilities—now this approach is becoming a national model.
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Staff training: Refreshed materials, including a quick-reference poster and hands-on sessions using our mobile training unit Doora, helped boost staff confidence. Effective tech requires confident users.
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Integrated support: Safehinge Primera and Pinpoint created a joint troubleshooting guide and enhanced communication between systems, enabling faster resolution of technical issues and clearer accountability.
From 600 alarms to just 6
The transformation was dramatic. By April 2025, Safehinge Primera’s data showed alarm rates had plummeted—from over 600 to just 6. The system was restored to its intended role: a reliable safety aid, not a constant distraction.
With continual monitoring, adjustable thresholds, and improved firmware, the system supports staff in focusing on care while ensuring service user safety.
When the built environment adds noise instead of support, Estates teams are asked to act fast. What made this initiative work was the openness on all sides. Together, we made the full-door ligature system smarter and safer—and created a model for other NHS Trusts.
— Chris Murphy, Assistant Director of Estates and Facilities, Mersey Care NHS Trust
A model for best practice
Aspen Wood’s journey is a powerful example of how alarm fatigue can be overcome through collaborative problem-solving, technical innovation, and a commitment to continuous improvement.
By working together—clinicians, engineers, estates, and suppliers—we delivered real change. And now, these improvements are being applied in mental health units across the country.
This initiative reminds us of a central truth: technology must support, not hinder, human care. When we stay curious, open, and determined, we can design better—and protect better.
Sources:
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HSSIB – Investigation into staff fatigue and patient safety, hssib.org.uk
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Griffiths et al., 2024 – Surveillance technology in mental health inpatient settings, medrxiv.org
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BBC News – Essex mental health patient died despite staff alarm – inquest, bbc.com
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Mersey Care NHS – Aspen Wood Full Door Ligature Alarm Review (Quality Improvement Initiative)