Alarm systems are designed to protect patients. But when alarms trigger too frequently, they can create a dangerous new problem: alarm fatigue.
In mental health environments, an ignored alarm could mean a missed opportunity to intervene during a ligature attempt. Research has shown that alarm fatigue can have fatal consequences when staff become desensitised to repeated alerts.
This challenge became clear at Aspen Wood, Mersey Care NHS Foundation Trust’s 40-bed low secure unit for people with learning disabilities. The ward had installed 67 full-door ligature alarm systems, designed to detect sustained loads anywhere on a door and alert staff to potential self-harm incidents.
However, shortly after installation the system began generating more than 600 alarms per month, often triggered by routine ward activity rather than genuine risk events.
Frontline staff reported hearing 10–20 alarms per day, creating noise, disruption and growing concern that critical alerts could eventually be overlooked.
Recognising the potential patient safety risk, Mersey Care NHS Foundation Trust partnered with Safehinge Primera and Pinpoint to launch a collaborative Quality Improvement (QI) initiative.
A cross-functional working group was formed including clinicians, estates managers, patient safety leads and technology partners. The goal was not to eliminate alarms completely, but to reduce nuisance alerts while preserving true safety signals.
Through detailed analysis of alarm data and ward activity, the team implemented several targeted improvements:
• Adjusting the alarm weight sensitivity threshold from 7 kg to 15 kg, better aligning with other safety fixtures on the ward while maintaining ligature detection capability.
• Introducing firmware improvements and smarter data logging, allowing the system to better identify and diagnose nuisance triggers.
• Reconfiguring the alarm network so alerts were localised to the ward, rather than broadcasting across the entire hospital.
• Delivering simplified training and quick-reference guides to support clinical and bank staff.
The results were dramatic.
Within weeks, alarm activity dropped from over 600 alarms per month to just 6, representing a 99% reduction in nuisance alarms.
The system was restored to its intended role: a trusted safety aid rather than a constant distraction.
Staff reported improved confidence that when an alarm activates, it is far more likely to indicate a genuine safety concern. The quieter environment also supports calmer therapeutic spaces for service users.
Crucially, this improvement required no major capital investment. Through collaborative analysis, firmware updates and operational changes, the project delivered a significant safety improvement across 67 monitored doors at minimal cost.
The Door Alarm V2 initiative demonstrates how collaboration can transform technology already in place, improving safety while reducing operational burden.
By reducing alarm fatigue while maintaining rapid ligature detection, the project strengthens a fundamental principle of mental health design:
Safety systems must support clinical care, not overwhelm it.
Looking ahead, Mersey Care’s Aspen Wood can serve as a model of best practice that we’re actively rolling with other mental health Trusts. This initiative shows that when we listen, learn, and refuse to give up, we can make things better together.
