Best Practice in Managing Risk · RAMAS: Risk Assessment Management and Audit Systems 36 GIRAFFE:...

Best Practice in Managing Risk

Principles and evidence for best practice in the assessment and management of risk to self and others in mental health services

Document prepared for theNational Mental Health Risk Management Programme

June 2007

DH InformatIon reaDer BoX

Policy EstatesHR/Workforce PerformanceManagement IM&TPlanning FinanceClinical PartnershipWorking

Document purpose BestPracticeGuidance

Gateway reference: 8079

title BestPracticeinManagingRisk

author DepartmentofHealth,NationalRiskManagementProgramme

Publication Date 14June2007

TargetAudience PCTCEs,SHACEs,CareTrustCEs,FoundationTrustCEs,DirectorsofPH,LocalAuthorityCEs,DirectorsofAdultSSs,AlliedHealthProfessionals,GPs,DirectorsofChildren’sSSs

Circulation list VoluntaryOrganisations/NDPBs

Description Thisframeworkisaguideformentalhealthprofessionalsworkingwithserviceuserstoassessrisk.Itunderpinsriskassessmentwithprinciplesofgoodpracticeforallmentalhealthsettingsandprovidesalistoftoolsofferingstructuretoriskmanagement.

Cross reference ReviewingtheCareProgrammeApproach2006

Superseded document N/A

action required None

timing None

Contact details DawnFlemingNationalRiskManagementProgrammeLondonDevelopmentCentre11-13CavendishSquare,LondonW1G0AN02073072431www.nimhe.csip.org.uk/risktools

for recipient’s use

Foreword by the National Director for Mental Health, Professor Louis Appleby 3

Executive summary 4

16 best practice points for effective risk management 5

Introduction 7

Fundamentals 9

Basicideasinriskmanagement 13

Workingwithserviceusersandcarers 21

Individualpracticeandteamworking 25

Appendix 1: Tools for supporting best practice 30

Preamble 30

Overview 32

Multiplerisks 33CRMT:ClinicalRiskManagementTool/WorkingwithRisk 33FACE:FunctionalAnalysisofCareEnvironments 34GRiST:GalateanRiskScreeningTool 35RAMAS:RiskAssessmentManagementandAuditSystems 36GIRAFFE:GenericIntegratedRiskAssessmentforForensicEnvironments 37START:Short-termAssessmentofRiskandTreatability 38

Riskofviolenceorsexualviolence,andantisocialoroffendingbehaviour 39HCR-20:HistoricalClinicalRisk-20 39PCL-R:PsychopathyChecklist-Revised 40PCL:SV:PsychopathyChecklist:ScreeningVersion 41STATIC-99 42SVR-20:SexualViolenceRisk-20 43VRAG:ViolenceRiskAppraisalGuide 44

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Contents

BestPracticeinManagingRisk

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Riskofsuicideorself-harm 45ASIST:AppliedSuicideInterventionSkillsTraining 45BHS:BeckHopelessnessScale 46SADPERSONS 47SIS:SuicidalIntentScale 48SSI:ScaleforSuicideIdeation 49STORM:Skills-basedTrainingonRiskManagement 50

Appendix 2: Risk factors for violence and suicide 51

Appendix 3: 12 points to a safer service 54

Appendix 4: Glossary 56

Appendix 5: Methods used to develop this framework 59

Appendix 6: Acknowledgements 62

References 66

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Safetyisatthecentreofallgoodhealthcare. Thisisparticularlyimportantinmentalhealthbutitisalsomoresensitiveandchallenging. Patientautonomyhastobeconsideredalongsidepublicsafety. Agoodtherapeuticrelationshipmustincludebothsympatheticsupportandobjectiveassessmentofrisk.

Inproducingthispracticalbestpracticeadvice,wewanttosupportservicesinadoptingamoresystematicapproachtoriskassessmentandmanagement–atindividualpractitioner,teamandorganisationallevel. Theaimistoembedriskmanagementinday-to-daypractice,inparticularaspartoftheCareProgrammeApproach(CPA).

WeknowthatanunacceptablenumberofpatientswhodiebysuicideorcommithomicidehavenotbeensubjecttoenhancedCPA,despiteindicationsofrisk. Wealsoknowthatstaffsometimesfeelunabletointervenetoreducerisk,feelingthattragediesareinevitable.

Thisdocumentoffersguidanceonwhatcanbedone. Itisunrealistictoexpectservicestopreventalldeaths,buttheclinicalmanagementofriskcanbestrengthened.

AtthemomentweareupdatingtheMentalHealthActtobringitinlinewithcommunity-basedpractice. Anewpower–supervisedcommunitytreatment–willbeintroducedtohelptoensurethathigh-riskandvulnerablepatientsreceivethetreatmentthattheyneedafterhospitaldischarge. Itisas importanttohavetherightlegalpowersasitistohavethebestclinicalpractice:botharepartofthevitaltaskofimprovingsafety.

Foreword by the National Director for Mental Health, Professor Louis Appleby

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Thisframeworkdocumentisintendedtoguidementalhealthpractitionerswhoworkwithserviceuserstomanagetheriskofharm.Itsetsoutaframeworkofprinciplesthatshouldunderpinbestpracticeacrossallmentalhealthsettings,andprovidesalistoftoolsthatcanbeusedtostructuretheoftencomplexriskmanagementprocess.Thephilosophyunderpinningthisframeworkisonethatbalancescareneedsagainstriskneeds,andthatemphasises:

• positiveriskmanagement;

• collaborationwiththeserviceuserandothersinvolvedincare;

• theimportanceofrecognisingandbuildingontheserviceuser’sstrengths;and

• theorganisation’sroleinriskmanagementalongsidetheindividualpractitioner’s.

Organisations,careteamsandindividualpractitionersshouldbenchmarktheircurrentpracticeagainsttheprinciplessetouthere,andconsiderwaysofmovingtowardsembeddingtheseprinciplesindailypractice.Theyshouldalsoexaminethelistoftoolsgivenhereandconsiderhowtheirpracticecouldbeimprovedbyincorporatingoneormoreofthetoolsintotheirriskassessmentandriskmanagementpractice.

Executive summary

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Summary

Introduction

1. Bestpracticeinvolvesmakingdecisionsbasedonknowledgeoftheresearchevidence,knowledgeoftheindividualserviceuserandtheirsocialcontext,knowledgeoftheserviceuser’sownexperience,andclinicaljudgement.

Fundamentals

2. Positiveriskmanagementaspartofacarefullyconstructedplanisarequiredcompetenceforallmentalhealthpractitioners.

3. Riskmanagementshouldbeconductedinaspiritofcollaborationandbasedonarelationshipbetweentheserviceuserandtheircarersthatisastrustingaspossible.

4. Riskmanagementmustbebuiltonarecognitionoftheserviceuser’sstrengthsandshouldemphasiserecovery.

5. Riskmanagementrequiresanorganisationalstrategyaswellaseffortsbytheindividualpractitioner.

Basic ideas in risk management

6. Riskmanagementinvolvesdevelopingflexiblestrategiesaimedatpreventinganynegativeeventfromoccurringor,ifthisisnotpossible,minimisingtheharmcaused.

7. Riskmanagementshouldtakeintoaccountthatriskcanbebothgeneralandspecific,andthatgoodmanagementcanreduceandpreventharm.

8. Knowledgeandunderstandingofmentalhealthlegislationisanimportantcomponentofriskmanagement.

9. Theriskmanagementplanshouldincludeasummaryofallrisksidentified,formulationsofthesituationsinwhichidentifiedrisksmayoccur,andactionstobetakenbypractitionersandtheserviceuserinresponsetocrisis.

16 best practice points for effective risk management


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10. Wheresuitabletoolsareavailable,riskmanagementshouldbebasedonassessmentusingthestructuredclinicaljudgementapproach.

11. Riskassessmentisintegraltodecidingonthemostappropriatelevelofriskmanagementandtherightkindofinterventionforaserviceuser.

Working with service users and carers

12. Allstaffinvolvedinriskmanagementmustbecapableofdemonstratingsensitivityandcompetenceinrelationtodiversityinrace,faith,age,gender,disabilityandsexualorientation.

13. Riskmanagementmustalwaysbebasedonawarenessofthecapacityfortheserviceuser’sriskleveltochangeovertime,andarecognitionthateachserviceuserrequiresaconsistentandindividualisedapproach.

Individual practice and team working

14. Riskmanagementplansshouldbedevelopedbymultidisciplinaryandmulti-agencyteamsoperatinginanopen,democraticandtransparentculturethatembracesreflectivepractice.

15. Allstaffinvolvedinriskmanagementshouldreceiverelevanttraining,whichshouldbeupdatedatleasteverythreeyears.

16. Ariskmanagementplanisonlyasgoodasthetimeandeffortputintocommunicatingitsfindingstoothers.


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Introduction

RiskmanagementisacorecomponentofmentalhealthcareandtheCareProgrammeApproach.Effectivecareincludesanawarenessofaperson’soverallneedsaswellasanawarenessofthedegreeofriskthattheymaypresenttothemselvesorothers.Manypractitionersmakedecisionseverydayabouthowtohelpaserviceusertomanagetheirpotentialforviolence,self-harm,suicideorself-neglect.Thisframeworkdocumentisintendedtoguidementalhealthpractitionersinmakingthesedecisionsandalsotoguidetheorganisationsthatemploythem.Theframeworkisbasedontheprinciplethatmodernriskassessmentshouldbestructured,evidence-basedandasconsistentaspossibleacrosssettingsandacrossserviceproviders.1,2,3Thisconsistencyisessentialforgoodcommunicationbetweenagenciesandpractitioners.Aconsistentapproachtoriskanditsmanagementwillenablebettercommunicationandwillcontributetoimprovedcare.Allserviceprovidersshouldhaveinplaceasetofpoliciesandproceduresrelatingtothemanagementofrisk,4,5andthisframeworkdocumentshouldbeusedtoinformthesepolicies.

Thisframeworkrelatestothreemainareasofrisk:violence(includingantisocialandoffendingbehaviour),self-harm/suicide,andself-neglect.Itaimstoanswerthisquestion:whatisbestpracticeforconductingriskmanagementintheseareas?Bestpracticeinvolvescombiningthehighestqualityevidencewithprofessionaljudgementaboutthepersonwhoisbeingassessed.ThemainprinciplesofbestpracticearesetouthereandAppendix1containsdetailedinformationonsometoolsthatcanguideriskdecision-making.Thesetoolsaredescribedbelowinordertohelppractitionerstodecidewhichofthemarebestsuitedtothesituationfacedbytheserviceuserswithwhomtheywork.

Best practice point 1:Bestpracticeinvolvesmakingdecisionsbasedonknowledgeoftheresearchevidence,knowledgeoftheindividualserviceuserandtheirsocialcontext,knowledgeoftheserviceuser’sownexperience,andclinicaljudgement.

Theprinciplessetouthereareapplicableinallmentalhealthcaresettings–fromcommunity-basedcare,includingcrisisintervention,assertiveoutreachandearlyinterventionservices,throughtohigh-securitycare.Guidanceabouttools,though,ismorecomplex.Someofthetoolslistedherearedesignedforspecialist(e.g.forensic)servicesandothersforgeneralservices.Somearedeliberatelydesignedtopredictrisk–ofteninspecificgroups–whileothersaredesignedtoaidtheclinicaljudgementofpractitionerswhoaretryingtogainanoverallviewoftheissues.


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Itisvitaltonotethatbothtypesoftoolcanonlycontributeoneelementtoabroaderoverallviewoftheriskspresentedbyaparticularindividual:theyshouldonlybeusedaspartofageneralclinicalassessmentconductedwiththeserviceuser.Andthefindingsoftool-basedassessmentsmustalwaysbecombinedwithinformationonmanyotheraspectsoftheserviceuser’slifeandcurrentsituation.Thetoolsarelistedherebecausetheywillsupporteffectiveandconsistentriskmanagementdecision-making.They are an aid to clinical decision-making, not a substitute for it.

Careteamsshouldconsiderhowtheirriskmanagementprocedurescouldbeimprovedbyintegratingtheprincipleshereandoneormoreofthetoolsintotheiroverallapproach.Byeffectivelycombiningresearchevidencewithclinicalexpertiseinacollaborativeapproach,caseteamswillbeimplementingthehigheststandardsofevidence-basedpractice.6

Fundamentals

Positive risk management

Decisionsaboutriskmanagementinvolveimprovingtheserviceuser’squalityoflifeandplansforrecovery,whileremainingawareofthesafetyneedsoftheserviceuser,theircarerandthepublic.7Positiveriskmanagementaspartofacarefullyconstructedplanisadesirablecompetenceforallmentalhealthpractitioners,andwillmakeriskmanagementmoreeffective.8,9Positiveriskmanagementcanbedevelopedbyusingacollaborativeapproach.10Over-defensivepracticeisbadpractice.Avoidingallpossiblerisksisnotgoodfortheserviceuserorsocietyinthelongterm,andcanbecounterproductive,creatingmoreproblemsthanitsolves. Anyrisk-relateddecisionislikelytobeacceptableif:

• itconformswithrelevantguidelines;

• itisbasedonthebestinformationavailable;

• itisdocumented;and

• therelevantpeopleareinformed.11

Aslongasadecisionisbasedonthebestevidence,informationandclinicaljudgementavailable,itwillbethebestdecisionthatcanbemadeatthetime.

Safety first

Giventhenatureofseverementalillness,therewillalwaysbecircumstancesinwhichdecisionsaboutthecareplanaregoingtobedominatedbyimmediateconcernsaboutthesafetyoftheserviceuserandothers.Lackofinsightand


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non-adherencetotreatmentplansthathavebeenputinplacetoreducepsychopathologicalsymptomsareparticularlychallengingaspectsoftherelationshipbetweentheserviceuserandthepractitioner.Psychopathologicalsymptomscanseriouslyimpactonaserviceuser’sabilitytocriticallyassesstheimplicationsofsomeoftheiractions,andthiscanresultinunpredictableandpotentiallydangerousbehaviour.Inthesesituations,practitionershavetotakedecisionsonbehalfofaserviceuserwiththeirbestinterestsinmind.TheuseoftheMentalHealthActmaywellbepartofthemostappropriateriskmanagementstrategyhere.Acollaborativeapproachbasedontheprinciplesofpositiveriskmanagementisstilltheaim,butclearlythiswillrequirespecialeffortsinthesesituations.

Best practice point 2:Positiveriskmanagementaspartofacarefullyconstructedplanisarequiredcompetenceforallmentalhealthpractitioners.


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Box 1: What is positive risk management?

Positiveriskmanagementmeansbeingawarethatriskcanneverbecompletelyeliminated,andawarethatmanagementplansinevitablyhavetoincludedecisionsthatcarrysomerisk.Thisshouldbeexplicitinthedecision-makingprocessandshouldbediscussedopenlywiththeserviceuser.

Positiveriskmanagementincludes:

• workingwiththeserviceusertoidentifywhatislikelytowork;

• payingattentiontotheviewsofcarersandothersaroundtheserviceuserwhendecidingaplanofaction;

• weighingupthepotentialbenefitsandharmsofchoosingoneactionoveranother;

• beingwillingtotakeadecisionthatinvolvesanelementofriskbecausethepotentialpositivebenefitsoutweightherisk;

• beingcleartoallinvolvedaboutthepotentialbenefitsandthepotentialrisks;

• developingplansandactionsthatsupportthepositivepotentialsandprioritiesstatedbytheserviceuser,andminimisetheriskstotheserviceuserorothers;

• ensuringthattheserviceuser,carerandotherswhomightbeaffectedarefullyinformedofthedecision,thereasonsforitandtheassociatedplans;and

• usingavailableresourcesandsupporttoachieveabalancebetweenafocusonachievingthedesiredoutcomesandminimisingthepotentialharmfuloutcome.

Anotherwayofthinkingaboutgooddecision-makingistoseeitassupporteddecision-making.Independence, choice and risk12hasthistosay:

“Thegoverningprinciplebehindgoodapproachestochoiceandriskisthatpeoplehavetherighttolivetheirlivestothefullaslongasthatdoesnotstopothersfromdoingthesame.Fearofsupportingpeopletotakereasonablerisksintheirdailylivescanpreventthemfromdoingthethingsthatmostpeopletakeforgranted.Whatneedstobeconsideredistheconsequenceofanactionandthelikelihoodofanyharmfromit.Bytakingaccountofthebenefitsintermsofindependence,well-beingandchoice,itshouldbepossibleforapersontohaveasupportplanwhichenablesthemtomanageidentifiedrisksandtolivetheirlivesinwayswhichbestsuitthem.”


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A collaborative approach to risk management

Aswithallaspectsofmentalhealthcare,thekeytoeffectiveriskmanagementisagoodrelationshipbetweentheserviceuserandallthoseinvolvedinprovidingtheircare.Athree-waycollaborationbetweentheserviceuser,carersandthecareteamcanoftenbeestablished,andthisrelationshipshouldbebasedonwarmth,empathyandasenseoftrust–withtheaimofinvolvingtheserviceuserinacollaborativeapproachtoplanningcare. Fullengagementissometimesnotpossible,butthepotentialforitshouldalwaysbeconsidered.Thismeansthattheprocessofriskmanagementshouldbeexplainedtoeverybodyinvolvedattheearliestopportunity.Thedevelopmentoftheriskmanagementplanitselfshouldbecarriedoutinanatmosphereofopennessandtransparency.If,forwhateverreason,theserviceuserisnotinvolvedinsomeelementofriskmanagement,thisshouldbedocumented.

Best practice point 3:Riskmanagementshouldbeconductedinaspiritofcollaborationandbasedonarelationshipbetweentheserviceuserandtheircarersthatisastrustingaspossible.

Recognising strengths and protective features

Riskmanagementworksbestwhenaserviceuser’sstrengthsarerecognisedalongsidethepossibleproblemsthattheymightencounterandwithwhichtheymightpresent.13Everytimeaproblemisidentified,astrategyshouldbesuggestedanddiscussed,buildingonthepositiveskillsoftheserviceuser.Theemphasisshouldalwaysbeonarecoveryapproachandonthenextstageindevelopingtheserviceuser’sabilitytocopewhentheyarefeelingvulnerableorhavingdifficultdemandsplacedonthem.

Best practice point 4:Riskmanagementmustbebuiltonarecognitionoftheserviceuser’sstrengthsandshouldemphasiserecovery.

Risk management at the organisational level

Riskmanagementisnotjusttheresponsibilityofindividualpractitioners.Organisationsmustadoptanintegratedriskmanagementapproachinwhichrisksaresystematicallyidentified,managedandreduced.TheframeworkgiveninSeven Steps to Patient Safetyshouldguidethedevelopmentofasafetyculturethatlearnsfromnegativeeventsandbuildsgoodpractice.5Thesevenstepsareto:

• buildasafetyculture;

• leadandsupportyourstaff;

• integrateyourriskmanagementactivity;

• promotereporting;


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• involveandcommunicatewithserviceusersandthepublic;

• learnfromandsharesafetylessons;and

• implementsolutionstopreventharm.

Servicesforpeopleatriskofsuicideandself-harmshouldalsobedesignedwiththe‘12Pointstoasaferservice’recommendationsinmind.14,15ThesepointsarelistedinAppendix3.

Best practice point 5:Riskmanagementrequiresanorganisationalstrategyaswellaseffortsbytheindividualpractitioner.

Figure 1: Positive and negative risk management cycles16

Defensive approach to risk

‘Negative events’

Increasingly defensive approach:

escalating risk

Negative experience for the service user

Disengagement from services

No strategy in place to manage risk positively

Defensive risk management

Collaborative approach to risk

Lower risk as strategies for

management are designed and acted upon

Open approach: engaging with the user in planning

for risk

Positive experience for the

service user

More engagement with the process

Greater collaboration with

services

Collaborative riskmanagement


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Basic ideas in risk management

Defining risk and risk management

Itisimportanttobeclearaboutthebasicideasunderpinningthenotionofrisk.Riskrelatestoanegativeevent(i.e.violence,self-harm/suicideorself-neglect) andcoversanumberofaspects.

• Howlikelyitisthattheeventwilloccur.

• Howsoonitisexpectedtooccur.

• Howseveretheoutcomewillbeifitdoesoccur.

Riskassessmentinvolvesworkingwiththeserviceusertohelpestimateeachoftheseaspects.Informationabouttheserviceuser’shistoryofviolence,self-harmorself-neglect,theirrelationshipsandanyrecentlossesorproblems,employmentandanyrecentdifficulties,housingissues,theirfamilyandthesupportthat’savailable,andtheirmoregeneralsocialcontactscouldallberelevant.Riskmanagementtheninvolvesdevelopingoneormoreflexiblestrategiesaimedatpreventingthenegativeeventfromoccurringor,ifthisisnotpossible,minimisingtheharmcaused.Riskmanagementmustincludeasetofactionplans,theallocationofeachaspectoftheplantoanidentifiedprofessionandadateforreview.

Best practice point 6:Riskmanagementinvolvesdevelopingflexiblestrategiesaimedatpreventinganynegativeeventfromoccurringor,ifthisisnotpossible,minimisingtheharmcaused.

Defining risk factors

Ariskfactorisapersonalcharacteristicorcircumstancethatislinkedtoanegativeeventandthateithercausesorfacilitatestheeventtooccur.Riskfactorscanbecategorisedinanumberofways.17

• Static factorsareunchangeable,e.g.ahistoryofchildabuseorsuicideattempts.

• Dynamic factors arethosethatchangeovertime,e.g.misuseofalcohol.Dynamicfactorscanbeaspectsoftheindividualoraspectsoftheirenvironmentandsocialcontext,suchastheattitudesoftheircarersorsocialdeprivation.Becausetheyarechangeable,thesefactorsaremoreamenabletomanagement.

• Dynamicriskfactorsthatarequitestableandchangeonlyslowlyarecalledstableorchronicriskfactors.


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• Thosefactorsthattendtochangerapidlyareknownasacute factorsortriggersand,astheydochangerapidly,theirinfluenceonthelevelofriskmaybeshort-lived.ThekeyriskfactorsidentifiedthroughresearchforviolenceandsuicidearegiveninAppendix2.

Particularsensitivityshouldbeexercisedwhendiscussinghistoricalfactorsfromearlierinthelifeoftheserviceuser.Therelevanceandaccuracyofthesemayneedtobeexplainedtotheserviceuser,anditispossiblethatcarersmaybeunawareofthesehistoricaleventsoroftheirsignificancesomanyyearson.

The purpose of risk management

Theaimofriskmanagementisfirsttoassessthelikelihoodofriskeventsandthentoworkwiththeserviceusertoidentifywaysofreducingthelikelihoodofthemoccurring.Riskmanagementshouldbebasedonaplantoreducetheriskofharmoccurringandincreasethepotentialforapositiveoutcome.Itisimportantthatcareteamsandtheserviceuserhaveaclearideaaboutwhatrisktheyareassessingandwhytheyarecarryingoutariskassessment.18Riskassessmentshouldbeusedtoidentifythecircumstancesinwhichaparticularharmfulbehaviourcouldpossiblytakeplace,andthisinformationcanthenbeusedtofocuseffortsandexpertiseondealingwiththemostrelevanttriggers.Ariskmanagementplanincludesanawarenessofthepotentialforchangesinthelevelofriskovertime.Thisrequiresaparticularemphasisonthedynamicfactorsoutlinedabove,aswellasattentiontoregularlyreviewrisksandtheirmanagement.

Best practice point 7:Riskmanagementshouldtakeintoaccountthatriskcanbebothgeneralandspecific,andthatgoodmanagementcanreduceandpreventharm.

Risk management and the Care Programme Approach

RiskmanagementispartoftheCareProgrammeApproach(CPA)andshouldbealignedcloselywithit.19TheCPAinvolvesidentifyingspecificinterventionsbasedonanindividual’ssupportneeds,takingintoaccountsafetyandriskissues.Careplansshouldbedrawnuptomeetalloftheserviceuser’sneeds,includingthoseneedsrelatingtorisk.Thiscreatesarecordedmanagementplanfortheelementsofrisktobothselfandothers.20Theoutcomeoftheriskassessmentshouldalsofeedbackintooverallclinicalmanagement,sinceEnhancedCPA(ratherthanStandard)shouldbeappliedincaseswherethereisanincreasedriskrelatedtomentalhealthproblemsofharmingoneselforothers.Thesestepshelptosupportthecontinuityofcare,whichisessentialforeffectiveriskmanagement.


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Risk management and the Mental Health Act

Giventhenatureofmentalhealthproblems,thereareoccasionswhereserviceshavetointervenewithouttheuser’sconsent:theMentalHealthActisusedregularlytomanageariskofharmtoselfandothers.Itshouldalwaysbeseenasalastresortanditisimportantthatserviceuserswhoneedtobetreatedunderconditionsofcompulsiongetthehelpthattheyneed.UsingtheActdoesnotremovetheneedfordiscussionwiththeserviceuser–itisstillnecessarytomaximisetheserviceuser’sautonomyasmuchaspossiblewithintherestrictions.AgoodknowledgeoftheAct–anditsassociatedCodeofPracticeandMemorandum–isessentialtogoodriskmanagementinmentalhealth.TheGovernmentiscurrentlyupdatingtheMentalHealthActandproposalsincludeintroducingsupervisedcommunitytreatmentwiththeaimofimprovingsafetyforpatientslivinginthecommunity,andabolishingthetreatabilitytestwiththeaimthatpatientswithpersonalitydisorderreceiveappropriateriskmanagement.

Best practice point 8:Knowledgeandunderstandingofmentalhealthlegislationisanimportant componentofriskmanagement.

Screening and prioritising cases

Serviceuserswillvaryinthedegreetowhichtheyneedaformalriskmanagementplan.Screeningforriskandneedsshouldbepartofaroutinementalhealthassessment,butisnotanendinitselfandshould,wherenecessary,leadtofurtheraction.Someserviceuserswillbeidentifiedasapriorityformorein-depthassessmentandinterventionasaresultofthisroutinescreening,orwillidentifythemselvesasinneed.Generalandforensicserviceshavedifferentdegreesofexperienceofworkingwithviolence,andsotheyshouldworktogethertoensurethattherightlevelofassessmentisconductedinallcases.Asecondopinionshouldbesoughtfromspecialistserviceswhenappropriate,forinstanceifaserviceuserhasahistoryofseriousviolence.

Duty of care to those who present a risk and others

Asabasicprinciple,allmentalhealthprofessionalsrecognisethatreducingtheriskofself-harm,suicideandself-neglectispartofthepractitioner’sfundamentaldutytotrytoimproveaserviceuser’squalityoflifeandrecovery.Thereisalsoaclearprofessionaldutyofcaretoaserviceuserwhopresentsahighriskofharmtootherswhenthisriskisduetoamentalhealthproblem–thisdutymayincludetacklingstigmaanddiscrimination.Thereisalsoadutyofcaretootherserviceusers,otherprofessionalsandwidersociety.Inmanycases,improvingaserviceuser’squalityoflifemayhavewiderbenefitsforothers,suchasreducingtherisktovulnerablegroupsofpotentialvictims,includingchildren.Thesegoalsaremost


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likelytobeachievedinthecontextofagoodrelationshipbetweentheserviceuserandthoseprovidingtheircare.

Box 2: Supplementary NICE guidance on the short-term management of self-harm21

Respect, understanding and choice Peoplewhohaveself-harmedshouldbetreatedwiththesamecare,respectandprivacyasanypatient.Inaddition,healthcareprofessionalsshouldtakefullaccountofthelikelydistressassociatedwithself-harm.

Triage Allpeoplewhohaveself-harmedshouldbeofferedapreliminarypsychosocialassessmentattriage(orattheinitialassessmentinprimaryorcommunitysettings)followinganactofself-harm.Assessmentshoulddetermineaperson’smentalcapacity,theirwillingnesstoremainforfurtherpsychosocialassessment,theirlevelofdistressandthepossiblepresenceofmentalillness.

Assessment of risk Allpeoplewhohaveself-harmedshouldbeassessedforrisk.Thisassessmentshouldincludeidentificationofthemainclinicalanddemographicfeaturesknowntobeassociatedwiththeriskoffurtherself-harmand/orsuicide,andidentificationofthekeypsychologicalcharacteristicsassociatedwithrisk–inparticulardepression,hopelessness–andcontinuingsuicidalintent.

Psychological, psychosocial, and pharmacological interventions Followingpsychosocialassessmentforpeoplewhohaveself-harmed,thedecisionaboutreferralforfurthertreatmentandhelpshouldbebaseduponacomprehensivepsychiatric,psychological,andsocialassessment,includinganassessmentofrisk,andshouldnotbedeterminedsolelyonthebasisofhavingself-harmed.

Thisguidanceisavailablefrom:www.nice.org.uk/guidance/CG16/quickrefguide/pdf/English

Planning risk management

Riskassessmentonlyhasapurposeifitenablesthecareteamandtheserviceusertodevelopaplanofactioninspecificareastomanagetherisksidentified.Thisplanshouldbedevelopedwiththeserviceuserandtheircarer,andshouldberegularlyreviewed.


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Risk formulation

Riskformulationisaprocessinwhichthepractitionerdecideshowtheriskmightbecomeacuteortriggered.22Itidentifiesanddescribespredisposing,precipitating,perpetuatingandprotectivefactors,andalsohowtheseinteracttoproducerisk.Thisformulationshouldbeagreedwiththeserviceuserandothersinvolvedintheircareinadvance,andshouldleadtoanindividualisedriskmanagementplan.Everyriskformulationshouldhaveattachedtoitaplanforwhattodowhenthewarningsignsbecomeapparent.Theplanshouldalsoincludemoregeneralaspectsofmanagement,suchasmonitoringarrangements,therapeuticinterventions,appropriateplacementsandemploymentneeds.

Best practice point 9:Theriskmanagementplanshouldincludeasummaryofallrisksidentified,formulationsofthesituationsinwhichidentifiedrisksmayoccur,andactionstobetakenbypractitionersandtheserviceuserinresponsetocrisis.

Figure 2: The risk management planning cycle

Risk assessment

Risk formulation: how does the risk become acute or triggered?

Specific risk management plan:

what to do when the warning signs are

apparent

Review dates

General risk management plan:

monitoring arrangements, etc.

Risk management

planning


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Types of risk assessment

Therearethreemainapproachestoriskassessment.

• Inthepast,riskassessmentwasanecdotalandinconsistent.Itwasbasedonlyonalargelyunstructured clinical approachwhereinformationobtainedinthecourseofanongoingclinicalassessmentwasconsidered.Thisinformationwasnotgatheredsystematically,andanyinformationconsideredrelevantwasnotenteredintotheformulationofriskinaconsistentandstandardisedway.

• Theactuarial approachtoriskassessmentfocusesonstaticriskfactorsthathavebeenshowntobestatisticallyassociatedwithincreasedriskinlargesamplesofpeople.Aformulaicapproachisusuallyused:anoverallscoreiscalculatedasanindicatorofpresumedriskoveraspecifictimeperiod,generallymeasuredinyears.Thisapproachshouldbeusedwithcautionwithindividualpatientsinclinicalpractice.Errorsarelikelytooccuriftoolsbasedonthisapproachareusedtopredictriskratherthantomanageit.Theyshouldonlybeusedasonepartofanoverallriskassessment.

• Structured clinical (or professional) judgementistheapproachthatoffersthemostpotentialwhereviolenceriskmanagementistheobjective.Thisapproachinvolvesthepractitionermakingajudgementaboutriskonthebasisofcombining:

– anassessmentofclearlydefinedfactorsderivedfromresearch;

– clinicalexperienceandknowledgeoftheserviceuser;and

– theserviceuser’sownviewoftheirexperience.

Best practice point 10:Wheresuitabletoolsareavailable,riskmanagementshouldbebasedonassessmentusing thestructuredclinicaljudgementapproach.

Alltool-basedassessmentsshouldbeconductedasonepartofathoroughandsystematicoverallclinicalassessment.Thisisparticularlyimportantwhenassessingtheriskofsuicideandself-harm,asthereiscurrentlynoinstrumentwithasufficientlystrongevidencebase.


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Structured risk assessment

Riskmanagementinmentalhealthcareshouldbestructured andconsistent.1Itshouldbeexplicittotheserviceuserandshouldinvolvetheserviceuser’sownpriorities.Itshouldalsoincludethestructuredclinicaljudgementoutlinedabove.Decisionsaboutcareandsecurityshouldnotbebasedsimplyonthelargelyunstructuredclinicalapproach,whichcouldbesubjecttopersonalbiasesabouttheserviceuserandmaymissimportantfactorssuchastheserviceuser’sstrengthsandresourcesortheviewsofthecarer.Thesebiasescouldleadtopoorjudgementswheretheriskiseitheroverestimatedorunderestimatedifkeyfactorsaremissed.Thisisespeciallytrueifthejudgementsaremadebyanindividualpractitioneraloneratherthanbyaclinicalteamworkingtogether.Ifitisnotcleartotheserviceuserthattheirriskisbeingassessed,theprincipleofengagementisbroken.

Providing care proportionate to risk

Afundamentalprincipleofmentalhealthcareisthatthelevelofsecuritytowhichaserviceuserissubjectedshouldbeasnon-restrictiveaspossibleandshouldbeproportionatetothedegreeofriskthattheyactuallypresentatthetime.20Riskassessmentcanbeintegraltodecidingontherightlevelofinterventionandsupportforaserviceuser.Whenitisdoneproperly–usingtheprinciplesofinvolvement,workingtogetherandindividualisedsupport–riskmanagementisempoweringratherthandisempoweringfortheserviceuser23andcanbeavitalpartofrecovery.

Best practice point 11:Riskassessmentisintegraltodecidingonthemostappropriatelevelofriskmanagementandtherightkindofinterventionforaserviceuser.

Embedding risk management in everyday practice

Theinformationthatinformsariskmanagementplancanbebasedonspecialinterviewsorreports,butriskmanagementisalsobasedonroutinepracticesinmentalhealthcare.Theseroutinepracticesincludeenhancedobservationandpreventingabscondingwherethisisappropriate.19Thinkingaboutandrecordingriskmanagementdecisionsisnotan‘add-on’topractice,butshouldproduceastructuredanddocumentedversionoftheclinicaljudgementsthatpractitionersmakeeveryday.Thisformalversionofeverydaypracticeshouldincreasetheconfidenceofpractitionerswhenmakingdecisions,especiallyiftheyareworkingcollaboratively.


20

Box 3: A brief critique of three approaches to risk assessment

Unstructured clinical approach Sincethisisnotastructuredapproach,importantfactorsmaybemissed.Whilethisunstructuredapproachsometimesprovidesvitalinformation,itisnotafeatureofbestpracticeinplannedandformalriskmanagement.

Actuarial approach Thisapproachhasanumberoflimitations.First,ittendstoignoreriskfactorswhichdonotoccurcommonly.Second,thecapacityoftheactuarialtooltomake‘predictions’onlyapplieswhentheserviceuserbeingassessedcomesfromthepopulationforwhichthetoolwasdeveloped.Third,anemphasisonriskpredictionratherthanriskmanagementislessusefulforpractitionerstaskedwithplanningcare.Finally,theemphasisonunchangeablestaticriskfactorsinthisapproachseverelylimitstheusefulnessofdevelopingriskmanagementstrategiesthatarerobustyetflexible.SomeofthetoolslistedinAppendix1areactuarial,andtheselimitationsmustbeborneinmindwhenconsideringwhethertousetheminpractice.Theydonotprovideameasureofriskinanindividualserviceuserandshouldneverbeusedastheonlywayofevaluatingtherisksposedbyanindividualserviceuser.Actuarialtoolsusedontheirownalsocontradicttheprinciplesofdiversityandindividualisedworking.

Structured clinical judgement Basedonpractice-basedevidence,thisisthemosteffectiveapproachtoviolenceriskmanagement.Although,liketheactuarialtools,theseinstrumentsarederivedfromresearchevidence,theclinician’sdiscretionisseenasavitalelement–especiallyinrelationtoformulatingtheassessmentofriskandpreparingriskmanagementplansbasedontheriskfactorsidentified.Theeffectivenessofthesetoolscanbehardtotest,giventheirrangeofapplicationsandthedifficultyofmeasuringthepreventedharm.Giventheirresearchfocus,theymayalsoexcludeissuesthattheindividualserviceuserconsidersimportant–althoughmoststructuredclinicaljudgementtoolsofferpractitionerstheopportunitytoaddextrariskfactorsandconsiderationsasrequired.

Structuredassessmentisimportantinassessingsuiciderisk,buttherearenoinstrumentswithasatisfactoryevidencebase.Inthiscase,structuredassessmentmeansasystematicassessmentofkeyriskfactorsandmentalstateleadingtoaninformedclinicaljudgement.


21

Working with service users and carers

Sharing decision-making

Eachstepintheprocessofdevelopingariskmanagementplanshouldbebasedondiscussionsbetweentheserviceuserandthoseinvolvedintheircare.Theserviceusershouldbeofferedtheopportunitytotakealeadroleinidentifyingtherisksfromtheirpointofview,drawingupplansfordealingwithdifficultsituations,andindicatingthesortofsupportthattheywouldprefer:serviceusersandcarersareofteninthebestpositiontocommentontherobustnessandpracticalityoftheplan.Theplanshouldincludenegotiatedandindividualisedadvancedecisionsonearlywarningsignsofarelapse,aswellaspreferredearlyinterventionsattimesofcrisis.3,4

“Riskmanagementcanincreaseauser’sawarenessoftheirownbehaviourandofhowothersviewthem.Thiscanenablethemtomanagetheirlivesandrelationshipsmoreeffectively.”

Auser’sview

Collaborative work with carers

Wherethereisacarerinvolved,theyareavitalsourceofsupportfortheserviceuserandmayalsobeakeypersoninhelpingtomanagetherisksidentified.24Practitionersshouldbesensitivetotherelationshipbetweentheserviceuserandthecarer,astheremayberiskswithinthisrelationshipanddifferentpointsofviewaboutthebestactionstobetaken.Ifthecarerisatrisk,theyshouldbeseenindividuallysothattheriskscanbeexploredandactionscanbeagreed.Thecarershouldreceiveenoughinformationinacomprehensibleformattoenablethemtoprovidethenecessarycare.24Thecarer’sworriesabouttheserviceusershouldalwaysbetakenseriously,evenifthecareteamislessconcerned.2Thecarershouldbeofferedanassessmentandshouldbehelpedtodevelopaplanformeetingtheirownspecificneeds.

Confidentiality and disclosure

Agenciesshouldhaveinplaceclearagreedpoliciesoninformation-sharing,whichadviseonthe‘needtoknow’.Ifsomeoneotherthantheserviceuserisatrisk,advicemustbesoughtfromthepolicepublicprotectionteamormulti-agencypublicprotectionarrangements(MAPPA)sothatanappropriatepublicprotectionplancanbeactivated.Therationaleforanydisclosurewithoutconsent,e.g.topreventharm,shouldbeclearlydocumented.


22

Avoiding exclusion on the basis of negative risk

Socialinclusionshouldbeoneofthegoalsofanyriskmanagementplan,andstrategiestosupporttheserviceuserinachievingthisshouldbeidentified.Serviceusersarelikelytobeawareoftheirownriskandtowanthelp,butmayfinditdifficulttotalkaboutthisincaseitincreasesstigma.9Anyrisksidentifiedshouldnotbeoverstatedorneedlesslyusedtoexcludetheserviceuserfromservicesorcontactwithpeople;thiscontributestomythsaboutmentalhealthproblems,stigmaanddiscrimination.Unnecessaryexclusioncanbeavoidedbycarefullylinkingriskassessmenttoriskmanagement.Regularreassessmentcanprovideopportunitiesforinformation-sharingwiththeserviceuserandtheircarer,andcanestablishaforuminwhichrisk-relatedissuescanbeopenlydiscussed.

“Atrustingrelationshipbetweentheuserandtheircareco-ordinatoristhebestfoundationforsuccessfulriskmanagement.”

Auser’sview

Diversity

Clinicaljudgementisbasedonperceptionsthatcanbebiasedwithoutthepractitionerbeingaware.Thereforeallstaffinvolvedinriskassessmentmustbecapableofdemonstratinganappropriatelevelofculturalsensitivityandcompetence.3,4,25Thiscompetenceappliestodiversityintermsofrace,faith,age,gender,disabilityandsexualorientation.Assumptionsaboutanyoftheseaspectsmayinfluenceperceptionsofrisk.Thepractitionershouldreflectontheirassumptionsaboutpeoplefromdiversegroupswithinsocietyandthinkaboutanyjudgementsofriskthattheyaremakingaboutpeoplefromthesegroups. Someauthoritieshavearguedthatassumptionsaboutracecanhaveaninfluenceonjudgementsofrisk.25

Assumptionsaboutgendercanalsoframethewaythatriskisassessedinwomenandmen.Itisessentialtostayopen-mindedaboutthepotentialforviolenceandself-harmorsuicide–regardlessofraceandgender–andnottoexpectserviceuserstoconformtobasicstereotypes.4,26Othersocialgroupsaresometimesstigmatisedas‘always’difficultinsomeway(e.g.serviceuserswithapersonalitydisorderdiagnosisorsubstanceuseproblem).Structuredassessmentapproachesandanawarenessof relevantresearchontheuseofdifferentinstrumentswithdifferentgroupswillhelpwiththisaim.Practitionersshoulddrawupontheirownknowledgeofequalityissuesandontheequalityanddiversityresourceswithintheirorganisationforguidance;thiswillhelptosetthecontextforfairandrespectfuljudgementsofrisk.Reflectivepractice,clinicalsupervisionandateamapproacharealsocrucial.


23

Best practice point 12:Allstaffinvolvedinriskassessmentmustbecapableofdemonstratingsensitivityandcompetenceinrelationtodiversityinrace,faith,age,gender,disabilityandsexualorientation.

Recognising the fluidity of risk

Riskcanchange–sometimesoververyshorttimescales.Bydefinition,dynamicfactorsfluctuateintheircontributiontotheoverallrisk.Giventhefluidityofrisk,onlythetoolsbasedonstructuredprofessionaljudgementareusefulinmonitoringchangeandengagementwiththeserviceuserandcarer.Sothereshouldbeanestablishedproceduretoformallyreviewtheassessmentofriskatregularintervals.

Howeverthesereviewsshouldnotberigidlylimitedtothesetimepoints.Itisimportantthattheprocedurehassomeflexibilitysothat,inparticularcircumstances,anearlierormoretimelyformalreviewcanbeundertaken.Thisalsoguardsagainsta‘tickbox’mentalityincompletingriskassessmentforms.Allpractitionersworkingwiththeserviceuserneedtobefamiliarwithpreviousriskassessmentssothattheycanbealerttochangesinthelevelofrisk.Particularattentionshouldbepaidtotherelationshipbetweensubstancemisuseandchangesintheriskofharmtoselforothers.27Itiscrucialthatserviceusersandcarershaveaccesstosomeonewhomtheycancontactinacrisisiftheneedarises,andthattheyaretakenseriouslyifthisoccurs.

Regular review

Whileremainingflexible,riskmanagementplansshouldincludescheduleddatesforreassessment,sothattheyarenotsimplyamendedasareactiontoacrisisorotherevents.Thesereviewrequirementsshouldbepartoftheriskmanagementplanandnotseparatefromit,andtheserviceuserandallthoseinvolvedintheircareshouldbeinvolvedinthisreview.Riskmanagementplansshouldalsoincludeaclearstatementofresponsibilityforcarryingoutspecifiedtasksintheplan,aswellasforreviewingthem.Fromdiscussionwiththeserviceuser,itisessentialtoanticipatewhatcircumstanceswouldtriggerareviewoutsidethenormaltimetable,aswellaswhichtimesofyearareparticularlydifficult.Thereshouldbescopefortheserviceuserorcarertorequest areview.Inaddition,theriskmanagementplanshouldberevisitedbeforeandduringtimeperiodsthatarerecognisedtobeassociatedwithincreasedrisk,forinstancepriortoleave,onreturnfromleaveandaroundthetimeofdischarge.19


24

Box 4: Supplementary NICE guidance on the short-term management of violence3

Prediction Measurestoreducedisturbedorviolentbehaviourneedtobebasedoncomprehensiveriskassessmentandriskmanagement.Thereforementalhealthserviceprovidersshouldensurethatthereisafullriskmanagementstrategyforalltheirservices.

Working with service users Serviceusersidentifiedtobeatriskofdisturbedorviolentbehaviourshouldbegiventheopportunitytohavetheirneedsandwishesrecordedintheformofanadvanceddecision.Thisshouldfitwithinthecontextoftheiroverallcareandshouldclearlystatewhatintervention(s)theywouldandwouldnotwishtoreceive.Thisdocumentshouldbesubjecttoperiodicreview.

Risk assessment Riskassessmentshouldincludeastructuredandsensitiveinterviewwiththeserviceuserand,whereappropriate,withcarers.Effortsshouldbemadetoascertaintheserviceuser’sownviewsabouttheirtriggerfactors,earlywarningsignsofdisturbedorviolentbehaviourandothervulnerabilities,andthemanagementofthese.Sensitiveandtimelyfeedbackshouldcompletethisprocess.

Care plans Riskassessmentshouldbeusedtoestablishwhetheracareplanshouldincludespecificinterventionsfortheshort-termmanagementofdisturbedorviolentbehaviour.

Tools Actuarialtoolsandstructuredclinicaljudgementshouldbeusedinaconsistentwaytoassistriskassessment,althoughno‘goldstandard’toolcanberecommended.

Thisguidanceisavailablefrom:www.nice.org.uk/guidance/CG25/niceguidance/pdf/English

Recognising the individuality of risk

Eachserviceuserbehavesdifferentlywhentheybegintoneedsupport.Itisimportantforcareteamstoprioritisetheirrelationshipwiththeserviceusersothatpersonalsignsandtriggers(‘signatures’)canbeidentifiedbythoseinvolvedintheircareaswellasbytheserviceuserherorhimself.Thesesignsandtriggerswilloftenbeveryindividualtoeachserviceuser.Whentheyhavebeennotedandtheirrelevancetoriskhasbeenunderstood,theyshouldleadtointerventionasearlyaspossibleandshouldneverbeignored.2Advanceddecisionsareanimportantcomponentofdevelopingindividualisedandcollaborativecare.


25

Best practice point 13:Riskmanagementmustalwaysbebasedonawarenessofthecapacityfortheserviceuser’sriskleveltochangeovertime,andarecognitionthateachserviceuserrequiresaconsistentandindividualisedapproach.

First contact with services

Whentheserviceuserhasafirstcrisisepisodeandhasnothadcontactwithmentalhealthservicesbefore,thefamily’s–andinparticularthemaincarer’s–contributiontoinformation-gatheringiscritical.Inthissituation,thecarerhasthemostknowledgeabouttheserviceuserandisavitalsourceofbothinformationandsupport.Butthiswillbeaparticularlydifficulttimeforthecareraswellasfortheserviceuser,andpractitionersmustacknowledgethiswhenworkingwithcarersatthistime.

“Thereisoftenadefensivenessfromstafftowardscarers.”Acarer’sview

Individual practice and team working

What should trusts be doing to manage risk?

Therearemanypracticalstepsthattrustsshouldbeconsideringintheareaofriskmanagement.Thesestepsinclude:

• keepingthephysicalenvironmentunderregularreview;

• conducting investigationsasrecommendedbyDepartmentofHealthguidance;

• learningfrominquiriesandreportsbytheNationalPatientSafetyAgencyandtheHealthcareCommission;and

• appointingseniorstafftooverseeclinicalriskmanagement.

Who should be doing risk management?

Riskmanagementiseveryone’sbusiness–includingtheserviceuser’s. Thecarerandthepractitionerwithwhomtheserviceuserworksareinthebestpositiontomakethemostimportantandrelevantcontributiontoriskmanagementplanning,butallofthoseinvolvedinprovidingcarehavearoletoplay.Anybodyinvolvedintool-basedriskassessmentmustknowtheirownstrengthsintermsoftheirpersonalcompetenciesandskills.Newlyqualifiedstaffshouldbeallocatedless


26

complexcasesandcloselysupervised.Themoreformaltheriskassessment,thehigherthedegreeofpersonalcompetencyrequired.Allstaffshouldreceivesupervision–regardlessoftheirskills,competencyorexperience.SomeoftheinstrumentslistedinAppendix1requirespecialtrainingorspecificqualificationsasaconditionofusingthem,howeverriskmanagementismuchmorethanjusttheuseoftools.

“Ifapositiveandopenrelationshipexistsbetweentheuserandtheirkeyworker,riskmanagementcanbeapositiveprocessandavitalsteptowardsrecovery.”

Auser’sview

Sources of information

Avarietyofsourcesshouldbeusedforgettingholdofinformationonwhichtobasetheassessmentandmanagementplan.Thesesourcesmustincludeinterviewswiththeserviceuserandcarer,butcanalsodrawonreports,casenotesandtherelevanttoolslistedinAppendix1.23

Effective team work and partnerships

Thepractitionermaysometimesbeworkingalone,butinmostsituationsthebestriskassessmentsandthemosteffectivedecisionsaremadebyateamofexperiencedpractitionersinconsultationwiththeserviceuserandcarer.Decisionsandassessmentsshouldalsobebasedoncollaborationbetweenhealthandsocialcareagenciesinhospitalsandinthecommunity.1,20Insomecasestheyshouldbebasedoncollaborationbetweengeneralandspecialistservices.Thejudgementsmadeinariskassessmentshouldbemadeincollaborationwithothersinthemultidisciplinaryteamandwiththeserviceuserandcarer.Ininstanceswheretheriskseemshigh,theinvolvementofseniorcolleaguestoadviseandsupportmaybehelpful.

Careteamsshouldthinkaboutthewaythattheyoperateandcommunicate:effectivedecision-makingismorelikelyinanatmosphereofopennessandtransparency,whereallviewsarewelcomedandresponsibilityisshared.Teamsshouldconsiderthebestwayforthemtoresolvedisagreementsaboutadecision,toensurethatthebestdecisionsaremadeandthatteamcohesionispreserved.Teamsshouldalsobealerttogroupprocessessuchasthepressuretoconformandthepotentialforgroupstorecommendmoreriskycoursesofactionthananindividualwould.Whenworkingacrossagencies,acommonunderstandingandlanguageshouldbeestablishedfortheissuesthatwillbeaddressed.23


27

Best practice point 14:Riskmanagementplansshouldbedevelopedbymultidisciplinaryandmulti-agencyteamsoperatinginanopen,democraticandtransparentculturethatembracesreflectivepractice.

Meetings

Thereshouldbeacleardiscussionabouttheriskmanagementplanataformalmeeting,whichtheserviceuserandtheircarershouldbeenabledtoattendthismultidisciplinarymeeting.Theissueofriskneedstobediscussedwithsensitivityatthismeetingand,sincetheserviceuserorcarermayfeelinhibitedinalargegroup,theyshouldbegivenanopportunitytomeetwithkeycliniciansbothbeforeandafterthemainmeeting.Theyshouldalsobeabletohavemeetingsseparatelyfromeachother.

“Thereisnothingworsethantokenism,andwecansmellitamileoff.”Acarer’sview

Training

Allpractitionersinvolvedinriskmanagement shouldreceiverelevanttraining,andthisshouldbeupdatedatleasteverythreeyears.Thistrainingdoesnothavetobeclassroom-basedbutshouldincludeattentionto:

• theindicatorsofrisk;

• theimportanceofidentifyinghigh-riskperiods;

• optionsforflexibleandrobustriskmanagement;

• waysofmaximisinginvolvement;

• communicationandtherapeuticrelationships;and

• relevantaspectsoftheMentalHealthAct.

Serviceusersandcarersshouldbeinvolvedindeliveringtrainingtopractitioners.Thetrainingshouldincludeanemphasisonanawarenessoflong-termclinicalandsocialneeds,aswellasknowledgeoftheperson’scurrentmentalconditionandanawarenessofhowriskchangesastheserviceuser’slevelofcarechanges(e.g.followingdischargeorwhenonleave).14

Best practice point 15:Allstaffinvolvedinriskmanagementshouldreceiverelevanttraining,whichshouldbeupdatedatleasteverythreeyears.


28

Recording information

Allsignificantrisk-relateddecisions shouldberecorded,signedanddatedinsuitabledocumentation.Also,wheneveritisnotpossibletofollowanimportantprincipleofbestpractice,thereasonforthisshouldbedocumented,signedanddated.Theserviceuserandallthoseinvolvedintheircareshouldhavetheopportunitytocontributetothisdocumentationandshouldbeprovidedwithcopies.Thisinformationcanbeusedcollaborativelytoplanfuturecare.

Negativeandjudgementallabelsmustbeavoided,astheyareabarriertocollaboration.Awrittenrecordoftheriskmanagementplanallowspractitionerstotrackchangesinthelevelofriskandtonotefactorsthathavepreviouslybeenconsideredimportant.Thisisparticularlyimportantwhenpeoplehavecomplexneedsandareincontactwithseveralagencies.Documentationalsohelpstoprotectpractitionersintheeventofareview.

Standardised documentation

ThetoolslistedinAppendix1mayassistinthedevelopmentofastandardisedapproachtodocumentationwithinatrustorservice.Localriskassessmentproformasshouldbedesignedwithevidence-basedprinciplesinmind,statingclearandverifiableriskindicatorsandprovidingfreetextspaceforindividualopinions.28Whenharmhasoccurred,thedetailsshouldberecordedaspreciselyaspossible:

• Whathappened?

• Whatwerethecircumstances?

• Whatweretheconsequences?

• Howdoeswhathappenedrelatetomentalillness?

Serviceusers’viewsontheseissues,riskanditsfuturemanagementshouldbeincludedinthedocumentation.9Allrelevantinformationshouldalsoberecordedintheappropriatelocalformat(e.g.CPAdocumentation)andstoredconfidentially.Theprocessofdocumentationshouldnotbecomeabureaucraticendinitselfandshouldnotbeaimedatself-protection.Writtendocumentationmustbemanagedinaccordancewiththerelevantlegalstatutes(e.g.theDataProtectionActandtheFreedomofInformationAct).Ultimately,localriskinformationwillbestoredelectronicallyinthenationalConnectingforHealthsystemthatiscurrentlyunderconstruction.

Communication

Onceariskmanagementplanhasbeendevelopedorreviewed,itmustbecomealivedocumentandbecommunicatedtotheserviceuserandallofthoseinvolvedinprovidingtheircare:theriskmanagementplanhasnopurposeifitisnotshared


29

betweentherelevantpartiesandusedasabasisforjointaction.Theserviceuser’sconsentforsharinginformationinthiswayshouldbesought,althoughthedutyofconfidentialitycanbeoverriddenifthereisaclearriskofharm.Thelocalpolicyoninformation-sharingshouldgovernthisprocess.

Best practice point 16:Ariskmanagementplanisonlyasgoodasthetimeandeffortputintocommunicatingitsfindingstoothers.

Decision-making in the real world

Decision-makingbyprofessionalsinvolvedinriskassessmentandriskmanagementiscomplexandisaffectedbymanyfactorsthatarespecifictothepractitionermakingthedecision,suchastheirpersonalvalues,theirownattitudetowardsrisk,theirworkloadandthetimethattheyhaveavailabletoaddressthemattersinhand.Itisimportantforprofessionalstobeawareofandreflectonthefactorsthatinfluencetheirdecision-making,toensurethattheirvaluesareenhancingtheprocessratherthandistortingit.Again,effectiveteamworking,individualsupervisionandgoodcommunicationwithotherswillallsupporttheseprocesses.Feedbackfromtheserviceuseronthisaspectofpracticeisausefulpartofreflectivepractice.

Learning from adverse incidents

Thingscangowrongevenwhenbestpracticehasbeenused.Ifthingsdogowrongordonotgoaccordingtoplanitisimportanttolearnwhy,includingidentifyinganymistakesthatweremade.29Learningfrom‘nearmisses’isvitaltoimprovingservices,5althoughnotalllessonslearnedwillrequirechangesinpractice–theymaynotnecessarilyleadtobetteroutcomes.Thecultureofanorganisationcanmakeallthedifferenceinensuringthatstafffeelabletobehonestaboutthedecisionsthattheyhavetaken,thebasisonwhichtheymadetheirdecisions,andhowthingsmighthavebeendonedifferentlyandbetter:lessonscanbelearnedand,wherenecessary,practicescanbe changedforthebetter.Trainingcouldalsobeimprovedasaresult.Itisimportanttorememberthatanydecisionislikelytobeacceptableifitconformedtorelevantguidelines,itwasbasedonthebestinformationavailable,itwasdocumentedandtherelevantpeoplewereinformed.11

Learning from good practice

Mostofourlearninginriskmanagementisbasedonlookingbackatadverseincidents.Itis vitallyimportant,though,toacknowledgethatdealingwithriskandmakingdecisionsispartofeverydaypractice,andpractitionersmaketherightdecisionmostofthetime.Everyrightdecisionhelpstopreventanadverseincident,somentalhealthorganisationsshouldsetupsystemsforsystematicallylearningfromgoodpracticeaswell.Thisshouldincludesharingexperiencesamongpractitionersandencouragingmultidisciplinaryandpeerreviewofclinicalpractice.

30

Preamble

Bestpracticeinthisarearelies,inpart,onaconsistentapproachtotheassessmentofriskwhenworkingwithanindividualserviceuser.Thisconsistentapproachcanbeimprovedbyusingtoolsandotherpackagesthathavebeendevelopedforthispurposeandwhichhavebeentestedinsomewayinrealmentalhealthcaresettings.Inthisappendixinformationisprovidedaboutaselectionofstructuredapproachesthatcanbeusedaspartofanoverallriskmanagementplanandwhichhavebeentested,atleasttosomeextent,inthisway.Mostofthesestructuredapproachesareriskassessmenttoolsorguidestoclinicaljudgement,butsomebroaderapproaches,suchastrainingprogrammes,havealsobeenincluded.Theyhavebeenselectedandevaluatedthroughaprocesscombiningsystematicreviewoftheresearchliteratureandextensiveconsultationwithexpertsinthisarea.

Whenthinkingaboutriskassessmenttools,twokeywarningsmustbeborneinmind.

Riskassessmenttoolsmustbeusedwithcaution.

Atoolcanonlycontributeonepartofanoverallviewoftheriskpresentedbyaparticularindividualataparticulartime.Toolsshouldonlyeverbeusedaspartofageneralclinicalassessmentconductedwithaserviceuser.Theresultsofthetool-basedassessmentmustalwaysbecombinedwithotherinformationonmanyaspectsoftheserviceuser’slifeandcurrentsituation.

Appendix 1: Tools for supporting best practice


31

Figure 3: Risk assessment tools as one part of the overall clinical assessment process

The risk assessment tool

Many other aspects of the service user’s

life

The current situation

Clinical assessment

Choosingtherighttoolforthejobisacomplextask.

Thetoolslistedherehavebeendesignedwithavarietyofpurposesandwithavarietyofserviceusersinmind.Someareactuarialandothersprovidestructureforclinicaljudgements.Somehavebeenthrougharigorousprocessofscientificdevelopmentwhileothershavebeentestedwithregardtotheirutilityandacceptabilitytopractitioners.Bothapproacheshaveadvantagesanddisadvantageswhenunderpinninggoodpractice.Sometoolshavebuilt-inpromptsforthinkingaboutthemanagementofanyrisksthatareidentifiedwhileothersdonot.Thechoiceofaparticulartoolbyacareteammustbebasedonaconsiderationofalltherelevantfactorsandhowtheyrelatetotherangeofrisksencounteredbytheteaminpractice.


32

SomeofthestructureforthissectionisadaptedfromtheScottishRiskManagementAuthority’sRisk Assessment Tools Evaluation Directory.Thisdirectory30providesinformationonawiderrangeofviolenceinstrumentsrelatingtocourtproceedingsandshouldbeconsultediffurtherinformationisneededinthisarea.

Overview

Page

Vio

lenc

e

Sexu

alv

iole

nce

Ant

isoc

iala

ndo

ffen

ding

be

havi

our

Self-

harm

/sui

cide

Self-

negl

ect/

vuln

erab

ility

Multiplerisks

CRMT 33 • • •FACE 34 • • •GRiST 35 • • • • •RAMAS 36 • • • • •GIRAFFE 37 • • • • •START 38 • • •Risk of violence, sexual violence, antisocial or offending behaviour

HCR-20 39 •PCL-R 40 •PCL:SV 41 •STATIC-99 42 •SVR-20 43 •VRAG 44 •Risk of self-harm or suicide

ASIST 45 •BHS 46 •SADPERSONS 47 •SIS 48 •SSI 49 •STORM 50 •


33

Multiple risks

CRMT: Clinical Risk Management Tool/Working with Risk

Violence Sexualviolence Antisocialandoffendingbehaviour

Self-harm/suicide

Self-neglect/vulnerability

• • •

Description TheCRMTisastructuredtemplatechecklistofrelevantriskandcontextualfactors.Thetoolincludesastructuredassessmentofsuicide,neglect,violenceandotherrisks(ratedas‘present’or‘absent’)andfreetextboxes(threepages)fordescriptionsofthecontextofriskfactors,positiveresources,riskmanagementconsiderations,opportunitiesforriskprevention,andriskmanagementoptions(short-andlong-term).Amodifiedversion(MST)isavailablewithtwolevels(screeningandcomprehensive),andthisversionisembeddedwithina‘WorkingwithRisk’trainingpackagewhichemphasisespositiveriskmanagement.

Depth Screeningandin-depth.

Setting Allmentalhealthservicesettings.

Practitioners Alllevels.

Riskmanagement

Thereisanemphasisonconsideringeffectivemanagementoncerisksareidentified.Guidanceonpositiveriskmanagementisprovidedinthemanualanddedicatedtrainingworkshopson‘WorkingwithRisk’.

Training ATrainer’sManualandaPractitioner’sManual,withoptionalconsultanttraininganddevelopmentfromPracticeBasedEvidence.

Cost Trainer’sManualfor£179andadditionalcopiesofthePractitionerManualfor£29.

Manual AvailablefromPavilionPublishing(01273623222orwww.pavpub.com).

Evidence Thereisnopublishedevidenceontooldevelopmentintermsofreliabilityorvaliditybecausetheemphasishasbeenontheclinicalutilityofthetool.Ithasbeenconstructedanddevelopedinresponsetofeedbackfromlargenumbersofpractitionersattendingtrainingworkshopsandpracticedevelopmentprojects.Inonepublishedstudy,themodifiedversionofthistoolwasthepreferredriskassessmenttoolwhencomparedagainstthreeothers.

Origin UK

Formats Paperonly

Contact SteveMorgan,PracticeBasedEvidence

Phone 07733105264

Email [email protected]

Website www.practicebasedevidence.com


34

FACE: Functional Analysis of Care Environments


Self-harm/suicide


• • •

Description FACEisaportfolioofassessmenttoolsdesignedforadultandolderpeople’smentalhealthsettings.Itincludesbothscreeningandin-depthlevelsofassessmentandcontainsspecialistformsapplicabletoareassuchassubstanceuse,mentalcapacity,perinatalservicesandforensicservices.ThetoolsmeetbothCPAandHealthoftheNationOutcomeScalesrequirements.RiskisassessedusingtheFACERiskProfile.ThismaybeusedeitherasastandalonetoolorinconjunctionwithotherFACEorlocaltools.Fivesetsofriskindicatorsarecodedaspresentorabsentandthenajudgementofriskstatus(0–4)insevenareas(includingviolence,self-harmandself-neglect)ismade.Scopeforserviceuserandcarercollaborationisbuiltintothesystemthroughtailoredforms,includingfeedbackonservices(e.g.relationshipwithpsychiatrist).


Setting Allgeneralandforensicmentalhealthsettings.

Practitioners AnymentalhealthpractitionerwhohasattendedFACEtraining.

Riskmanagement

TheFACERiskProfilespecificallypromptsrecordingofactionsrecommendedorrequiredasaresultoftheassessment.

Training Oneday’strainingisrequired.

Cost Outrightpurchaseofthefullsystemcurrentlycostsapproximately£4,000perannum.Foramedium-sizedtrust,thecostoftheRiskProfileonlyis40%ofthis.

Manual Adetailedtrainingguideisavailable,includingstandardisedvignettes,promptsandguidance.

Evidence ThetoolhasbeendevelopedwithaUKmentalhealthsample.Thereisevidencethattheriskindicatorsetsareinternallyconsistentandthatratersagreewhencompletingthemindependently.Thereisalsoevidenceofgoodvalidity.

Origin UK

Formats Electronicandpaperformatsareavailable,includinganenterprisedatabaseimplementationwithalerts,plans,incidentrecords,aggregationsystems/benchmarkingfacilitiesandinterfacingcapabilitieswithothersystems.

Contact IntermationLtd,Nottingham

Phone 01159838788


Website www.facecode.com


35

GRiST: Galatean Risk Screening Tool


Self-harm/suicide


• • • • •

Description GRiSTisadecisionsupportsystem,basedontheexpertiseofmultidisciplinarymentalhealthpractitioners,thatidentifiesdetailedinformationaboutallrisks.Whenfullydeveloped,itwillbeaweb-basedprogramforcollectinginformationandgeneratingriskquantifications,withfullexplanationsofhowtheseassessmentswerederived.Thecurrentversion(May2007)organisesquestionswithrapidscreeningonesfirst,whichdirecttheassessortomorein-depthonesifrequired.However,theunderlyingrepresentationofriskknowledgemakesiteasyfortheinformationtobecustomisedtoparticularclinicalrequirements.Free-textentryisallowedforeachoverallriskdomain,andtheelectronicversionenablesittoberecordedforanypieceofriskdata.


Setting Allmentalhealthservicesettings.

Practitioners Alllevels–versionstailoredforvariouslevelsofpractitionerexpertiseareunderdevelopment.

Riskmanagement

Thereisafreetextprompttoconsideractiontobetaken,butotherwisethereisnoguidanceonriskmanagement.

Training Notrequired,butreferencetoinformationonthewebsiteisadvised.

Cost Freetoserviceproviders,subjecttoacknowledgementandinternaluseonly.

Manual Notavailable,butinformationisavailableonthewebsite.

Evidence ThementalhealthexpertiseunderlyingGRiSThasbeenderivedfromextensiveinterviews,focusgroupsandindividualvalidationoveraperiodoffouryears.Therigorousmethodofdatacollectionandanalysishasbeendescribedandthereisevidenceofgoodfacevalidity.Thetoolisdesignedtomakeriskpredictions,butthereisnopublishedevidenceasyetonitsreliabilityorvalidity.

Origin UK

Formats Web-basedandpaper

Contact DrChristopherBuckingham,AstonUniversity

Phone 01212043450


Website www.galassify.org/grist


36

RAMAS: Risk Assessment Management and Audit Systems


Self-harm/suicide


• • • • •

Description RAMASconsistsofaframeworkandasetofstructuredprofessionaljudgementtoolsdesignedtoimprovequalityandsafetyinmentalhealthcare.Thetoolsrelatetorisktoself,risktoothers,vulnerabilityandmentalhealthrisk.Broaderneedsareconsideredalongsidethoserelatedtorisk.Thereisalsoanemphasisondevelopingacommonrisklanguageacrosscaresettings,andthesystemmapsontotheCPA.Serviceusers,carersandvoluntaryagencieswereinvolvedinitsdevelopmentandtheframeworkincludesaserviceuser’scharter.

Depth Triageandin-depth/review.

Setting Allmentalhealthandsocialcaresettings.

Practitioners PractitionersandteamswishingtoadoptRAMASmustattendtraining(seebelow).

Riskmanagement

Thereisanemphasisonapartnershipapproachtoriskneedandresponsivity.

Training Threelevelsareavailable:Level1(Triage)–StartSafe,StaySafe(includesriskrecognitionandcommunicationandissuitableforallstaff);Level2–RiskandCareManagement(suitableforqualifiedpractitionersandmapsontotheCPA);andLevel3–TrainingtheTrainers(forexperiencedLevel2usersandriskmanagers).

Cost Seethewebsitebelow.

Manual Level1:Handbookavailable.Level2:Professionalmanualcomesaspartofthetrainingpackage.

Evidence TheriskassessmenttoolswithintheRAMASsystemhavebeendevelopedandtestedinUKmentalhealthsettings.Thereisevidenceofgoodinternalreliability,considerableconstructvalidityandsomeconcurrentvalidity.Intermsofclinicalutility,implementingRAMAShasbeenassociatedwithincreasedpractitionersatisfactionandthereisevidenceofgoodinteragencyagreementonriskratingsbetweencommunitymentalhealth,highsecureandprobationstaff.

Origin UK

Affiliation NHS;UniversityofSurrey;UniversityCollegeCork.

Formats Anelectronicversionisunderdevelopment.ItwillbesuitableforautomationthroughnationalpatientrecordsandcompatiblewiththeCPA.

Contact Seewebsite

Phone Seewebsite

Email [email protected];[email protected]

Website www.ramas.co.uk


37

GIRAFFE: Generic Integrated Risk Assessment for Forensic Environments


Self-harm/suicide


• • • • •

Description GIRAFFEisariskassessmentsoftwaresuitearrangedinfunctionalmodules.These includeriskhistory,riskformulation,riskmonitoring,riskmanagement, riskhandoverandanadverseeventsrecorder.Thesystemenablesthecompilation,analysis,reportingandchartingofrisk-relatedinformationderivedfromawiderangeofsources,suchascasenotes,interviews,observationandquantitativemeasuresincludingdatafromotherrisktoolslistedhere.Whilethereisnodirectserviceuserinputtothesystem,itencouragesacollaborative/consultativeapproach.

Depth In-depth.

Setting GIRAFFEwasdevelopedinaforensicmentalhealthsettingbut isadaptabletootherforensicorsocialcaresettings.

Practitioners Itisintendedforcollaborativeusebyallmembersofthemultidisciplinaryteam.

Riskmanagement

Thereisastrongemphasisonanindividualisedapproachtoriskformulation,riskmanagementandreview.

Training Recommendedon-sitecascadetraining.

Cost Thesystemcanbepurchasedoutrightbuttheprojectmustbecontacteddirectlyforaquote.

Manual Thesystemincorporatesanelectronichelpmanualtogetherwithwebsiteinformation.Usersupportisoffered.

Evidence Thereisnoevidenceavailableontheclinicalutilityofthetool.

Origin UK

Formats Electronicwithtextual/graphical printouts/dumps

Contact JulianFuller,ProjectDirector,‘GiraffeOnline’,POBox35,Dawlish,DevonEX79DQ

Phone 01626864985


Website www.giraffeonline.co.uk


38

START: Short-term Assessment of Risk and Treatability


Self-harm/suicide


• • •

Description STARTisariskassessmentandmanagementdecisionsupportsystemdevelopedinCanada.Itadoptsaglobalapproachtoriskbycoveringunauthorisedleave,substanceabuse,victimisationbyothersaswellasrisktoothers,self-harm,suicideandself-neglect.Theserviceuser’sstrengthsandrisksoneachof20dynamicfactorsareassessedonascaleof0–2.

Depth In-depth.

Setting Itwasdevelopedinaforensicpsychiatricsettingbutmaybeapplicableingeneralmentalhealthsettingsaswell.

Practitioners Practitionersfromanymentalhealthbackgroundcanusethetool,butattendanceatatrainingworkshopisrequired.

Riskmanagement

Thetoolisdesignedtoprovideguidanceonclinicalinterventionsandtoassesschangesovertime.

Training Contactbelowforfurtherinformation.

Cost Notknown.

Manual Amanualisavailable.

Evidence Thereispreliminaryevidenceofgoodinter-raterreliabilitywhencompletedbypractitionersfromdifferentprofessions,andevidenceofvaliditywithaconfirmedrelationshipbetweenSTARTscoresandobservedaggression.Intermsofclinicalutility,completiontakeslessthantenminutesonaverageandthereisevidenceofhighacceptabilityamongstaff(e.g.easeofuse).

Origin Canada

Formats Paperonly

Contact BritishColumbiaMentalHealthandAddictionServices,70ColonyFarmRoad,PostCoquitlam,BCV3C5X9Canada

Phone +16045247730


Website www.bcmhas.ca/Research/Research_START.htm


39

Risk of violence or sexual violence, and antisocial or offending behaviour

HCR-20: Historical Clinical Risk-20


Self-harm/suicide


•

Description TheHCR-20isastructuredclinicaljudgementtool.Itconsistsof20items,dividingriskassessmentintothreecomponents:historicalfactors,clinicalfactorsandriskmanagementfactors.Theseareseenasinformingtheclinicianofrelevantissuesinaserviceuser’spasthistory,evaluatingthepresenceofcurrentdynamicissuesinrisk,andinformingthepractitioneroffutureriskmanagementrequirements.Eachitemiscodedonathree-pointscale(‘absent’,‘possiblypresent’or‘definitelypresent’).Timescalesforconductingtheassessmentarequiteflexibleandallowconsiderableleewayforindividualjudgement.Thereisgoodscopeforinvolvingtheserviceuserintheassessment.

Depth In-depth.

Setting Generalandforensicmentalhealthsettings,malesandfemales.

Practitioners Psychologyorrelateddegreeplusrelevanttestadministrationtraining.

Riskmanagement

Riskmanagementplanningisbuiltintothe‘R’componentofthetoolandthepublishercansupplyariskmanagementcompanionguideinadditiontothebasictool.

Training Specifictrainingrequirementsarenotstated.Thetestdeveloperandtrainedothersprovidetrainingsessionsinternationally.

Cost Currentlyapproximately£80start-upthenapproximately£2percodingsheet.Seepublisher’swebsitefordetails.Anewversionisplannedforpublicationshortly.

Manual Availablefromthepublisherforapproximately£20.

Evidence Whilenotdesignedasanactuarialtool,thereisaninternationalevidencebase(includingtheUK)whichsupportsanassociationbetweenthefindingsoftheHCR-20andsubsequentviolenceoverlongtimeperiodsinsamplesofbothforensicandgeneralmentalhealthserviceusers.

Origin Canada

Formats Paperonly

Contact PsychologicalAssessmentResourceInc.,16204NorthFloridaAvenue,Lutz,FL33549,USA

Phone +18003318378

Email Seewebsite

Website www.parinc.com


40

PCL-R: Psychopathy Checklist-Revised


Self-harm/suicide


•

Description ThePCL-Rwasdesignedasanassessmenttoolfortheidentificationofpsychopathyinforensicpatients.Ithassubsequentlybeenusedwidelyasaviolencepredictiontool,butthetestauthorarguesthatanyassociationwiththepredictionofviolenceisviaapresumedlinkwithpsychopathyandviolenceratherthanadirectlinkbetweenPCL-Ritemsandthelikelihoodofaggression.Thetoolisa20-itemscalewithitemsscoredonthebasisofasemi-structuredinterviewandacollateralreviewoffile-basedinformation.Eachitemisscoredonathree-pointscalebasedonhowcloselytheraterjudgesaclient’scharacterconformstothescaleiteminquestion.

Depth In-depth.

Setting Primarilyforensicsettingsbutmaybeapplicabletoantisocialandoffendingbehaviouringeneralmentalhealthsettings.Usuallymalesonly;evidenceforitsclinicalutilitywithwomenismorelimited.

Practitioners Postgraduatequalificationinamentalhealthprofessionisrequired.

Riskmanagement

Noexplicitlinktoriskmanagementstrategiesisincorporatedintothetool.

Training Specifictrainingisrequired:seewww.hare.org

Cost Currentstart-upcostsareapproximately£225(paperformat)and£290(electronicformat),thenapproximately£2percodingsheet(£10eachifelectronic).Seepublisher’swebsitefordetails.

Manual Availablefrompublisher.

Evidence Theevidencebaseforthistoolisextensive.Thereisevidence(includingUKstudies)ofatleastamoderateassociationbetweenPCL-Rscoreandviolencepost-discharge. TheevidenceforalinkbetweenPCL-Rscoreandsexualviolencerecidivismislessstrong. Oneofthefactorsmakingupthetool(‘antisocialbehaviour’)ismorereliableinthisrespectthantheother(‘emotionaldetachment’).

Origin Canada

Formats Paperandelectronic

Contact Multi-HealthSystemsIncorporated,MHS(UK),9aKingfisherCourt,HambridgeRoad,Newbury,BerkshireRG145SJ

Phone 08456017603


Website www.mhs.com


41

PCL:SV: Psychopathy Checklist: Screening Version


Self-harm/suicide


•

Description ThePCL:SVwasdevelopedtoprovideashorterformofthePCL-Rfortheassessmentofpsychopathyingeneralpsychiatricpopulations.Itisa12-itemscalewithitemsscoredonthebasisofasemi-structuredinterviewandreviewofcollateralfile-basedinformation.Eachitemisscoredonathree-pointscalebasedonhowcloselytheraterjudgesaclient’scharacterconformstothescaleiteminquestion.

Depth Screening.

Setting Generalandforensicmentalhealthsettings.

Practitioners Postgraduatequalificationinamentalhealthprofessionisrequired.

Riskmanagement


Training Specifictrainingisrecommended:seewww.hare.org

Cost Currentlyapproximately£110start-upthenapproximately£1.60percodingsheet.Seepublisher’swebsitefordetails.

Manual Availablefrompublisher.

Evidence ThePCL:SVhasnotbeenasextensivelyevaluatedasthePCL-RandthebulkofavailableevidencederivesfromoutsidetheUK.AvailabledatasuggestmoderatetogoodassociationsbetweenPCL:SVscoresandaggressioninbothforensicandgeneralpsychiatricpopulations.

Origin Canada

Formats Paperonly

Contact Multi-HealthSystemsIncorporated,MHS(UK),9aKingfisherCourt,HambridgeRoad,Newbury,BerkshireRG145SJ

Phone 08456017603

Email

Website www.mhs.com


42

STATIC-99


Self-harm/suicide


•

Description TheSTATIC-99isanactuarialscaledevelopedspecificallytoassessthelong-termpotentialforsexualrecidivisminadultmalesexoffenders.Thetoolismadeupofaten-itemlist,witheachiteminvitinga‘yes/no’response.Onepointisgivenfora‘yes’responsetoeachofnineitems,withthreepointsgiventotheremainingitem(priorsexualoffences).Arevisedversion,theSTATIC-2002,remainsintheprocessofdevelopment.

Depth Screening.

Setting Forensicmentalhealth,males.

Practitioners Requiredqualificationsarenotspecified.

Riskmanagement

Asanactuarialtool,thescopeforactivelyguidingindividualisedriskmanagementplansislimited.

Training Trainingqualificationsnotspecified.

Cost Free.

Manual Noneavailable.Codingguidelinesareavailablefrom<ww2.ps-sp.gc.ca/publications/corrections/pdf/Static-99-coding-Rules_e.pdf>

Evidence TheevidencebaseforthistoolisrelativelysmallandwillsoonbecomeoutdatedwhentheSTATIC-2002becomesavailable.However,evidencefromanumberofstudiesinvariouscountries(includingtheUK)indicatelowtomoderateestimatesofthepredictivevalidityoftheSTATIC-99inpredictingsexualandnon-sexualviolentrecidivisminrapistsandchildmolesters.

Origin Canada/UK

Formats Paperonly

Contact Themainsourceisthefollowingpaper:HansonandThornton,2002.Thecorrespondingauthor’saddressis:DrAndrewHarris,SeniorResearchOfficer,CorrectionsDirectorate,SolicitorGeneralCanada,11thFloor,340LaurierAve.West,ONK1A0P8Canada

Phone USA+(613)9912033


Website www.sgc.gc.ca


43

SVR-20: Sexual Violence Risk-20


Self-harm/suicide


•

Description TheSVR-20isastructuredclinicaljudgementtool.Itwasdesignedtoaddresstheriskofviolenceinsexoffendersandthereisgoodevidenceforitspsychometricpropertiesanditsefficacy.The20-itemscaleisdividedintothreeriskfactordomains:psychosocialadjustment,sexualoffencesandfutureplanning.Eachitemisratedonathree-pointscale(‘notpresent’,‘somewhatorpossiblypresent’or‘clearlypresent’)andthegeneralpatternobservedistakenintoaccountinevaluatingriskas‘low’‘medium’or‘high’.TheSVR-20hasbeenupdatedtotheRiskforSexualViolenceProtocol(RSVP).

Depth In-depth.

Setting Generalandforensicmentalhealthsettings,malesonlyalthoughtheRSVPmaybeusedwithwomen.


Riskmanagement

TheaimoftheSVR-20–andtheRSVP–istohelpinthedevelopmentofriskmanagementplans.

Training Trainingrequired.

Cost Currentlyapproximately£60start-up,thenapproximately50ppercodingsheet.Seepublisher’swebsitefordetails.

Manual Availablefromthepublishersforapproximately£20.

Evidence AswiththeHCR-20,theSVR-20andtheRSVPwerenotdesignedasanactuarialtoolalthoughthereisgoodevidenceoftherelationshipbetweenSVR-20riskfactorsandtheriskofsexuallyviolentreoffending.

Origin Canada

Formats Paperonly

Contact PsychologicalAssessmentResourceInc.,16204NorthFloridaAvenue,Lutz,FL33549,USA

Phone +18003318378

Email Seewebsite

Website www.proactive-resolutions.com


44

VRAG: Violence Risk Appraisal Guide


Self-harm/suicide


•

Description TheVRAGisanactuarialtoolmadeupof12items.OneoftheseitemsisthetotalscoreofthePCL-Rtool(seepage40)andtherestarebasedoninformationheldinclinicalfiles(e.g.psychosocialhistory).Thereisnorelianceoninterviewsorquestionnaires.All12itemsarescoredfrom–5to+12andthetotalscoresaredividedintonineequalriskgroupings.

Depth Screening.

Setting Forensicmentalhealthsettingsformales.Thereisaheavyrelianceonitemsrelatingtopreviousoffendingbehaviour.

Practitioners Qualifiedmentalhealthprofessionals.

Riskmanagement

Therearenospecificpromptsonriskmanagementstrategies.

Training Nospecificqualificationshavebeenset.

Cost Free.

Manual Notavailablebutmuchoftheworkisdescribedinthefollowingbook:Quinsey,V.L.,Harris,G.T.,Rice,M.E.,andCormier,C.A.,Violent offenders: Appraising and managing risk(SecondEdition),AmericanPsychologicalAssociation.Washington,DC,2006.

Evidence ThereisquiteextensiveevidencefromvariouscountriessupportingtheabilityoftheVRAGtopredictfutureviolencebyoffenders.Muchofthisisprovidedbythescale’sauthors.AsmallnumberofstudiesintheUKsupportmoderatelevelsofpredictiveaccuracy.

Origin Canada

Formats Paper

Contact ResearchDepartment,MHC,500ChurchSt.,PenetanguisheneONL9M1G3,Canada

Phone Notknown


Website www.mhcp-research.com/index.htm


45

Risk of self-harm or suicide

ASIST: Applied Suicide Intervention Skills Training


Self-harm/suicide


•

Description ASISTisatrainingprogrammedevelopedinCanadathatisdesignedtopreparecaregiversfromawiderangeofsettingsinsuicide‘firstaid’.Itconsistsofatwo-daypackageonsuicideriskmanagementforcaregiverswhichisinteractive,intensiveandcloselyrelatedtopractice.Theaimistopreparecaregiverstorecogniseriskanddevelopskillstointervenetoreducetheimmediaterisk.Awarenessisraisedontheimportanceofattitudesinthisareaandtheresourcesavailablewithinlocalcommunities.TheprogrammehasbeenruninanumberofcountriesworldwideandhasbeenadoptedasanationalsuicideinterventiontrainingprogrammebytheScottishExecutive.

Depth In-depth.

Setting Allmentalhealthsettingsinwhichsuicide‘firstaid’wouldbeappropriate.

Practitioners Allpractitionersinthesesettings.

Riskmanagement

Thecourseincludeslearningaboutinterveningtopreventtheimmediateriskofsuicide.

Training See‘Description’above.

Cost Seewebsitebelow.Arangeofpaperandelectronicsupportingmaterialsareavailable.

Manual Approximately£15.

Evidence ASISThasbeenadoptedasanationalsuicideinterventiontrainingprogrammeinScotland.Forfurtherinformation,seethewebsitebelow.

Origin Canada

Formats Notapplicable

Contact LivingWorks,4303D11StreetSE,Calgary,ABT2G4X1,Canada

Phone +14032090242


Website www.livingworks.net


46

BHS: Beck Hopelessness Scale


Self-harm/suicide


•

Description Thisisaself-reportscale,measuringanimportantsuicide/self-harmriskfactor,thattakeslessthantenminutestocomplete.Thereare20itemsassessingfeelingsaboutthefuture.Eachitemisatrue/falsestatementandscored0or1.Negativeresponsesoneachitemareaddedtogethertogiveatotalscoreoutof20.

Depth Screening.



Riskmanagement


Training Generaltestadministrationtrainingisrequiredforpurchase.

Cost Approximately£70forastarterpack(manualand25forms),thenapproximately£1.50perform.

Manual Availablefromthepublisherfor£36.50.

Evidence Thereisanextensiveinternationalevidencebaseincludingtestingofthetool’sstructureandsupportforhopelessnessasariskfactorforcompletedsuicide.SomeoftheavailableevidenceisderivedfromtheUK.TheBHShasbeenfoundtocorrelatewellwithchangeinclinicalsymptomsinrandomisedcontrolledtrialsofinterventionsforhigh-riskorsuicidalpatients.

Origin USA

Formats Paperonlyforadministration,butelectronicanalysissoftwareisavailable

Contact HarcourtAssessment,HalleyCourt,JordanHill,OxfordOX28EJ

Phone 01865888188


Website www.harcourt-uk.com/


47

SADPERSONS


Self-harm/suicide


•

Description Thisbrieftoolassessesthepresenceorabsenceoftenriskfactorsforsuicide,e.g.malegender,socialisolation.Eachfactorisrated1or2ifpresent.Riskmanagementisindicatedifcertaincut-offscoresareexceeded.Itisaverybriefinstrumentsoiseasytoadministerbutmakesalimitedcontributiontooverallassessment.

Depth Screening.

Setting ItwasdevelopedforAmericancommunitysettingsbuthasbeenusedinsecondarymentalhealthsettings.

Practitioners Originallydevelopedforseniormedicalstudentsasnoviceriskassessors.

Riskmanagement

Fromacommunityperspective,interventionssuchasfurtherevaluation/treatmentorimmediatehospitalisationarelinkedtospecificcut-offscores,butthesearenotrelevanttotheUKsetting.

Training Noinformationavailable.

Cost Notknown.

Manual Notavailablebutinformationcanbegainedfromtheoriginalsource(Patterson,W.etal.,Psychosomatics,24,1983:343–9)andamorerecentpaper(Roudebushetal.,Psychological Services,3,2006:137–41).

Evidence TheavailableevidenceisbasedonAmericansamplesandindicatesthatthetoolisadequateasonepartofanoverallassessment.Onereviewhascriticisedthelackofevidenceindicatingacceptablereliabilityandvalidity.ThereisalackofevidencebasedonUKsamples.

Origin USA

Formats Paperonly

Contact W.M.Patterson,SmolianClinic,Room210,DepartmentofPsychiatry,UniversityStation,Birmingham,AL15294,USA

Phone Notavailable

Email Notavailable

Website Notavailable


48

SIS: Suicidal Intent Scale


Self-harm/suicide


•

Description Thisinterview-basedorself-administeredscalewasdesignedtoassesstheintentiontodieamongpeoplewhohaveattemptedsuicide.Ithas15itemsseparatedintocircumstancesrelatedtothesuicideattempt(e.g.presenceofasuicidenote)andself-reportitems(e.g.expectationsoffatality).Thefirstgroupofitemscanbecompletedretrospectivelyfromcasenotes.Eachitemisscoredonathree-pointscaleandcut-offsforseverityareprovided.Fiveadditionalitemsdonotcontributetotheoverallscore.Therearenospecificcut-offsandapositiveresponsetoanyitemshouldbeacauseforconcern.

Depth Screening.


Practitioners Nolimitationsspecifiedintheoriginalsource(see‘Manual’below).

Riskmanagement


Training Nonespecifiedintheoriginalsource.

Cost Nonespecifiedintheoriginalsource

Manual Notknownbutthesourceforthetoolis:Beck,A.,Schuyler,D.,andHerman,I.,‘Developmentofsuicideintentscales’,InBeck,A.,Reesnick,H.,andLettieri,D.(eds)The Prediction of Suicide,CharlesPress,Bowie,Maryland,USA,1974.

Evidence AnAmericanreview31concludedthattheSISscorewasnotariskfactorforcompletedsuicideoverseveralyearsamongin-patientshospitalisedforattemptedsuicide.ArecentUKstudy32concludedthatthescaleremainsvaluableasaclinicalaid.Otherstudieshavereportedsomeassociationsbetweentotalorsubscalescoresandsuicide-relatedoutcomes.

Origin USA

Formats Paperonly

Contact BeckInstituteforCognitiveTherapyandResearch, OneBelmontAvenue,Suite700,BalaCynwyd,PA19004-1610,USA

Phone USA+16106643020


Website beckinstitute.org/


49

SSI: Scale for Suicide Ideation


Self-harm/suicide


•

Description Thisisa21-itemscalethatcanbeself-administeredorcompletedviaaninterviewinabouttenminutes.Itisdesignedtoassesstheintensityofaperson’sattitudeswithregardtosuicideandtheirbehavioursandplanstocompletesuicideduringthepastweek.Some19testitemsareeachratedbetween0and2andaddedtogethertoyieldatotalscorerangingfrom0–38.Twoadditionalitemsaskaboutprevioussuicideattemptsandtheseriousnessofintentinthemostrecentattempt.Thefirst5ofthe19itemsactasascreeningfilter.Whileahigherscoreisassociatedwithahigherrisk,therearenospecificcut-offs,andapositiveresponsetoanyitemshouldbeacauseforconcern.

Depth Screening.


Practitioners Itmaybeadministeredandscoredbyallpractitionersbutrequiresspecialisttrainingforpurchaseandinterpretation.

Riskmanagement


Training Generaltestadministrationtrainingisrequiredforpurchase.

Cost Approximately£70forastarterpack(manualand25forms),thenapproximately£1.50perform.

Manual Availablefromthepublisherfor£36.50.

Evidence AmajorAmericanreview31foundevidenceofanassociationbetweenscoresontheinterviewversionofthisscaleandcompletedsuicideinoutpatients.Nosuchevidencefortheself-reportversionlistedherewasreported.ThereisUKevidenceofsensitivitytochangeinaself-harminterventiontrial.Aself-reportversionhasbeenusedtodetectchangeinaUKtrial.

Origin USA

Formats Paperonlyforadministration,butelectronicanalysissoftwareisavailable

Contact HarcourtAssessment,HalleyCourt,JordanHill,OxfordOX28EJ

Phone 01865-888188


Website www.harcourt-uk.com/


50

STORM: Skills-based Training on Risk Management


Self-harm/suicide


•

Description STORMisasuicidepreventiontrainingpackageboughtaspartofanoverallsuicidepreventionstrategybyorganisationsorpartnershipsoforganisationsinstatutoryandvoluntarysectors.Itcanbedeliveredon-siteeitherinashortmodularformatoroveroneortwodays.Thepackagecoversassessment,crisismanagement,crisispreventionandproblem-solvingwhenworkingwithpotentiallysuicidalserviceusers.AChildren’s&YoungPerson’sversionisavailableaswellastheadultversion.Facilitatorsareprofessionals,non-professionalsorserviceuserswithrelevantexperiencewhohavebeentrainedtodeliverthepackageinacascademodel.

Depth In-depth.

Setting Designedforapplicationinanymentalcaresettingaswellasforsocialcareandcriminaljusticestaff.

Practitioners Suitableforallmentalhealthpractitioners.

Riskmanagement

Aspartofanoverallstrategy,themainemphasisisonriskmanagement.

Training See‘Description’above.

Cost Currently£1,500perfacilitatorbutcontactbelowforaquotation.

Manual Notapplicable

Evidence STORMhasbeengivenasanexampleofgoodpracticeinarecentreviewofprogressindeliveringontheNationalServiceFrameworkstandardrelatingtosuicide.

Origin UK

Formats Notapplicable

Contact GillLever-Green,STORMCo-ordinator,UniversityofManchester,RusholmeAcademicUnit,RusholmeHealthCentre,WalmerStreet,ManchesterM145NP

Phone 01612751869


Website www.medicine.manchester.ac.uk/storm/

51

Thissectionprovidesabriefsummaryofthemainfactorsthathavebeenfoundtobeassociatedwithviolenceandsuicideintheresearchliterature.

Risk factors for violence

Demographic factors

• Male

• Youngage

• Sociallydisadvantagedneighbourhoods

• Lackofsocialsupport

• Employmentproblems

• Criminalpeergroup

Background history

• Childhoodmaltreatment

• Historyofviolence

• Firstviolentatyoungage

• Historyofchildhoodconductdisorder

• Historyofnon-violentcriminality

Clinical history

• Psychopathy

• Substanceabuse

• Personalitydisorder

• Schizophrenia

• Executivedysfunction

• Non-compliancewithtreatment

Appendix 2: Risk factors for violence and suicide


52

Psychological and psychosocial factors

• Anger

• Impulsivity

• Suspiciousness

• Morbidjealousy

• Criminal/violentattitudes

• Commandhallucinations

• Lackofinsight

Current ‘context’

• Threatsofviolence

• Interpersonaldiscord/instability

• Availabilityofweapons

Ref:33,34,

Risk factors for suicide

Demographic factors

• Male

• Increasingage

• Lowsocioeconomicstatus

• Unmarried,separated,widowed

• Livingalone

• Unemployed

Background history

• Deliberateself-harm(especiallywithhighsuicideintent)

• Childhoodadversity(e.g.sexualabuse)

• Familyhistoryofsuicide

• Familyhistoryofmentalillness


53

Clinical history

• Mentalillnessdiagnosis(e.g.depression,bipolardisorder,schizophrenia)

• Personalitydisorderdiagnosis(e.g.borderlinepersonalitydisorder)

• Physicalillness,especiallychronicconditionsand/orthoseassociatedwithpainandfunctionalimpairment(e.g.multiplesclerosis,malignancy,painsyndromes)

• Recentcontactwithpsychiatricservices

• Recentdischargefrompsychiatricin-patientfacility

Psychological and psychosocial factors

• Hopelessness

• Impulsiveness

• Lowself-esteem

• Lifeevent

• Relationshipinstability

• Lackofsocialsupport

Current ‘context’

• Suicidalideation

• Suicideplans

• Availabilityofmeans

• Lethalityofmeans

Ref:35,36

54

TheNationalConfidentialInquiryintoSuicideandHomicidebyPeoplewithMentalIllness19hasdevelopedasetofrecommendationstoimprovepolicyandpracticeinmentalhealthcaresettings.These12pointsareintendedtobeusedasachecklistforlocalservicesandarethebasisofariskmanagementtoolkitwhichtheNationalInstituteforMentalHealthinEngland(NIMHE)iscurrentlymakingavailabletoservices.

The12pointsrecommend:

• stafftraininginthemanagementofrisk–bothsuicideandviolence–everythreeyears;

• allpatientswithseverementalillnessandahistoryofself-harmorviolencetoreceivethemostintensivelevelofcare;

• individualcareplanstospecifyactiontobetakenifpatientisnon-compliantorfailstoattend;

• promptaccesstoservicesforpeopleincrisisandfortheirfamilies;

• assertiveoutreachteamstopreventlossofcontactwithvulnerableandhigh-riskpatients;

• atypicalanti-psychoticmedicationtobeavailableforallpatientswithseverementalillnesswhoarenon-compliantwith‘typical’drugsbecauseofside-effects;

• strategyfordualdiagnosiscoveringtrainingonthemanagementofsubstancemisuse,jointworkingwithsubstancemisuseservices,andstaffwithspecificresponsibilitytodevelopthelocalservice;

• in-patientwardstoremoveorcoveralllikelyligaturepoints,includingallnon-collapsiblecurtainrails;

• follow-upwithinsevendaysofdischargefromhospitalforeveryonewithseverementalillnessorahistoryofself-harminthepreviousthreemonths;

• patientswithahistoryofself-harminthelastthreemonthstoreceivesuppliesofmedicationcoveringnomorethantwoweeks.;

Appendix 3: 12 Points to a safer service


55

• localarrangementsforinformation-sharingwithcriminaljusticeagencies;and

• policyensuringpost-incident,multidisciplinarycasereviewandinformationtobegiventofamiliesofinvolvedpatients.

AfulleraccountoftheconclusionsthatsupporttheserecommendationsareavailableintheSafety Firstreport14:www.dh.gov.uk/assetRoot/04/05/82/43/04058243.pdf

56

Actuarial approach:Anapproachtoriskassessmentinvolvingtheuseofstatisticalmodels3toestimatethelikelihoodofariskeventsuchassuicideorharmtoothers.Actuarialassessments,though,dependonthepersonbeingassessedcomingfromthesamepopulationthatgeneratedthestatisticaldatausedtomaketheriskevaluation.Soaccuracyofassessmentsdependsonthesimilarityoftheindividualwiththispopulation.Riskfactorsmeasuredbyactuarialtoolsaregenerallystatic(unchangeable)–someoftheneweractuarialguidesincludedynamic(changeable)factorsalso.

Aggression:Adisposition,awillingnesstoinflictharm,regardlessofwhetherthisisbehaviourallyorverballyexpressedandregardlessofwhetherphysicalharmissustained.3

Assessment:Theprocessofgatheringinformationviapersonalinterviews,psychological/medicaltesting,reviewofcaserecordsandcontactwithcollateralinformantsforuseinmakingdecisions.30

High risk:Atermusedofaserviceuserwhopresentsariskofcommittinganactthatiseitherplannedorspontaneous,whichisverylikelytocauseseriousharm.Therearefew,ifany,protectivefactorstomitigateorreducethatrisk.Theserviceuserrequireslong-termriskmanagement,includingplannedsupervisionandclosemonitoring,and,whentheserviceuserhasthecapacitytorespond,intensiveandorganisedtreatment.30,37

Low risk:Atermusedofaserviceuserwhomayhavecaused,attemptedorthreatenedseriousharminthepastbutarepeatofsuchbehaviourisnotthoughtlikelybetweennowandthenextscheduledriskassessment.Theyarelikelytocooperatewellandcontributehelpfullytoriskmanagementplanningandtheymayrespondtotreatment.Inallprobablefuturescenariosinwhichriskmightbecomeanissue,asufficientnumberofprotectivefactors(e.g.ruleadherence,goodresponsetotreatment,trustingrelationshipswithstaff)tosupportongoingdesistancefromharmfulbehaviourcanbeidentified.30,37

Medium risk:Atermusedofaserviceuserwhoiscapableofcausingseriousharmbut,inthemostprobablefuturescenarios,therearesufficientprotectivefactorstomoderatethatrisk.Theserviceuserevidencesthecapacitytoengagewith,and

Appendix 4: Glossary


57

occasionallytocontributehelpfullyto,plannedriskmanagementstrategiesandmayrespondtotreatment.Thisserviceusermaybecomehighriskintheabsenceoftheprotectivefactorsidentifiedinthisassessment.30,37

Protective factor:Anycircumstance,event,factororconsiderationwiththecapacitytopreventorreducetheseverityorlikelihoodofharmtoselforothers.30,37

Risk:Thenature,severity,imminence,frequency/durationandlikelihoodofharmtoselforothers.Ahazardthatistobeidentified,measuredandultimately,prevented.2

Risk factor:Aconditionorcharacteristicassumedtohavearelationshiptothepotentialtoharmanotherpersonorself.37

Risk formulation:Anexplanationofhowrisksinspecifiedareasariseinaparticularindividualgiventhepresenceandrelevanceofconditionsthatareassumedtoberiskfactorsforahazardousoutcomethatistobeprevented.Ariskformulationshouldaccountfortheroleofprotectivefactorsaswellasriskfactors.37

Risk management:Theactionstaken,onthebasisofariskassessment,thataredesignedtopreventorlimitundesirableoutcomes.Keyriskmanagementactivitiesaretreatment(e.g.psychologicalcare,medication),supervision(e.g.helpwithplanningdailyactivities,settingrestrictionsonalcoholuseorcontactwithunhelpfulothers,andsoon),monitoring(i.e.identifyingandlookingoutforearlywarningsignsofanincreaseinrisk,whichwouldtriggertreatmentorsupervisionactions),and,ifrelevant,victimsafetyplanning(e.g.helpingavictimofdomesticviolencetomakeherselfsafeinthefutureandknowbetterwhattodointheeventofperceivedthreat).37

Self-harm:Self-poisoningorself-injury,irrespectiveoftheapparentpurposeoftheact.21

Sexual violence:Actual,attemptedorthreatenedharmtoanotherpersonthatisdeliberateandnon-consentingandissexuallymotivated.3

Structured professional judgement:Anapproachtowardriskassessmentdevelopedoverthepastdecade.It involvesthepractitionermakingajudgementaboutriskonthebasisofcombininganassessmentofclearlydefinedfactorsderivedfromresearchwiththeuseoftheirclinicalexperienceandknowledgeoftheserviceuser.


58

Violence:Actual,attemptedorthreatenedharmtoanotherpersonthatisdeliberateandnon-consenting.3

Vulnerability:Specificfactorsthatrelatetothelikelihoodofanindividualbeingvictimised,takenadvantageof,orexploitedbyothers.Vulnerableindividualsmaybesubjecttoverbalabuseorharassment,physicalorsexualabuseorintimidation,coercionintounwantedactsandbullying.Assessmentofvulnerabilitymayincludeconsiderationofmentalstate,physical/physiologicalconditions,psychologicalorsocialproblems,culturalorgenderissues.3

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Theprinciplessectionofthisframeworkismadeupofconsensusstatementsbasedonconsultationwiththefollowinggroupsthroughgroupmeetings,groupinterviews,individualinterviewsandemailcontact:

• theNationalMentalHealthRiskManagementProgramme‘RiskAssessmentandManagementToolsandMethods’ExpertAdvisoryGroup(July2006–June2007)

• hospitalandcommunity-basedstaffworkingforMerseyCareNHSTrustandNorthEastWalesNHSTrustinadultmentalhealth,mediumsecurecareandhighsecurecare(August–October2006);

• serviceusersfromacrossEnglandaffiliatedtotheMentalHealthFoundationSurvivorResearchNetwork(March2007);

• carersaffiliatedtotheBathCarersGroup(March2007);and

• researchersandpractitionersfromIreland,theNetherlands,NorwayandTurkeyaffiliatedtotheEuropeanViolenceinPsychiatryResearchGroup(September2006).

Appendixwasdevelopedinthefollowingway.Themultiplerisktoolswereselected(1)followingconsultationwiththeExpertAdvisoryGrouponthebasis(2)thattheyhadevidenceofclinicalutility,reliabilityorvalidityfromatleastonepublishedstudyand(3)thattheyhadbeenimplementedinatleastoneUKmentalhealthtrust.

Thetoolsassessingrisktoothers(violence,antisocialandoffendingbehaviour)wereselectedbytheDepartmentofHealthtoreflectpolicyprioritiesandwereevaluatedwithreferencetoasystematicreviewonthistopic.Fulldetailsofthesearchstrategyareavailableintheprojectreporttogetherwithadetailedanalysisoftheevidencebase.38Insummary,theelectronicsearchterminFigure3wasappliedtoallmainhealthandcriminaljusticedatabases(includinggreyliterature)forpublicationsupto2006.Inaddition,41journalswerehand-searchedfrom1990to2003.Theresultingdatabaseofmorethan41,000citationswassearchedforempiricalstudiesofriskassessmentand662relevantstudieswereidentifiedevaluatingover200structuredriskassessmenttools.

Appendix 5: Methods used to develop this framework


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Figure 3: ‘Risk to others’ tools search term

(((Homicid*ORmurder*ORmanslaughter*ORinfanticid*ORparricid*ORassault*OR(bodilyAND(harmORassault))ORassail*ORbugger*ORsodom*ORmolest*ORpedophil*ORpaedophil*ORsadis*ORsadomasochis*ORsado-masochis*ORanger*ORcruel*ORrapist*OR(rape*ANDoffend*)ORphysicalabus*ORspouseabus*ORpartnerabus*ORsexualabus*)OR(((dangerous*AND(behavior*ORbehaviour*ORhistor*ORconduct*))orviolen*)AND(risk*ORpredict*ORanteced*ORassess*ORcause*ORreason*ORinterven*ORprevention*ORpreventing*ORcontrolling*ORmanage*ORtreatment*ORtreating*ORreduction*ORreducing*ORstop*ORmental*ORforensic*ORpsychiatric*ORoffend*ORAxis1ORAxis2ORcriminal*ORdetain*ORinsan*ORNGRIORretard*OR(learningdisab*ORlearning-disab*)ORacquit*))OR((childabus*ORelderabus*ORhostil*ORkilling*ORattack*ORaggress*)AND(mental*ORforensic*ORpsychiatric*ORoffend*ORaxis1ORaxis2ORcriminal*ORdetain*ORinsan*ORNGRIORretard*OR(learningdisab*ORlearning-disab*)ORacquit*ORdisorder*)))NOT(cancer*ORcancer[mh]ORtumo*ORtumour[mh]ORheart*ORheart[mh]))

Theself-harm and suicide toolswereselectedbyoneoftwomethods.

Thefirstmethodwastodrawonasystematicreview31fundedbytheAmericanNationalInstituteofMentalHealth(NIMH).Threeofthetoolsselectedwerethoseinthereviewwhichhadevidenceofpredictivevalidityfrommentalhealthsamples.EvidencerelatingtothesetoolsandanynewtoolspublishedsincecompletionoftheNIMHsearch(1998)wasthensoughtbysearchingadatabaseofsuicide-relatedliteratureconstructedforanotherproject.Toconstructthisdatabase,theelectronicsearchterminFigure4ahadbeenappliedtoawiderangeofsources(i.e.C2Spectr,CINAHL,Cochrane,CRIB,Dissertationabstracts,Econlit,Medline,NationalResearchRegister,Psychinfo,SocialSciencesAbstracts,andSocialSciencesIndex)andtheresultingdatabasecontainedmorethan23,000citations.Evidencerelatingtotoolsidentifiedinthesourcereview31wassoughtbyusingthenameofthetoolandthemainauthors.Thisevidencewasaddedtotheappraisalinthesourcereview.EvidencerelatingtonewtoolswassoughtusingtheterminFigure4b,andthreenewtoolsrelatingtoworking-ageadultsinsecondarycarewereidentifiedbutnoneofthesehadsufficientinformationavailable.


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Figure 4a: Suicide citations search term

suicid*ORselfharm*ORself-harm*OR(selfANDharm*)ORselfinjur*ORself-injur*OR(selfANDinjur*)ORselfpoison*ORself-poison*OR(selfANDpoison*)ORselfmutilat*ORself-mutilat*OR(selfANDmutilat*)ORselflacerat*ORself-lacerat*OR(selfANDlacerat*)ORselfcut*ORself-cut*OR(selfANDcut*)ORparasuicid*ORpara-suicid*OR((deliberat*Orintent*)ANDoverdos*)

Figure 4b: Suicide tools search term

riskANDassessmentAND(instrument*ORscale*ORmeasure*Ortool*)

Thesecondmethodwasthesameasthatforthemultiplerisktoolsabove,i.e.threeadditionaltoolswereselected(1)followingconsultationwiththeExpertAdvisoryGrouponthebasis(2)thattheyhadevidenceofclinicalutility,reliabilityorvalidityfromatleastonepublishedstudyand(3)thattheyhadbeenimplementedinatleastoneUKmentalhealthtrust.

Threetoolsspecifictoself-neglectwereinitiallyidentifiedthroughsystematicreviewbutweresubsequentlynotincludedduetocoverageofthisdimensionbythemultiplerisktools.

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DrRichardWhittington UniversityofLiverpoolandMerseyCareNHSTrustDrWallyBarr UniversityofLiverpoolAndrewBrown MerseyCareNHSTrustDrMariaLeitner InfoTechUKResearchDrCarolineLogan MerseyCareNHSTrustandUniversityofLiverpoolDrRajanNathan MerseyCareNHSTrustandUniversityofLiverpool

TheprojectteamgratefullyacknowledgetheadviceprovidedbymembersoftheNationalMentalHealthRiskManagementProgramme‘RiskAssessmentandManagementToolsandMethods’ExpertAdvisoryGroup:

JanetDavies(Chair) ProgrammeLead,NationalMentalHealthRiskManagementProgramme

DawnFleming ProgrammeSupportManager,NationalMentalHealthRiskManagementProgramme

ProfessorSueBailey RoyalCollegeofPsychiatristsDrRichardBenson UniversityofGlamorganDrChristopherBuckingham AstonUniversityMadelineBucknell RAMASFoundationChrisBurrows MetropolitanPoliceServiceBurtBurton ManchesterMentalHealthandSocialCareTrustPhilChick WelshAssemblyDrPaulClifford FACERecordingandManagementSystemsDrMaireadDolan Bolton,SalfordandTraffordNHSTrustand

UniversityofManchesterDrMikeDoyle Bolton,SalfordandTraffordNHSTrustand

UniversityofManchesterDrLouiseFountain AvonandWiltshireMentalHealthPartnershipNHS

TrustProfessorLindaGask UniversityofManchesterCarolineGodleman DepartmentofHealthHughGriffiths DepartmentofHealthProfessorChrisHawley HertfordshirePartnershipNHSTrustandUniversity

ofHertfordshireKateHunt SussexPartnershipNHSTrustMikeJones NHSConnectingforHealthGillLever-Green UniversityofManchesterGavinMackintosh NHSConnectingforHealthProfessorTonyMaden WestLondonMentalHealthNHSTrustandImperial

CollegeLondon

Appendix 6: Acknowledgements


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ChrisMerchant NationalWorkforceProgrammeSteveMorgan PracticeBasedEvidenceDrMargaretO’Rourke RAMASFoundationandUniversityCollegeCorkInspectorMikePartridge MetropolitanPoliceServiceDrPaulRogers UniversityofGlamorganDrFrankRohricht QueenMaryUniversityofLondon,andEastLondon

andTheCityUniversityMentalHealthNHSTrustProfessorRobertSnowden CardiffUniversityDrBenThomas NationalPatientSafetyAgencyProfessorKathrynTyson DepartmentofHealthSueWaterhouse SussexPartnershipNHSTrust

Theprojectteamalsogratefullyacknowledgetheadviceprovidedbythefollowingadditionalexpertsconsultedinthedevelopmentoftheframework:

AlisonBaker MerseyCareNHSTrustDrSteveBarlow Newcastle,NorthTynesideandNorthumberland

MentalHealthNHSTrustDrVenkatBoyapati MerseyCareNHSTrustProfessorHulyaBilgin UniversityofIstanbul,TurkeyGillianCarlyle NorthEastWalesNHSTrustJonCarey Tees,EskandWearValleysNHSTrustBobCooper MerseyCareNHSTrustEmmaDavis ChooseLife,ScotlandDrMojcaDernovsek UniversityHospitalLjubljana,SloveniaPeterDisley MerseyCareNHSTrustAlisonDrage TrowbridgeRethinkCarers’GroupMichaelDrage TrowbridgeRethinkCarers’GroupLouDuhig TrowbridgeRethinkCarers’GroupAlisonFaulkner IndependentServiceUserConsultantFransFluttert UniversityofUtrecht,NetherlandsDrJulianFuller DevonPartnershipNHSTrustDrGillHolt MerseyCareNHSTrustSusanneGibbons CatholicUniversityofAmericaDrHelenGilburt MentalHealthFoundationSurvivorResearch

NetworkAudreyGachen MentalHealthFoundationSurvivorResearch

Network/MindinKingstonThomasGoodwin MerseyCareNHSTrustDorothyGould MentalHealthFoundationSurvivorResearch

NetworkSueImlack MentalHealthFoundationSurvivorResearch

NetworkDrGerardJansen UniversityofGroningen,NetherlandsDesJohnson MerseyCareNHSTrustJoeJohnson MerseyCareNHSTrust


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DebbieLand NorthEastWalesNHSTrustBrianLangshaw 5BoroughsPartnershipNHSTrustProfessorWilliamLauder UniversityofDundeeChrisLawton NorthEastWalesNHSTrustDrPeterLepping UniversityofWalesandNorthEastWalesNHSTrustSallyLuxton TrowbridgeRethinkCarers’GroupNeilMcBride MerseyCareNHSTrustProfessorJamesMcGuire UniversityofLiverpoolandMerseyCareNHSTrustKevinMcKenna HealthServiceExecutive,IrelandDavidMort 5BoroughsPartnershipNHSTrustProfessorHenkNijman RadboudUniversityNijmegen,NetherlandsDrStephenNoblett MerseyCareNHSTrustGeirOlsen HaukelandUniversityHospital,NorwayJulieOwen MerseyCareNHSTrustDrIanRogerson CheshireandWirralPartnershipNHSTrustSteveRose MerseyCareNHSTrustRolandvandeSande UniversityofProfessionalEducationUtrecht,

NetherlandsRuthSayers MentalHealthFoundationSurvivorResearch

NetworkKaySheldon MentalHealthFoundationSurvivorResearch

NetworkProfessorJohnSnowden UniversityofSydney,AustraliaDrBillStein GlasgowCaledonianUniversityAngelaSweeney MentalHealthFoundationSurvivorResearch

NetworkDrEdSilva MerseyCareNHSTrustGinaSmith AvonandWiltshireMentalHealthPartnershipNHS

TrustDrIndiraVinjamuri MerseyCareNHSTrust

RiskManagementAuthority,Scotland

65

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2. Maden,T.,Review of Homicides by Patients with Severe Mental Illness,NationalInstituteforMentalHealthinEngland,Leeds,2006.Availablefrom:www.nimhe.csip.org.uk/risk/sui

3. NationalInstituteforHealthandClinicalExcellence,Violence:The short-term management of disturbed/violent behaviour in in-patient psychiatric settings and emergency departments,ClinicalGuideline25,NICE,London,February2005

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11. Logan,C.,Structured Professional Judgement and Risk Formulation: Managing the Risk of Harm,paperpresentedatMerseyCareNHSTrustConference,November2006

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