i. The group confined its deliberations to personal risk - of harm to self or others. Consideration was given to the needs of those with a mental health problem to feel secure, to be cared for in safe surroundings and to be separated from exposure to harmful or illicit substances.
ii. In particular the systems through which organisations and their staff detect, record, communicate and react to minimise the danger arising from any perceived risk were addressed.
iii. Recognition was given to the assessment of risk as a continuous activity for staff during an individual's contact with a care service.
iv. No single worker has the ability to detect, assess severity of and make arrangements to minimise risk - a systematic and co-ordinated approach is necessary.
v. The management of risk has quality, management and fiscal dimensions. Actions taken have to be viewed against individual human rights.
vi. Mental health service delivery occurs through a coalition of statutory and non-statutory agencies, working in partnerships with both the users of the service and often with those who care for the user. To identify and minimise risk all components of the service need to develop robust, reliable and effective ways of mutual working.
vii. To minimise the risk of suicide and other risk of harm to self and others, service users, and those who care for them, need to be introduced to and linked with those providing continuing care services in the community prior to any discharges from hospital.
viii. Predictions of dangerousness should be based on reasonable evidence and expressed in terms of possibilities. The prediction should arise from actual findings - from an examination or third party evidence - and should be made with awareness of both the needs of the patient (for the best available treatment) and society (for reasonable protection).
ix. At present there is no substitute for personal judgement in the assessment of risk. The results from the instruments or rating scales currently in development cannot be replaced. In complementing judgement, they play a useful role in the future broad approach to the minimising of risk. A checklist may be helpful only if it is used to provide as comprehensive a set of relevant detail as possible on which an informed judgement can be based.
x. Risk is ever present and has its source in a complex interaction between factors intrinsic to the individual and the environment, including:
xi. The degree of risk arising from personal feelings will not always be apparent. The process of establishing risk can depend on:
However, there are cases where the degree of risk is quite unpredictable.
xii. Procedures protecting confidentiality must be in place within all organisations providing a mental health service. The basic requirements are:
xiii. The individual's right to confidentiality has to be balanced against the reduction of predictable risk.
xiv. A network of Caldicott Guardians is being established throughout the NHS in Scotland. Their responsibilities include developing appropriate protocols for the transfer of patient related information to partner organisations.
xv. Respect, empathy and personal warmth are important factors for sensitive interviewing aimed at a proper assessment of the risk of self harm. These have to be balanced by a caring, informed scepticism and independent corroboration.
xvi. The "Assessment of Risk" (Royal College of Psychiatrists 1996)7 is a recommended source for an acceptable basis of approach to managing the assessment, recording, discussion and support of a person thought to pose a risk.
xvii. The Care Programme Approach29 remains the essential mechanism to ensure care which is lasting and fit for purpose, for those with severe and/or enduring mental health problems and complex care needs.
xviii. Organisations providing in-patient or residential care should have established policies regarding action to be taken if a user of the service consumes an illicit substance.
xix. The principles underlying clinical governance -placing delivery of care at an acceptable level (and correcting under-performance) on a par with responsible stewardship of an organisation's resources -are recommended to all service providing organisations.
xx. Regardless of their training and awareness, staff are at risk unless they are operating as part of a system of care based on:
xxi. The Critical Incident Review (see Appendix D) is the best means by which an organisation can learn from the failures of the system, identify deficiencies and introduce change.
xxii. A confidential reporting system must complement the Critical Incident Review and properly operated allows the organisation to react positively to findings.
xxiii. It is recognised that all involved in care seek to avoid mistakes. The Critical Incident Review is the organisation's opportunity to learn from any mistakes and do better. It is not the opportunity to blame a person or persons for the failure of the system. Only defined issues arising out of the incident should become matters of discipline and should be dealt with separately.