Mental Health Reference Group: October2000: Page 6

Mental Health Reference Group: Risk Management

Chapter 3 Defining Risk Management

6. The NHS Confederation (1998)⁸ defines "the aim of clinical risk management as being to improve the quality of care by preventing occurrences which harm or may harm patients with the twin intention of both reducing the risk of such adverse events for patients and of reducing the costs of such events to healthcare providers. It involves:

identifying risks; using a range of data sources to find out what adverse events are happening or might happen;
analysing risks; exploring both actual and potential adverse events to work out how often they happen, what impact they have on patients and on the organisation and what causes or contributes to them;
controlling and reducing risks; finding ways to change clinical and organisational practices so that adverse events are eliminated or made less likely; and
funding risks; recognising that some adverse events will happen and ensuring that the costs of such events are both minimised and provided for..."

7. This definition illustrates several points:

that risk management is a quality issue;
that it is a management issue; and
that there has been a strong financial dimension for NHS Trusts due not least to the risk of litigation (arising from the North American experience).

8. Failure to acknowledge these points may put agencies in breach of the Human Rights Act (1998). However for mental health services in the community, working with individuals to promote personal independence and autonomy, this may mean that, at times, staff have to stand back while an individual tests out surroundings that entail some degree of risk.

Good Practice Guidance

9. The Royal College of Psychiatrists (1996)⁷ in guidance on the assessment and clinical management of the risk of harm to other people, emphasises that risk cannot be eliminated, that risk is dynamic, that the level of risk changes and that assessment therefore can only have a short-term time perspective and must be subject to review as frequently as the situation demands.

10. Some risks are general, other risks more specific, with particular potential victims. Perhaps most important of all, some interventions can increase risk while attempting to decrease it. This makes the maintenance of good relationships between members of staff and patients essential.

11. The CRAG Working Group on Mental Illness Good Practice Statement⁹ on the prevention and management of aggression (1996) stated that "The biggest danger lies in the failure of an organisation to recognise the management of violence as a complex and technical issue which requires specific attention at all organisational levels."

UKCC Guidance for Nurses - Risk Management

As a registered nurse, midwife or health visitor, you are personally accountable for your practice and, in the exercise of your professional accountability, must ensure that no action or omission on your part, or within your sphere of responsibility, is detrimental to the interests, condition or safety of patients and clients. (UKCC Code of professional conduct, clause 2).

The risk management process should enable the optimum level of care to be given to a client. Risk management involves the assessment of risk relating to client care, care systems and the environment of care. The calculation of risk must be based on your knowledge, skills and competence and you are accountable for your actions and omissions. You should value the process of risk taking, following assessment and in the context of appropriate management, as it will increase your ability to help clients to achieve their potential. However, you should be aware that there may be conflicts between your professional accountability and the autonomy of the client. Although it is rarely possible to eliminate risk entirely, you are still responsible for attempting to reduce risk to an agreed acceptable level. This level should be agreed within the inter-disciplinary team and, where possible, with the client.

Local Authorities

12. There is a legal dimension to all of the work undertaken by social workers employed by the Local Authorities.

13. Under the Mental Health (Scotland) Act 1984, Local Authorities have a duty to provide aftercare services for people with a mental disorder whether or not they have been in hospital. Thus if a person with a mental disorder does not appear to have adequate aftercare support the Social Work Department may be in breach of its statutory duty.

14. Under the Social Work Scotland Act 1968, it is the duty of the Social Work Department to provide social welfare by making appropriate advice and assistance available. Under the NHS and Community Care Act 1990, Local Authorities have a duty to carry out assessments of need for anyone who requires community care services. This includes those with a mental health problem.

15. Those responsible for the care and supervision of a person, will, under the common law of duty of care, be required to take reasonable care for their safety. This duty of care may extend to areas where the person under supervision causes damage to property. Staff should take reasonable steps to avoid harm coming to those in their care if they can foresee the risk. If not, their duty of care responsibility may be deemed to be negligent if the risk ought to have been foreseen (this has not yet been tested in a Scottish court).

Care in the Community

16. Many of the sources quoted in this report have a health emphasis. However, the Framework is firmly based on the development of multi-agency care in the community, with Health Boards and partner authorities commissioning services jointly. If it has been difficult for single organisations to cope with all aspects of management of risk what then of the situation where several organisations are in partnership but are coming to the task from different perspectives, different cultures, histories and priorities?

17. In a health-led facility an individual's presence is usually determined by a mental health problem. The service has a range of responses to situations of risk arising from the consequences of that problem which may, in certain situations, involve compulsory treatment or detention. Policy objectives of integration and inclusion will, however, bring some into closer contact with the wider public. Those in community residential facilities usually require support in aspects of life including socialisation, developing life skills for daily living and structuring the day. We all make choices wise or unwise. Support staff whose task is the development of the individual's competence rather than containment will have the difficult task of responding flexibly and sensitively to situations brought about by unwise choices - choices which they may know were not optimal, but which the individual has the right to make.

18. This report recognises this wider aspect to risk and promotes a joint approach between agencies in the management of risk.

Mentally Disordered Offenders

19. In January 1999, "Health, Social Work and Related Services for Mentally Disordered Offenders in Scotland" was launched - the Mentally Disordered Offenders Strategy.¹⁰

20. The Strategy, which had been the subject of long and detailed public consultation, sets out the roles and responsibilities of all those agencies - the courts, Procurators Fiscal, the police, social work, criminal justice teams, and health, both at secondary and at primary care level - in providing co-ordinated services fit for the purpose of care for the mentally disordered offender.

21. Specific inter-linked roles for each agency are set out and the particular function of workers from each component to liase closely with their counterparts is established. The policy forecasts a range of provision, from high secure accommodation in the State Hospital, through local in-patient forensic facilities, to supported accommodation and community care services. Such provision will allow individuals to be cared for in a manner appropriate to their assessed risk, social and clinical need.

22. The Policy acknowledges that the security of patients is partly governed by the availability of motivated and well trained staff and by patients having access to structured day time activities and a range of accommodation, support, day home and respite care, and advocacy.

23. It is clear that as the Strategy is implemented all components of the service will have to develop the robust, reliable, and effective ways of working referred to above. The Social Work Services Inspectorate has produced helpful guidance in this area, (1998) the Management and Assessment of Risk in Social Work Services.¹¹

Vignette

A senior registrar was called to an Accident and Emergency Department to see a young woman with a major mental illness. As was the usual practice he was shown to a room away from the clinical area to interview her. During the interview she left and he followed and attempted to restrain her, concerned about her safety. In a brief struggle watched by A & E staff who did nothing to help, his shoulder was dislocated. She ran off and was later brought back by the police. As the senior registrar was succumbing to the sedation and analgesia required to reduce the dislocation, he had to instruct the A & E senior house officer in his use of the emergency provisions of the Mental Health (Scotland) Act 1984 to allow the woman to be detained and transferred to in-patient care. Subsequently it took 3 years to persuade the A & E department and the Acute Trust to provide proper interview facilities within the main clinical area for people who might be at risk.

Accident and Emergency Departments

24. The National Medical Advisory Committee reported¹²on "the management of patients with mental disorders and/or disturbed behaviour who present to Accident and Emergency departments" in 1998.

25. The Report recognised the increased number of presentations of individuals with mental health problems and/or disturbed behaviour to A & E departments. This has been a major challenge for A & E departments and has arisen at a time when mental health services are changing rapidly.

26. Among the Report's recommendations is reference to the need for liaison between A & E departments, the local mental health services, and other agencies, (statutory and non-statutory), the creation of a liaison group, involving all service user organisations, the social work department, primary care and the police. The functions of the liaison group was suggested to cover local protocols, quality standards, training requirements, ensuring that mental health nursing skills were available when and where needed, safety arrangements, critical incident reviews, and monitoring arrangements.

27. The report recognised the need for improved practice, standards, and monitoring of activity, and suggested that audit and operational research was necessary. Not specified in the report but essential to its successful implementation is the identification of a responsible manager to take the matter forward.

The Risk of Suicide

28. "Safer Services" the 1999 report of the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness¹³ (based on data from England and Wales) found that 25% of all people who committed suicide had been in contact with mental health services in the year before death.

29. About 50% of deaths occurred in patients with a history of self-harm and either substance misuse or previous hospital admission. The Inquiry found that combinations of these risk factors indicate priority groups for mental health services. Fifty per cent of those with mental health service contact had been seen in the week before death, but the immediate risk of suicide was then estimated to be low or absent in 85% of cases.

30. When patients were seen by 2 services prior to suicide, key points of information known to one service were frequently not known by the other. Mental health teams regarded 22% of the suicides seen by them as preventable and in around 60% they believed that more could have been done to reduce risk. Improved patient compliance (with treatment) and closer supervision were seen as the factors which would have reduced risk in the largest number of cases. This begs the question of how to persuade patients to 'comply'. In those who had mental health service contact, a quarter of suicides occurred within 3 months of discharge from in-patient care, peaking in the first week post discharge, before the first follow-up appointment for nearly half of them. There was a general pattern of weak ties to society as a whole (shown through high rates of unemployment and living alone) as well as to mental health services.

31. Key is the need for all service users, their families or friends to be introduced to and linked properly with continuing care and support services prior to any transition from one form of care to another.

32. Many of the factors which predispose individuals to suicide and deliberate self-harm are also associated with drug misuse.

33. These factors include being a young man, having mental health problems (especially a depressive disorder), having physical illness (including HIV infection and its consequences), poor family relationships, social isolation, unemployment, stressful life events (including bereavement or past/continuing physical or sexual abuse) and ready access to the means of committing suicide including through supplies of illicit drugs.

34. Links between deliberate self-harm, drug use and premature death have been reported. Suicides by young men in Scotland have increased 250% in the last 20 years.¹⁴ Suicidal thoughts and feelings appear to be motivated by complex combinations of predisposing personal circumstances, past traumatic events, precipitating events and social exclusion.

35. Low self-esteem, a lack of psychological "resilience" and educational under-achievement also feature. Being lonely and the loss of a loved person were the most common reasons given for a suicide attempt in this group. The supportive social networks they need are absent or impoverished; there is a lack of social capital.

Safer Services

36. The report recommended:

improving the skills of front-line staff in the recognition, assessment, and management of suicide risk;
strengthening care planning to focus on those most at risk;
ensuring that information related to risk is passed between agencies and components of services; and
making the system more open to information and easier for people to use.
The report endorses these principles and shows a way forward for all providers of care services.

A Duty of Protection

38. Following a European Community Directive the Management of Health and Safety at Work Regulations 1999 were introduced. These provisions amplify a legal duty, previously placed by the Health & Safety at Work Act 1974, on all employers in the UK "to ensure, so far as reasonably practicable, the health, safety and welfare of their employees. This duty can extend to protecting employees from assaults".¹⁵ As a minimum employers are required to:

assess the risks to the health and safety of their employees and of anyone else who may be affected by their work activity;
record any significant findings, if the organisation has more than 5 employees;
arrange to put steps following on from this assessment into practice; this has to cover planning, organisation, control, monitoring and review;
allocate competent people, either from within their organisation, or outside it, to help them formulate and implement the necessary measures;
establish emergency procedures;
ensure that employees have "adequate health and safety training and are capable enough at their job to avoid risks"

39. It is clear from the regulations that organisations providing mental health services have to take initiatives to:

identify the extent of the problem;
establish and maintain an efficient monitoring and reporting system; incidents need to be defined clearly to allow events to be classified;
audit the working environment to reduce the number of incidents if they cannot be prevented altogether;
establish and maintain in good working order a system of post incident support and counselling;
initiate appropriate training in the recognition and management of incidents, bearing the needs of individual workers in mind; and
maintain an organisational commitment, with prevention being the overriding objective.