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The essentials of this report are as follows.
There are 4 general principles:
information from a single source is never going to be enough to assess risk, and corroboration will always have to be sought out and found;
similarly one person alone cannot do an adequate risk assessment, and access to the network of people surrounding an individual is crucial;
people who present a risk to others are likely also to be vulnerable, to self-harm, self-neglect or exploitation; (in other words the perception of others should not be allowed to blot out the possibility of that individual also needing protection); and
In the history taken from an individual being assessed, certain items must be enquired after:
previous violence or suicidal behaviour;
"social restlessness" - few relationships, frequent changes of address or employment;
evidence of poor engagement with mental health services;
presence of substance misuse;
a social background promoting violence;
any precipitants or changes in mental state or behaviour that have occurred prior to previous episodes of violence or relapse;
recent change in any of these risk factors;
evidence of recent severe stress, especially major losses;
evidence that medication has recently been discontinued.
It is important to identify potential victims, particularly those who figure in abnormalities in the patient's mental state (eg, the focus of delusions or the apparent source of hallucinations). In the patient's mental state the emotionality with which he presents (for example irritability, anger, hostility or suspicion) is important, as are specific threats made by the patient. Also beliefs of threat, or persecution or control of mind or body by external forces is noteworthy.
In recording the assessment the following points have to be noted:
how serious is the risk;
is the risk specific to one person or situation, or is it general;
how immediate is the risk;
how volatile is the risk;
what potential factors increase the risk, and what might decrease it;
what specific treatment, and which management plan can best reduce the risk.
In managing risk, there are 2 basic principles:
a person working within a mental health service, having identified the risk of dangerous behaviour, has a responsibility to take action with a view to reducing that risk and managing it effectively; and
in managing risk, the balance has to tip towards safety. That starts by engendering a relationship with the patient which makes him or her feel safer and less distressed.
Considerations for managing risk include:
does he or she require admission as an in-patient;
should he or she be detained under the Mental Health (Scotland) Act 1984;
what level of physical security is likely to be needed;
what level of observation is required;
what medication should be used;
it should be understood clearly by ward staff how the medication is to be employed;
if there is another episode of violence, how should it be managed.
If the patient is being managed in the community, other questions come to the fore:
is there a place for the Care Programme Approach;
can the Mental Health (Scotland) Act be used, or is there a case for a community care order;
what community supports are available, how effective might they be, and how can they best be assisted;
do the carers and family have access to appropriate support and help;
have the carers - in the family, and in other agencies - been adequately informed about the situation, how it is likely to develop, and what help they can expect to receive.
Fundamental to the management of any situation is:
the plan of management clearly recorded in an accessible place, in legible writing;
the date for review of the assessment and management plan should be set down, after agreement with all those involved. That date needs to be passed on to all those who need to know;
the patient's general practitioner must be informed;
individuals who should or are entitled to receive information should be identified and responsibility assigned to carry this out;
the threshold for breaching confidence to ensure public safety has been defined;
if responsibility for the management of a plan of action is being passed on to another team or individual, it must be accepted explicitly. The information passed on must include all relevant detail.
The Clinician
To respond as rapidly as possible when concern is expressed by a colleague or member of staff from a partner agency about an increased risk from a patient;
Always to make a systematic assessment;
Always to consult as widely as is possible and appropriate;
Not only to make a decision on what needs to be done, but to make explicit the reasons for that decision and to write them down;
Make a management plan based on the assessment;
Record details of the management plan;
Share the management plan as appropriate with all those who have a legitimate concern with its implementation;
Make no assumptions about what other people will do - if their co-operation is required in carrying out a management plan, make sure that there is explicit consent;
Make an appropriate arrangement for monitoring the management plan, making sure that a date is set and kept for subsequent review.
Clinical Teams
Should have an agreed protocol for responding to patients showing significant risk. This protocol should identify:
the appropriate senior clinicians to be contacted to conduct assessment or re-assessment;
the means by which they should be contacted must be clear;
if the identified person is not contactable, a subsidiary route should be available;
to have agreed protocols for follow-up and review of patients;
to establish and maintain links with other agencies, based on mutual respect for the contribution which can be made, to involve them in the care and management of patients who present a significant risk.
Service Managers
The effective assessment and management of people presenting increased risk of harm should be of the highest priority for allocation of resources;
Risk assessment and clinical risk management is time consuming and expensive; the appropriate resources should be made available;
Proper assessment and management of clinical risk cannot take place in an unsafe environment or within inadequate facilities;
Senior staff must be expected always to be available to take responsibility for decisions about assessment and management of risk;
Training has got to be supported and adequately resourced;
Allowances and partnerships with other agencies should be maintained, and mechanisms put in place to ensure their maintenance.
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