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The Royal College of Psychiatrists Improving the lives of people with mental illness

Assessment and management of risk to others


Risk assessment

General principles

  • Assessment should include a patient’s narrative about their own risk.

  • Consent to risk assessment should be sought and an explanation of the risks and benefits given.

  • Preparation is crucial and clinicians should try to gather information from as many reliable sources as possible.

  • Involving the patient and carers (where appropriate) in drawing up the plan can enhance safety.

  • The interaction between clinician and patient is crucial; good relationships make assessment easier and more accurate, and might reduce risk.

  • All clinicians should carry out careful, curious and comprehensive history taking.

  • It might be hard for one clinician alone to complete an adequate risk assessment. It is invariably helpful to discuss assessments and management plans with a peer or supervisor.

 

Factors to consider

History

  • Previous violence, whether investigated, convicted or unknown to the criminal justice system

  • Relationship of violence to mental state

  • Lack of supportive relationships

  • Poor concordance with treatment, discontinuation or disengagement

  • Impulsivity

  • Alcohol or substance use, and the effects of these

  • Early exposure to violence or being part of a violent subculture

  • Triggers or changes in behaviour or mental state that have occurred prior to previous violence or relapse

  • Are risk factors stable or have any changed recently?

  • Is anything likely to occur that will change the risk?

  • Evidence of recent stressors, losses or threat of loss

  • Factors that have stopped the person acting violently in the past

  • Are the family/carers at risk? History of domestic violence
  • Lack of empathy

  • Relationship of violence to personality factors.

 

Environment

  • Risk factors may vary by setting and patient group

  • Risk on release from restricted settings

  • Consider protective factors or loss of protective factors

  • Relational security (See, Think, Act; Department of Health, 2015)

  • Risks of reduced bed capacity and alternatives to admission

  • Access to potential victims, particularly individuals identified in mental state abnormalities

  • Access to weapons, violent means or opportunities

  • Involvement in radicalisation.

 

Mental state

  • Evidence of symptoms related to threat or control, delusions of persecution by others, or of mind or body being controlled or interfered with by external forces, or passivity experiences

  • Voicing emotions related to violence or exhibiting emotional arousal (e.g. irritability, anger, hostility, suspiciousness, excitement, enjoyment, notable lack of emotion, cruelty or incongruity)

  • Specific threats or ideas of retaliation

  • Grievance thinking

  • Thoughts linking violence and suicide (homicide–suicide)

  • Thoughts of sexual violence

  • Evolving symptoms and unpredictability

  • Signs of psychopathy

  • Restricted insight and capacity

  • Patient’s own narrative and view of their risks to others

  • What does the person think they are capable of? Do they think they could kill?

  • Beware ‘invisible’ risk factors.

 

Information from other sources

Has everyone with relevant information been consulted? This includes carers, criminal records, Police National Computer markers and probation reports.

 

Structured professional judgement

A structured professional judgement approach to assessing risk is preferred to actuarial or unstructured assessments. It involves combining clinical judgement and use of a structured pro forma (e.g. Historical Clinical Risk Management Version 3).

 

 

 

 

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Patient Safety Expert Guidance Working Group
Professor John Morgan (chair)
Dr Claire Flannigan
Dr Safi Afghan
Dr Daniel Beales
Dr Dallas Brodie
Dr Alys Cole-King
Dr David Hall
Dr Andrew Hill-Smith
Dr Soraya Mayet
Dr Philip McGarry
Mrs Julia Mills
Dr Caryl Morgan
Dr Huw Stone
Dr Dumindu Witharana
Mr Chris Wright