Assessing risk

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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