Assessing and managing risk of patients causing harm

The assessment and management of the risk of a person with a mental illness causing harm to another is an extremely important part of psychiatric practice.

It is integral to providing safe and effective care and making decisions on transition between services.

This guide to good practice is produced for psychiatrists, but might also be useful to other healthcare professionals, patients and carers, as all have a part to play in risk management.

A full background to this Good Practice Guide is given in the body of College Report 201 (Royal College of Psychiatrists, 2016).

  • Risk cannot be eliminated, but it can be rigorously assessed and managed or mitigated.
  • A history of violence or risk to others is vitally important.
  • A risk assessment should identify key factors that indicate a pattern or that risk is increasing.
  • Risk is dynamic and can be affected by circumstances that can change over the briefest of time-frames. Therefore, risk assessment needs to include a short-term perspective and frequent review.
  • Some risks are specific, with identified potential victims
  • Risk of violence increases in the teen years, with a peak from late teens to early 20s, then a dramatic reduction in the late 20s and a slow reduction until the 60s, when there is another marked reduction.
  • Empirical research cannot be relied upon to identify all risk factors.
  • Specialist risk assessment may be required (e.g. sex offending).

Clear communication of the outcome of risk assessment and the management plan is essential.

  • A formulation and plan should specifically describe the current situation and say what could be done to mitigate the risk in future.
  • Patient-identifying information may be shared:
    • with the patient’s explicit consent; or
    • on a need-to-know basis when the recipient needs the information because they will be involved with the patient’s care (where staff from more than one agency are involved, the patient needs to be told that some sharing of information is likely); or
    • if the need to protect the public outweighs the duty of confidentiality to the patient.
  • Patients who present a risk to others may also be vulnerable to other forms of risk (e.g. self-harm, self-neglect, retaliation or exploitation by others).
  • A positive risk-taking approach weighs up the benefits of interventions and autonomy.
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