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).