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



HoNOS-secure version 2b is the latest version of what was previously known as HoNOS-MDO*.  It is specifically designed for use in health and social care settings such as secure psychiatric, prison health care and related forensic services, including those based in the community.  Parts of the original HoNOS can be hard to interpret in secure settings, and this scale meets that need.

In 2002, Dr Philip Sugarman and Lorraine Walker developed the first version of HoNOS-secure within St Andrew’s Group of Hospitals.  (St Andrew’s Group of Hospitals is now known as St Andrew’s Healthcare).  The ‘MDO scale’ was developed into 7 security scales so that the completed score sheet provided a profile of 19 severity ratings, a total HoNOS score and a separate security score.  The title was changed from ‘MDO’ (Mentally Disordered Offenders) to ‘secure’ to include all users of secure services.


HoNOS-secure version 2 was developed in late 2004 by simplifying the original instructions and making some changes to the wording of the security scales (based on detailed feedback from users and a review of rating reliability).  The aim was to create a more ‘user friendly’ tool. In version 2b, developed February 2007, the scales are unchanged but the instructions have been simplified based on feedback received at training sessions.


The 7 security rating scales are:


  • A = risk of harm to adults or children
  • B = risk of self-harm (deliberate or accidental)
  • C = need of building security to prevent physical escape
  • D = need for a safely staffed living environment
  • E = need for escort on leave (beyond the secure perimeter)
  • F = risk to individual from others
  • G = need for risk management procedures.

Like the previous versions, HoNOS-secure version 2b is not a risk assessment tool.  It allows the outcome of clinical risk assessment to be rated in terms of need for care and need for clinical risk management procedures.


*HoNOS-MDO consisted of an amended version of the 12 original HoNOS scales and a single ‘MDO scale’ that set out the overall need for level of secure care.  It was piloted by the Kent Forensic Psychiatric Service across Regional Secure Units in the South Thames Region.  Results showed a very high inter-rater reliability and also good reliability in using HoNOS and HoNOS-MDO interchangeably in those settings.




Alice Parshall

Chief Medical Officer



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