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Assessment should include a patient’s narrative about their own
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
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.
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
Alcohol or substance use, and the effects of these
Early exposure to violence or being part of a violent
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
Lack of empathy
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
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
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
Specific threats or ideas of retaliation
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?
Has everyone with relevant information
been consulted? This includes carers, criminal records, Police
National Computer markers and probation reports.
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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