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).