Conducting violence risk assessment research using the ‘confidential inquiry’ approach: methodological and ethical implications Sarah Leonard & Jodie Alder Centre for Mental Health and Safety Under the supervision of Professor Jenny Shaw I’m a PhD student here at the centre for mental health and safety and I’m going to introduce you to my PhD project and present some preliminary finings

Objectives Identify limitations of modern risk assessment studies Identify novel confidential inquiry method for observational studies Highlight methodological and ethical implications of this method of data collection I hope to give you an introduction to the forensic mental health pathways for prisoners with severe mental health problems A description of novel confidential inquiry method Promote discussion of the management of prisoners requiring secondary mental health services

Limitations of common RA studies Differential participation – bias/sample size ‘Written informed consent and selection bias in observational studies using medical records: systematic review’ - (Kho et al, 2009) - BMJ Age, sex, race, income, education, and health status Consent Those who do not consent are perhaps most at risk of being non-compliant and anti-social – and therefore violent?   Approached Responded Consented Refused Site 1 24 5 1 4 Site 2 70 8 6 2

The secretary of state may by regulations make such a provision for and in connection with requiring or regulating the processing of prescribed patient information for medical purposed as he considered necessary or expedient – (a) in the interest of improving patient care, or (b) in the public interest

(2)The NHS Act and the Regulations a) enable the common law duty of confidentiality to be temporarily lifted so that the confidential patient information can be transferred from data controller fffffffffffff(e.g.NHS trust) to an application b) without disclosure being in breach of the common law duty of confidentiality.

Applications are made to the Confidential Advisory Group (independent body who scrutinise the application using the Health Service (Control of Patient Information) Regulations (2002)) to determine whether the application meets the criteria for approval. The CAG then provide a recommendation for approval to the Health Research Authority and the Secretary of State for Health (via the Department of Health). This application is made concurrently with an application to a NHS Research Ethics committee.

Confidential inquiry in RA research Differs to audit and epidemiological ‘big data’ studies Routinely collected data vs. objective standardised data collection Previous studies ‘Discharges to prison from medium secure psychiatric units in England and Wales’ (Doyle et al, 2014) - BJP ‘Predicting post-discharge community violence in England and Wales using the HCR-20V3’ (Doyle et al, 2014) - BJP ‘Identifying causal risk factors for violence among discharged patients’ (Coid et al, 2015) – PLOS ONE

Study sites Medium security Medium Secure Services n = 33 NHS trusts England and Wales FC-CAMHS n = 8 NHS trusts n= 8 England only We did assessments of prisoners patients discharged from 33 medium secure services provided my 29 NHS trusts in England and Wales

Risk assessment tools FC-CAMHS Medium security HCR:20v3 (Historical, Clinical & Risk 20 items Version 3) (Douglas, Hart, Webster, Belfrage Guy & Wilson, 2014) SAPROF (Structured Assessment of Protective Factors for Violence Risk) (De Vogel., 2009) PCL-SV (Psychopathy Checklist Screening Version) (Hare, 2001) MSRAG (Medium Secure Recidivism Assessment Guide) (Hickey, Yang & Coid, 2009)   FC-CAMHS SAPROF-YV (Structured Assessment of Protective Factors Youth Version) (De Vries Robbe, Geers, Stapel et al 2014)   SAVRY (Structured Assessment of Violence Risk in Youth) (Borum, Bartel and Forth, 2006) START-AV (Short Term Assessment of Risk and Treatability Adolescent Version) (Viljoen, Nicholls, Cruise et al 2014) DASH-13 (Desistance in Adolescents who Sexually Harm) (Worling 2013)

Procedure Link person at each site to inform of discharges Team administrator, clinician (nurse, psychologist, psychiatrist, clinical studies officer etc. In-depth review of clinical records Paper files/electronic systems, psychiatric and criminal records Interview with a member of the patients care team Named nurse, responsible clinician, care coordinator Score baseline assessments Generate a composite score using information from clinical records and collateral informants A link person was established at each site to provide notification of eligible discharges from there service Link people were of varied roles; medical secretaries, consultant psychiatrists, admission and referrals managers etc Review of clinical records: Admission and discharge summaries, risk assessments, Medical reports, CPA documentation etc Member of care team: named nurse, consultant, psychologist, occupational therapist etc To score the baseline assessments

Criminological outcomes Follow-up assessment >12m Prison MSU Baseline Community 12 month Follow-up Medium security Clinical outcomes Hospital admission Substance misuse Self harm / suicide Criminological outcomes Violence Reoffending Reconviction Accepted onto FC-CAMHS Baseline 12 month Follow-up

Methodological implications + Allows for the capture of a full cohort + Avoids bias related to differential participation + ‘Objective’ positon of independent researcher + Limits loss to follow-up + Avoids incidents of patient exposure + Avoids negative impact of assessment for research - Introduces bias from collateral informant accounts - Information retained from medical records is not CCCalways present or reliable - Loss of patient narrative and perspective

Ethical implications Is forensic mental health research ever without ethical issues? Nature of violence risk assessment research – research for patient benefit vs. research in the public interest / for public protection Patients right to privacy vs. research benefit to public / interest of improving patient care Forensic mental health patients have a vested gain in appearing low risk – concern about providing information which may impact their release or privileges or result in further convictions Research of this type puts clinicians in a difficult position – collateral informants and those undertaking the research – are the research activities at odds with their professional code of conduct?

Thank you Sarah Leonard & Jodie Alder @SarahJ_Leonard Doctoral researcher Centre for Mental Health and Safety University of Manchester @SarahJ_Leonard @NursePrincessJ sarah.leonard@manchester.ac.uk jodie.hart@postgrad.manchester.ac.uk We hope this research will generate discussion in this important area so that availability, configuration and quality of services provided to prisoners with mental health needs remains high on the commissioning agenda.