The assessment of clinical risk in mental health services Professor Nav Kapur

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Risk assessment tools & scales High Medium Low

Risk assessment tools & scales High Medium Low Positive predictive value of risk assessments with self-harm 5%

Risk assessment tools & scales Predictive ability of risk scales varies widely Suicide deaths in large ‘low risk’ group missed

Risk assessment tools & scales 80-90% of people who died by suicide rated as low/no risk In one third (36%) of cases risk assessment considered unsatisfactory

Aims of the study Which risk assessment tools are currently being used in mental health services? Views of clinicians, patients & carers on their experience of tools & how they might be improved. How these tools are being used prior to suicide in people rated as low risk.

Data collection Survey of tools Online survey Interviews We collected data on the main risk assessment tools used in all NHS mental health services in the UK Online survey We asked clinicians, patients & carers to share their views Interviews We interviewed 22 clinicians about their experience of assessing risk

1. Survey of tools used in mental health services

Content and Format of tools

Which tools are being used? Data from all NHS mental health services in the UK Risk tools used varied between services (except in Wales & NI) © National Confidential Inquiry into Suicide and Safety in Mental Health. All rights reserved. Not to be reproduced in whole or part without the permission of the copyright holder.

Which tools are being used? Data from all NHS mental health services in the UK Risk tools used varied between services (except in Wales & NI) © National Confidential Inquiry into Suicide and Safety in Mental Health. All rights reserved. Not to be reproduced in whole or part without the permission of the copyright holder.

Characteristics of tools Majority (94%) used risk categorisation to inform care 85% formatted in a checklist style 62% patient, family and wider involvement Under a fifth (19%) suggested liaising with GPs

2. Online survey

Who completed the survey? 42 patients 26 carers © National Confidential Inquiry into Suicide and Safety in Mental Health. All rights reserved. Not to be reproduced in whole or part without the permission of the copyright holder.

Online survey – staff views Most clinicians used risk assessment tools & many found them helpful Over a third (37%) used more than one Over a quarter (29%) had not received training in its use Icons made by Freepik from https://www.flaticon.com/ is licensed by CC 3.0 BY

Online survey – staff views Challenges with risk assessment tools Difficult to find relevant information Lengthy and time consuming Tick boxes not always read Inaccessible information Difficult to complete and navigate May provide false reassurance Icons made by Freepik from https://www.flaticon.com/ is licensed by CC 3.0 BY

Online survey - patient views Just over half (53%) felt listened to 77% not offered option to have family/carer present Patients wanted staff to be comfortable asking about suicidal thoughts Icons made by Freepik from https://www.flaticon.com/ is licensed by CC 3.0 BY

Online survey - carer views Over a third (35%) reported a lack of crisis information Under half (45%) reported being present at assessment Almost half (45%) felt views not acknowledged Icons made by Freepik from https://www.flaticon.com/ is licensed by CC 3.0 BY

3. Clinician interviews

“The dynamic nature of risk cannot always be predicted and managed” Clinician interviews “We can’t predict human behaviour. Likelihood is an opinion, a professional judgement” “Your job is not to predict who will die; your job is to engage with the problem the patient is presenting to you in a way that is helpful” “An assessment flows the way you direct it but also the way the patient takes you. If they say something alarming, check that out, it may not fit into a box” “The dynamic nature of risk cannot always be predicted and managed”

Clinical messages Risk assessment tools should not focus on prediction NICE guidelines: “Do not use risk assessment tools & scales to predict future suicide or repetition of self-harm” Treatment decisions should not be determined by a score

Clinical messages Tools need to be simple, accessible Emphasis on: a clinical judgement clinician/patient relationship gathering good information Staff should be comfortable asking about suicidal thoughts Better training & ongoing supervision Icons made by Freepik from https://www.flaticon.com/ is licensed by CC 3.0 BY

Clinical messages Family/carer involvement Personal, individualised approach leading to a collaborative management plan No role on own, part of wider system of mental health care Icons made by Freepik from https://www.flaticon.com/ is licensed by CC 3.0 BY

National Confidential Inquiry into Suicide and Safety in Mental Health www.manchester.ac.uk/ncish @NCISH_UK