Risk Management in Practice The NHS Perspective Morag Slesser, State Hospital Claire Hamill, NHS Fife

Levels of Security Maximum Security (The State Hospital) Medium Security Low Security Community – direct responsibility Consultation – indirect responsibility

Risk Processes – Tiered Approach Guided by SPJ Framework Tiers detailed in FRAME documentation – Scan – Examine – Scrutinise Sole vs. Team Based Assessment

SPJ Framework Gather information Evaluate presence and relevance of risk factors Evaluate presence of protective factors Offence analysis/formulation Scenario planning Risk management planning – Link with CPA process, traffic light plans

Training Basic information to all staff Risk awareness training – OPBs Training in SPJ paradigm Training in specific SPJ tools Training in personality assessments Supervision

The Challenges Working within the mental health act Patients with on-going impairments Dual role of care and managing risk Government policy and direction Theory into practice Organisational strategy and clinical leadership Implementing governance systems

Theory into Practice Generally too much focus on the SPJ “tool” rather than on the other parts of the risk management process Teams vs. individual emphasis Not everyone has equal training/competences in formulation of offending behaviour, scenario planning, writing risk management plans Risk management as part of the CPA process. How to make sure it doesn’t get lost.

Organisational Strategy Are senior management supportive? Is it part of the organisation’s strategy? Are their associated targets set? Is there a structure that everyone can follow? Keep it simple! Is there funding for training of staff? Is there a system for overseeing implementation? Is there a “change leader?”

Governance Audits (big and small/process vs. quality) Targets – Does everyone know what they are? Are they being achieved? Training – is it working? Supervision Consequences – what happens when targets are not achieved?

Audit Year No of care and treatment plans audited No of HCR-20s completed Formulation of offending behaviour Scenario plansWarning Signs Hospita l other 1 (04/07 – 03/0808) 8435 (42%)24 (29%)61 (73%) 35 (42%) 27 (32%) 2 (11/08 – 01/09) 3019 (63%)18 (60%) 25 (83%) 3 (12/09 – 02/10) 2119 (90.5%)16 (76%)19 (90.5%) 4 (12/10 – 02/11) 2726 (96%)25 (92%)26 (96%)24 (88%) Audits

HCR-20 risk factors HISTORICAL FACTORS Risk Factor Identified (definite or partial evidence) On problem list Objective set for risk management History of violence Relationship problems2552 Employment problems2609 Substance misuse History of major mental illness Psychopathy814 Early maladjustment2451 Personality disorder2083 Prior supervision failure2673

Table 15: Management Strategies by each Objective Heading (53 patients) Objectives ISMV Not known 1Improve Mental Health Improve physical Health and address health promotion Address any cultural spiritual or diversity issues (including disability if relevant) Provide appropriate treatment and management strategies to reduce risk of violence Tailor security levels and rehabilitation plan to level of risk (22 preset) 05 6Address any family or relationship issues Address any financial incapacity or other social welfare issues Provide appropriate structured activity Address daily living functions Develop /review future plans

Example: Results for Schedule 1 offenders - TSH 4/14 CSO did not have sexual violence risk assessment 5/18 had full description of main offence against a child in the CPA paperwork 9/18 had objectives that explicitly targeted offending against children VSP in relation to children in only 1 case 9/18 had objectives that explicitly targeted offending against children 10/18 scenario plans relating to children within TSH; 12/18 outwith TSH

Questions?