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

2. 2

3. Risk assessment tools & scales
High
Medium
Low

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

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

6. 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

7. 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.

8. 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

9. 1. Survey of tools used in mental health services

10. Content and Format of tools

11. 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.

12. 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.

13. 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

14. 2. Online survey

15. 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.

16. 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
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17. 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
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18. 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
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19. 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
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20. 3. Clinician interviews

21. “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”

22. 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

23. 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
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24. 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
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25. National Confidential Inquiry into Suicide and Safety in Mental Health
@NCISH_UK