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?
Audits
Audit
Year
Scenario plans
No of care
and
treatment
plans
audited
No of
HCR-20s
completed
1 (04/07 –
03/0808)
84
35 (42%)
24 (29%)
61
35
(73%) (42%)
27 (32%)
2 (11/08 –
01/09)
30
19 (63%)
18 (60%)
18 (60%)
25 (83%)
3 (12/09 –
02/10)
21
19 (90.5%) 16 (76%)
19 (90.5%)
19
(90.5%)
4 (12/10 –
02/11)
27
26 (96%)
26 (96%)
24 (88%)
Formulation
of
offending
behaviour
25 (92%)
Hospita
l
Warning
Signs
other
HCR-20 risk factors
HISTORICAL
FACTORS
Risk Factor
Identified
(definite or
partial
evidence)
On
problem
list
Objective set for
risk management
History of violence
27
22
17
Relationship problems
25
5
2
Employment problems
26
0
9
Substance misuse
24
20
11
History of major mental
illness
27
27
20
Psychopathy
8
1
4
Early maladjustment
24
5
1
Personality disorder
20
8
3
Prior supervision failure
26
7
3
Table 15: Management Strategies by each Objective Heading (53 patients)
Objectives
I
S
M
V
Not known
1
Improve Mental Health
96
7
55
0
3
2
Improve physical Health and
address health promotion
104
0
66
0
1
3
Address any cultural spiritual or
diversity issues (including
disability if relevant)
17
0
3
1
17
Provide appropriate treatment and
management strategies to reduce
risk of violence
78
3
19
2
3
5
Tailor security levels and
rehabilitation plan to level of risk
22
27
40 (22
preset)
0
5
6
Address any family or relationship
issues
69
4
5
3
6
7
Address any financial incapacity or
other social welfare issues.
11
2
1
0
16
8
Provide appropriate structured
activity
71
0
2
0
4
9
Address daily living functions
50
3
6
0
6
10
Develop /review future plans
22
52
2
0
9
4
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?
morag.slesser@nhs.net
claire.hamill@nhs.net