Violent and Aggressive
Patient Policy
Dr A. Lyon & Partners
September 2011
Document Control Page
Title of document
Violent and Aggressive Patient Policy
Author’s name
Anne Grundy
Author’s job title
Practice Manager
Doc. Status
Final
Signed off by
Anne Grundy
Original Publication Date
August 2011
Last Reviewed
July 2013
Next review date
2014
Distribution
General Practice
Consultation History
Version
0.1
0.2
0.3
0.4
Date
Consultation
May 2010
Practice Manager/Partners Meeting
September
2011
6th October
2011
Practice Manager/Partners/Reception
Meeting
July 2013
Revised by Practice Manager
Reception Meeting
1.0 Introduction
The NHS has a zero tolerance policy of all violence and aggression. This policy is for the
protection of all NHS staff, but also for the protection of other patients, their families,
visitors, etc. In order to ensure that this zero tolerance approach is adhered to, it is
essential to have robust policies and procedures in place. In General Practice, this will
need to cover a variety of situations in which incidents could occur.
2.0 Aims and Objectives
The aims and objectives of this policy are as follows:
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To ensure adequate processes are in place for the protection of staff and patients
To ensure staff are fully aware of their responsibilities when dealing with violent or
aggressive patients
To ensure that staff are fully aware of their rights when they have to deal with such
incidents
3.0 Aggressive Patient
What is an aggressive patient? This is a patient (or relative) who exhibits one or more of
the following patterns of behaviour:
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Verbally abusive, offensive or intimidating in their behaviour towards staff
Threatening physical violence
Making excessive demands and/or maintaining certain expectations and failing to
accept that these are unreasonable (e.g. wanting an immediate appointment and
becoming aggressive when this is not possible)
insisting that a member of staff is dismissed
insisting that treatment is carried out on demand
constantly requesting a different GP
demands to see a particular member of staff/clinician
4.0 Dealing with an Aggressive Patient
Patients can become aggressive for a variety of reasons, and it is always advisable to try
to calm down the situation as early as possible, as this may prevent an incident.
4.1 An Aggressive Incident
If the patient does become aggressive, then the following process should be followed:
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If they continue with their aggressive behaviour, then tell them that they will not
be dealt with until they calm down.
Remain calm and clear and keep repeating that the behaviour is unacceptable.
Insist that you are trying to help, but cannot do so until they calm down.
In the interests of safety, it is best to stay accompanied by another member of
staff. Staff should never isolate themselves with a potentially violent patient.
Get a more senior member of staff to speak to the patient, again keeping calm
and stressing that you are trying to help.
Following the incident, the main points should be recorded on a significant
events form

All incidents of violent and aggressive behaviour should be reported to the
Practice Manager
4.2 Repeated Incidents
If there are repeated incidents from a particular patient, then the practice should write
to the patient warning them that no other incidents will be tolerated, and the patient will
be removed from the list if this happens again. (See app 1 for sample letter)
Note that it is important to carry out this action once it has been written down. If the
patient continues with this behaviour, even after the written warning, then they should
be removed from the list for the sake of staff and other patients.
5.0 Violent Patients
Dealing with a violent patient requires a much more immediate response. As soon as a
patient turns violent, then immediate action must be taken, as follows:
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Lock the reception door
If the aggressive behaviour continues and a panic alarm is available, then press
this immediately
If the patient is in the consulting room with a clinician, then the correct procedure
should implemented (see app 2)
Phone the police. Once violence occurs, it becomes a crime.
If there are other patients in the vicinity, then there is a duty to protect them. If
possible remove other patients in the vicinity to another part of the waiting area or
another room away from the situation.
Following an incident of violence, the practice should hold a significant event
meeting to decide if the patient should be removed from the list.
If the patient is to be removed from the list, then the practice should now follow the
procedure for the removal of patients.
6.0 Removal of Patient from Practice List
When it becomes necessary to remove the patient from the practice list, for reasons of
violent or aggressive behaviour, then a specific process should be followed. (See info 4
Policy on removing Patients from the Practice List).
Under schedule 6 of the NHS (GMS Contracts) Regulations (2004), the PCT would be
required to remove a patient from the GP practice list if it is informed by the practice that
the patient has committed an act of violence against anyone present on the practice
premises, or at any place where the services were provided to the patient, or that the
patient has behaved in such a way that any person has feared for his/her safety.
It is essential in all cases that the incident has been reported to the police, prior to the
application to the PCT to remove the patient from the list. (See appendix 4 for an extract
of the GP Contract)
7.0 Following an Incident
Every incident of violence or aggression should be recorded in a log specifically used for
this purpose. This log should contain the following information:
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Patient ID (eg NHS number)
Time and date of incident
Nature of incident – particularly the trigger point (eg not able to get appointment)
Perspective of staff member dealing with the incident,
Names and statement of any witnesses
Record of any actions taken
8.0 Staff Support
The member of staff who was subjected to the violence or aggression will need support,
even though they may not recognise this fact immediately. The way this support is
handled can often make the difference to the way the staff member is able to deal with
what has happened, with minimal adverse effects.
The following process should take place as soon as possible after the incident:
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The Practice Manager should have a one-to-one discussion with the staff member,
in private and as informally as possible (if the Practice Manager is the person
affected, then a GP or Practice Nurse should do this)
The staff member should be encouraged talk about the incident from their
perspective, and encouraged to write it down (this is the best time to complete the
incident log)
Ask the staff member what support they feel they need to help them deal with the
situation
If the staff member feels they need counselling, then provide this as soon as
possible, either within the practice if there is a trained counsellor, or by referral to
the appropriate service
If the person affected is not employed by the practice (e.g a Health Trainer) then
inform their line manager immediately after the incident
9.0 When a Violent Patient Joins the Practice
Because of the length of time it takes for patient notes to come from LaSCA, it is possible
that a new patient could join the practice, and only after several weeks would you discover
that they have been violent in a previous practice.
In the event of this happening, it is advisable to write to the patient, to notify them that you
are aware of the previous incident, and that if there is any instance of violence or
aggression within your own practice, then the patient would be removed from the list. (see
app 3)
10.0 Governance Arrangements
This policy will be approved by the Practice Manager. The Practice Manager will be
responsible for notifying all staff of the process, ensuring all staff has up to date copies of
the document and that the staff are following the processes documented within.
This policy will be reviewed 2 years from the date of publication
Appendix 1
Dr Alison L Lyon MB. CH.B. M.R.C.G.P. FPA
Dr C J Earnshaw MB. CH.B.D[OBST] RCOG
Dr R L Swann MB. CH.B
Dr Eve Haworth MB. CH.B DCH DRCOG M.R.C.G.P. Tel:
Dr F Thagia MB.CH. B DRCOG M.R.C.G.P
1st Floor, Lever Chambers Centre for Health
Ashburner Street,
Bolton BL1 1SQ
Tel: 01204 462630
Fax: 01204 462636
Dr A. Lyon & Partners
Our Ref: ALL/AMG/STW
Date:
In Confidence
To:
Dear
On your visit to the surgery on ...................., you were .....................................................
We feel we must inform you that this behaviour is unacceptable.
It is our responsibility to point out to you that we have a zero tolerance policy across the NHS for
patients who are abusive and/or violent to staff. At Dr Lyon & Partners we take this policy very
seriously, and would not hesitate to remove patients from the list who do not abide by this policy.
We are happy for you to remain with the practice, but insist that you abide by the above mentioned
policy in all your dealings with the practice.
We hope you understand that should such poor behaviour occur again, we will have no alternative
other than to exercise our right to remove you from our List
Yours sincerely,
Dr. A. Lyon & Partners
Dr Lyon & Partners
Telephone: 462630
Web:www.boltondoctors.co.uk
Please look us up at www.nhschoices.net
Appendix 2
Dealing with a violent or aggressive patient if the patient is in the consulting room with a
clinician requires a much more immediate response. As soon as a patient turns violent,
then the correct procedure should implemented and immediate action must be taken, as
follows:
 If possible the Clinician should proceed to the door of the consulting room as
request assistance from reception staff.
 If unable to get to the door, press the panic button immediately
 A member of staff must immediately respond to the clinic room to provide
assistance
 Another member of staff should call security to aid the removal of the patient from
the premises
 Phone the police. Once violence occurs, it becomes a crime.
 If there are other patients in the vicinity, then there is a duty to protect them. If
possible remove other patients in the vicinity to another part of the waiting area or
another room away from the situation.
 Following an incident of violence, the practice should hold a significant event
meeting to decide if the patient should be removed from the list.
 If the patient is to be removed from the list, then the practice should now follow the
procedure for the removal of patients.
 Following the incident, the main points should be recorded on a significant events
form
 All incidents of violent and aggressive behaviour should be reported to the Practice
Manager
Appendix 3
Dr Alison L Lyon MB. CH.B. M.R.C.G.P. FPA
Dr C J Earnshaw MB. CH.B.D[OBST] RCOG
Dr R L Swann MB. CH.B
Dr Eve Haworth MB. CH.B DCH DRCOG M.R.C.G.P. Tel:
Dr F Thagia MB.CH. B DRCOG M.R.C.G.P
1st Floor, Lever Chambers Centre for Health
Ashburner Street,
Bolton BL1 1SQ
Tel: 01204 462630
Fax: 01204 462636
Dr A. Lyon & Partners
ALL/AMG/STW
Date ……………………………
In Confidence
To: …………………………………
……………………………………..
Dear
Thank you for registering with Dr A. Lyon & Partners
We are now in receipt of your full medical records.
We note, from these records, that you have a history of abusive and/or violent behaviour
at your previous practice.
It is my responsibility to point out to you that we have a zero tolerance policy across the
NHS for patients who are abusive and/or violent to staff. At Dr Lyon & Partners we take
this policy very seriously, and would not hesitate to remove patients from the list who do
not abide by this policy.
We are happy for you to remain with the practice, but insist that you abide by the above
mentioned policy in all your dealings with the practice.
If you wish to discuss this matter further, then please do not hesitate to contact me.
Yours sincerely
Anne Grundy
Practice Manager
Practice Manager – Anne Grundy AMSPAR[DIP]
Member of Institute Healthcare Management (MIHM)
Direct Tel: 01204 462644
E.mail: anne.grundy@nhs.net
Web. www.boltondoctors.co.uk
Appendix 4
Removals from the list of patients who are violent
202. Where the Contractor wishes a patient to be removed from its list of patients with
immediate effect on the grounds that:
202.1. the patient has committed an act of violence against any of the persons
specified in clause 203 or
behaved in such a way that any such person has feared for his safety; and
202.2. it has reported the incident to the police, the Contractor shall notify the PCT in
accordance with clause 204.
203. The persons referred to in clause 202 are:
203.1. if the Contract is with an individual medical practitioner, that individual;
203.2. if the Contract is with a partnership, a partner in that partnership;
203.3. if the Contract is with a company, a legal and beneficial owner of shares in
that company;
203.4. a member of the Contractor’s staff;
203.5. a person employed or engaged by the Contractor to perform or assist in the
performance of services under the Contract; or
203.6. any other person present on the practice premises or in the place where
services were provided to the patient under the Contract.
204. Notification under clause 202 may be given by any means including telephone or fax
but if not given in writing shall subsequently be confirmed in writing within seven days (and
for this purpose a faxed notification is not a written one).
205. The PCT shall acknowledge in writing receipt of a request from the Contractor under
clause 202.
206. A removal requested in accordance with clause 202 shall take effect at the time the
Contractor makes the telephone call to the PCT, or sends or delivers the notification to the
PCT.
207. Where, pursuant to clauses 202 to 206, the Contractor has notified the PCT that it
wishes to have a patient removed from its list of patients, it shall inform the patient
concerned unless:
207.1. it is not reasonably practicable for it to do so; or
207.2. it has reasonable grounds for believing that to do so would be harmful to the
physical or mental health of the patient or would put at risk the safety of one or
more of the persons specified in clause 203.
208. Where the PCT has removed a patient from the Contractor’s list of patients in
accordance with clause 206 it shall give written notice of the removal to that patient.
209. Where a patient is removed from the Contractor’s list of patients in accordance with
clauses 202 to 208, the Contractor shall record in the patient’s medical records that the
patient has been removed under this paragraph and the circumstances leading to his
removal.
GP Safehaven (Violent Patient) Scheme
Risk Assessment
CLIENT NAME
DATE
DATE OF BIRTH____________
NHS NO___________________
ADDRESS_____________________________________________________________________
Information sources available/accessed in completing Risk Assessment (tick all sources used and
state whom)
Patient
Case notes
Carer/relative
Other
Specify
Specify
Reason for referral onto the scheme.
Name of present
GP
Contact Number
of referring
person
Reason for
referral
Name of person making
referral
Section 1: Suicide.
a) Does the professional consider the individual at risk of suicide?
Yes/No
b) Is there a history of suicide attempts?
Yes/No
Section 2: Self Harm.
a) Does the professional consider the individual at risk of intentional self-harm?
Yes/No
b) Is there a history of intentional self-harm?
Yes/No
Section 3: Harm to others.
a) Does the professional consider the individual at risk of harming others?
Yes/No
b) Is there a history of harm to others?
Yes/No
c) If yes please provide more information
Section 4; Substance Misuse.
a) Is there evidence of substance misuse?
Yes/No
b) Is there a history of substance misuse?
Yes/No
c) Does the professional feel the level of misuse warrants concern for the
safety of the individual or others?
Yes/No
d) If yes to ( c ) please explain further:
Section 5: Social circumstances.
a) Does the professional feel any of the social circumstances or medical
conditions warrant concerns for the individual’s safety?
Yes/No
b) Have any social circumstances or medical conditions led to
deterioration in the past?
Yes/No
Section 6: Neglect.
a) Does the professional consider the individual is at risk of neglect
by self or others?
Yes/No
b) Is there a history of neglect (emotional, physical, mental)?
Yes/No
Section 7: Treatment related indicators.
a) Does the professional consider the individual is at risk of not complying
with treatments/services?
Yes/No
b) Is there a history of not complying with treatment/services?
Yes/No
Section 8: Risk to staff.
a) Does the professional consider that there are any risks involved in the
individuals care?
Yes/No
b) Is there a history of risk to staff?
Yes/No
Please provide any further relevant information
Reviewed By____________________________
Completed by
Designation
Date
Primary Care Support Services (Preston Office)
Incident Report Form
Please use this form for the removal of a patient following a violent incident towards a GP, a
member of staff or a patient. The incident must be reported to the police and the police incident log
number must be stated on this form. Without this number, immediate removal is not possible
under the regulations for violent patient removal.
Practitioner’s name:
Practice address:
Practice contact number:
Patient’s name:
Patient’s NHS number:
Date of birth:
Patient’s address:
Date of incident:
Time of incident:
Police incident log number:
Location of incident:
(Patient’s address/Surgery etc)
Date obtained:
Type of incident (please tick the appropriate box)
Non physical violence
i.e. intimidation, abuse, threats etc
Physical Violence
Vandalism to:
Aggravated Physical Violence
e.g. use of weapons
Premises
Vehicle
Approximate cost of damage (optional): £
Assault to: (please tick the appropriate box)
GP/Dentist
Verbal
Staff
Verbal
Other Patient(s)
Verbal
Physical
Physical
Physical
Please supply brief details of the incident
GP signature (actual signature must be provided):
****E-mail completed form to: lasca.registrations@nhs.net or fax to 01772 221447****
Info 4
Dr A Lyon & Partners
Policy on Removing Patients from the
Practice List
REVISED September 2011
Dr A. Lyon & Partners
POLICY ON REMOVING PATIENTS FROM PRACTICE LIST
PURPOSE
The surgery aims to provide the best possible health care for its patients. However there may be
circumstances when it would be considered reasonable, or in the best interests of the patient, to
remove patients from the list.
The purpose of this policy, therefore, is to define the practice guidelines for when it is reasonable to
remove a patient from the practice list and to ensure that any concerns about removing patients
from the list are dealt with fairly.
SITUATIONS WHICH JUSTIFY REMOVAL
VIOLENCE
DISTANCE
EMBARKATION
DEATH
FAILURE TO ATTEND PRE-BOOKED APPOINTMENTS
IRRETRIEVABLE BREAKDOWN OF THE DOCTOR-PATIENT RELATIONSHIP
UNDELIVERED MAIL
CRIME & DECEPTION DEFINED AS
VIOLENCE DEFINED AS
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When a patient:Is physically violent or threatening towards a doctor, practice staff or other patients on
the practice premises.
Causes physical damage to practice premises or other patient’s property
Gives verbal abuse or makes threats towards the doctor, practice staff or other
patients
Gives racist abuse, orally or physically
Is violent or uses or condones threatening behaviour to doctors [or some other
members of the primary health care team] while visiting the patient’s home. Such
behaviour may involve the patient, a relative, a household member, or pets [such as
unchained dogs].
Where a patient: Fraudulently obtains drugs for non-medical reasons
 Deliberately lies to the doctor or other member of the primary health care team [e.g.
by giving a false name or false medical history] in order to obtain any service or
benefit by deception
 Attempts to use the doctor or conceal or aid any criminal activity
 Steals from practice premises
/2 Policy on removing patients from practice list cont…
DISTANCE DEFINED AS
Where a patient has moved out of the designated practice area and has failed to register with
another GP
EMBARKATION DEFINED AS
Where a patient has moved abroad for a period of 3 months or more
FAILURE TO ATTEND PRE-BOOKED APPOINTMENTS DEFINED AS
Where a patient fails to attend pre-booked appointments on a number of occasions during a given
period
IRRETRIEVABLE BREAKDOWN OF THE DOCTOR-PATIENT RELATIONSHIP
DEFINED AS
Where a patients behaviour falls outside of that which is normally considered reasonable and leads
to an irretrievable breakdown of the doctor-patient relationship
UNDELIVERED MAIL IS DEFINDED AS
Letters returned to the practice by royal mail or occupant from the address which mail has been
sent but the addressee is no longer resident.
PROCEDURE FOR REMOVAL
VIOLENCE/CRIME AND DECEPTION
Any incident involving violence, crime or deception will be reported to the practice manager who
will complete an incident report and bring to the attention of the practice partners
Each individual case will be discussed at a practice meeting and a majority agreement will be
reached
Following agreement, the practice manager will write to the patient and explain the reasons for
removal
DISTANCE
On notification that the patient is no longer living within the practice boundary, the patient is
usually informed verbally that they will require to register at a new surgery in their area.
The change of address is completed on Vision and the Health Authority notified to deduct the
patient.
EMBARKATION
On notification that the patient has moved abroad the patient will be removed from the practice list
within 3 months of that notification
FAILURE TO ATTEND PRE-BOOKED APPOINTMENTS
If a patient fails to attend 2 pre-booked appointment on more than one occasion in the last year, a
warning letter will be sent to the patient, advising them that a further occurrence could risk removal
from the practice.
If the patient fails to attend another appointment, the matter will be discussed at a Practice Meeting
and a majority agreement will be reached as to whether the patient will be removed from the
practice list.
Following agreement, the practice manager will write to the patient and explain the reasons for
removal.
GUIDELINES ON REMOVING PATIENTS DUE TO IRRETRIEVABLE BREAKDOWN
OF THE DOCTOR-PATIENT RELATIONSHIP
Occasionally patients persistently act inconsiderately and their behaviour falls outside that which is
normally considered to be reasonable. In such circumstances the practice may consider there to be a
complete breakdown in the doctor-patient relationship.
Steps taken within the practice
All appropriate members of the practice will be informed about the problem
The patient and possible reasons for their behaviour [i.e. disagreeableness, cultural differences,
mental illness, personality disorder] will be discussed at a Practice Meeting
Steps to be taken with the patient
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The practice will inform the patient, either personally or in writing, that there is a problem,
explain the nature of the problem to the patient
obtain the patient’s perspective and interpretation of the situation.
If necessary the practice will obtain the advice of a Medical Defence Society
.
If discussion fails to resolve the problem, the practice may suggest that another GP within the
practice might better fit with the patient’s needs and expectations
Removing the patient when necessary

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The practice will inform LASCA in writing of the decision (See appendix A)
Inform that patient in writing of the decision and the reason for removal from the list (see
Appendix B)
Explain to the patient that he/she will not be left without a GP
Give the patient information on how to begin the process of registering with another GP
FAMILY MEMBERS
The decision to remove family members/extended family members of the patient removed may be
made if necessary. The practice will write to the family/patients concerned explaining the reason for
removal and allowing them 4 weeks to re-register with another practice rather than removing them
from the list immediately
RESPONSIBILITY for implementing and monitoring the policy will rest with the Practice
Partners/Practice Manager
The Partners at the surgery re-affirm their commitment to do everything possible to protect
staff, patients and visitors from unacceptable behaviour and their zero tolerance of any
incident that causes hurt, alarm, damage or distress.
Appendix A
Dr Alison L Lyon MB. CH.B. M.R.C.G.P. FPA
Dr C J Earnshaw MB. CH.B.D[OBST] RCOG
Dr R L Swann MB. CH.B
Dr Eve Haworth MB. CH.B DCH DRCOG M.R.C.G.P. Tel:
Dr F Thagia MB.CH. B DRCOG M.R.C.G.P
1st Floor, Lever Chambers Centre for Health
Ashburner Street,
Bolton BL1 1SQ
Tel: 01204 462630
Fax: 01204 462636
Dr A. Lyon & Partners
Date:
Patient Data Department
Lancashire & South Cumbria Agency (LaSCA)
3 Caxton Road
Fulwood
Preston
PR2 9ZZ
Dear Colleagues,
Please remove the patient’s detailed below from our List with immediate effect due
to________________________________________________________________.
Name
Address
Date of birth
Yours sincerely,
Dr Alison Lyon
Dr Richard Swann
Dr Christopher Earnshaw
Dr Eve Haworth
Dr Ferjana Thagia
Medical Secretary – Sharon
Telephone 462630 Ext: 7050 – Fax 462636
Email: sharon.wilmot@nhs.net
Web:www.boltondoctors.co.uk
Please look us up at www.nhschoices.net
NHS Number
Appendix B
Dr Alison L Lyon MB. CH.B. M.R.C.G.P. FPA
Dr C J Earnshaw MB. CH.B.D[OBST] RCOG
Dr R L Swann MB. CH.B
Dr Eve Haworth MB. CH.B DCH DRCOG M.R.C.G.P. Tel:
Dr F Thagia MB.CH. B DRCOG M.R.C.G.P
1st Floor, Lever Chambers Centre for Health
Ashburner Street,
Bolton BL1 1SQ
Tel: 01204 462630
Fax: 01204 462636
Dr A. Lyon & Partners
Our Ref:
Date:
In Confidence
To:
Dear
Unfortunately due to events which have taken place recently at the surgery, namely your
aggressive manner and inappropriate behaviour i.e. _____________________________,
leading to the irrevocable breakdown of communication and breach of trust between
yourself and the Practice, we feel we have no alternative other than to remove you from
our List and ask you to find another doctor.
You have been issued with enough medication until you register with a new Gp.
The Health Authority will contact you about finding another Practice to register with.
The Health Authority Patient Services Department can be contacted on
01772 221 444.
Yours sincerely,
Dr Alison Lyon
Dr Richard Swann
Dr Christopher Earnshaw
Dr Eve Haworth
Dr Ferjana Thagia
Dr Lyon & Partners
Telephone: 462630
Web:www.boltondoctors.co.uk
Please look us up at www.nhschoices.net