Low secure LD care pathway and gate-keeping guidance and templates
Dr Susan Johnston M.B., Ch.B., F.R.C.Psych.
Dr Richard Lansdall-Welfare M.B., Ch.B., M.R.C.Psych.
Ruth Sargent
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Low secure LD care pathway and gate-keeping guidance and templates
CONTENTS
Section
Page
no.
1 Preface
4
2 Introduction
5
3 Care pathway
6
4 Referral and Gate-keeping process for low secure services
7
4.1 Referral pathway
7
4.2 Timescale
8
4.3 The Gate-keeping assessment
8
4.4 Key decision points in the gate-keeping process
9
4.5 The Gate-keeping report
11
5 Model pathway within low secure services
12
6 Equality impact assessment
14
7 Review date
16
8 Approval
16
APPENDICES
1
Description of high, medium and low secure services and
locked rehabilitation services
17
2 The East Midlands learning disability community forensic
service model
19
3 East Midlands clinical Gate-keepers – low secure
23
4 Assessment tools and outcome measures
25
5 Gate-keeping assessment template
37
6 Steering group attendees
41
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Low secure LD care pathway and gate-keeping guidance and templates
Population in the East Midlands
East Midlands had one of the fastest growing populations between 2001 and 2009.
Above
average growth is projected to continue, with particularly large growth rates in older age groups.
The population of the East Midlands was estimated to be 4.5 million in 2009, 8.6 per cent of the
population of England. Population density was 290 residents per sq km, one of the lowest among
the English regions. It varied from less than 80 residents per sq km in West Lindsey in
Lincolnshire, to 4,200 in Leicester unitary authority.
It is projected the region will have 5.2 million residents by 2028, 17 per cent more than in 2008.
The projected increase for England is 15 per cent over the same time period.
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Low secure LD care pathway and gate-keeping guidance and templates
1.
Preface
This document has been developed as part of the East Midlands Next Stage Review, Towards
Excellence work programme.
The East Midlands Next Stage Review identified the need to develop a forensic care pathway for
people with learning disability. An element of the pathway that was causing considerable concern
was low secure provision. Low secure services provide hospital care for people with complex
needs, challenging behaviours and/or forensic needs.
The concerns were threefold; firstly that people were placed inappropriately far from home,
secondly that they may be staying longer than necessary in secure care, and finally that the costs
of the placements were not adequately monitored or controlled by commissioners.
With low secure commissioning moving to East Midlands Specialised Commissioning Group
(EMSCG) in April 2009 it was agreed that EMSCG would lead this work alongside the low secure
clinical lead, Richard Lansdall-Welfare, appointed in March 2009.
The Chief Executive lead for the work-stream is John McIver, Chief Executive NHS Lincolnshire.
The original milestones for the project concentrated on the handover of responsibility for
commissioning low secure services from local PCTs to EMSCG, and for audits of provider units to
be undertaken against Department of Health guidance. These were completed by June 2009.
A steering group was formed in October 2009 to progress the work on the learning disabilities
forensic care pathway, referral and gate-keeping processes for low secure care.
Representatives from the 6 East Midlands NHS provider Trusts and from the 9 Primary Care
Trusts were invited to join the steering group.
A full list of invited organisations and attendees can be found at the back of the document.
(Appendix 6) The authors of this document are grateful for the enthusiasm, hard work and
commitment from the steering group attendees.
A confirm and challenge event was held on 29th October 2010 to help finalise the document.
Focus groups were also held with service users in 2 provider units.
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Low secure LD care pathway and gate-keeping guidance and templates
2.
Introduction
Secure mental health and learning disability services are specialist, tertiary mental health services
that provide for both mentally disordered offenders and those whose behaviour has led, or could
lead to offending. They manage individuals who are a risk to others and require input from staff
with specialist expertise and knowledge and provide a level of security for detained patients.
Forensic/secure services serve the public and the criminal justice system by:
 “Providing secure services within a framework of clinical governance, specialised
assessment, treatment and rehabilitation for offenders with mental health problems or those
at risk of offending;
 Promoting better services through teaching, research and development; and
 Working closely with service users, carers, other health, local authority social services, nonstatutory and criminal justice agencies to reduce and manage risk.”
 (Jobbins, Abbott, Brammer, Doyle, McCann & McClean; 2007)
The range of forensic and secure services currently within the UK are generally categorised by the
level of security they provide. The term forensic and secure is often used interchangeably when
discussing these services, but may describe different populations and services.
A brief description of high, medium and low secure services is available in Appendix 1.
This document seeks to describe the forensic care pathway for people with learning disabilities in
the East Midlands, together with the gate-keeping process for low secure care.
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Low secure LD care pathway and gate-keeping guidance and templates
3.
Care Pathway
An overview of the care pathway and current population of people with learning disabilities cared
for by forensic services is set out below:
East Midlands Regional Learning Disability Forensic
Care Matrix
Criminal
Justice
System
COMMUNITY SERVICES
Community LD
Services
Community
Forensic Services
Local
Adult Mental
Health Services
PRISON
CAT C
Low Secure
Services
40
CAT
B/C
CAT
A/B
Medium Secure
Services
Local
10
Locked
Rehabilitation
Service
Regional
35
National
High Secure
Services
6
*The numbers denote East Midlands patients in services in May 2010.
Meeting the needs of learning disabled forensic patients involves a multi agency response and a
tiering of services in the overall learning disabilities service model. Individual care pathways may
utilise several of the elements above.
There is also an important relationship with the criminal justice system. Broadly speaking the
category of prisons mirrors the tiering of health services.
Community services patients may receive services from a range of organisations and services.
They are the hardest population to quantify.
The Steering Group agreed a model for a virtual community forensic team which will vary in it’s
specific make-up in each area but retains the same function. This is outlined in Appendix 2.
The diagram above implies a simplistic, linear process and system that does not always map well
onto a complex set of services or reflect individual pathways.
The aim is to assist in clarifying the pathway and processes, together with greater alignment of the
entries and exits into and out of services.
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Low secure LD care pathway and gate-keeping guidance and templates
4.
Referral and Gate-Keeping Process for Low Secure Services
Over the last 2 years the commissioning of low secure commissioning has transferred from
Primary Care Trusts to East Midlands Specialised Commissioning Group. This has enabled a
greater focus on patients with learning disabilities with these specialised needs.
This section sets out clear arrangements for referral to, and clinical gate-keeping of low secure
services which will be applied across the East Midlands to achieve consistency.
4.1.
Referral Pathway
LOW SECURE REFERRAL PATHWAY
Medium Secure
Services
Prison In-Reach
Teams/Courts/
Police/Probation
Forensic and Low
Secure Community
Teams
Adult Mental
Health Services
Learning
Disability
Services
Local consideration of appropriateness for Low Secure bed (arrangements will
vary by area)
SINGLE POINT OF ACCESS
Low Secure gate-keeping request via East Midlands Specialised Commissioning Group
LOCAL CLINICAL GATE-KEEPER
Assesses appropriateness of patient
Emergency
requires Low
Secure bed
EMSCG Case
Manager proceeds
with referral to Low
Secure bed
immediately-liaise
with local
commissioner
Requires Low
Secure bed
Does not require
Low Secure bed
Case manager
retrospectively
informs panel due to
urgency of
placement
LOCAL MULTI-AGENCY DECISION MAKING PANEL
Monitoring of all requests for individual placements (the panel has EMSCG
attendance)
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Low secure LD care pathway and gate-keeping guidance and templates
4.2.
Time scales
The time scales below are taken from the Best Practice Guidance Specification for adult Medium
secure services (Health Offender partnerships DH 2007) and should be considered as best
practice for low secure gate keeping assessment and placement.
The gate keeper should
ascertain the urgency of the situation on receipt of the referral.
“E3 For urgent referrals, an initial verbal response regarding the appropriateness of a referral
should be made within 24 hours of receipt of the referral, and an initial multidisciplinary
assessment within seven days. The outcome should be notified verbally within 24 hours of
the assessment, and a formal written assessment should follow within seven days. E4 For routine
referrals, an initial response as to whether a multidisciplinary team (MDT) assessment will
be appropriate should be notified within 14 days and an initial MDT assessment within one month.
A decision should be made within two weeks and a bed offered within a further six weeks.”
The steering group has identified that good practice would suggest that the gate- keeping
assessment is multidisciplinary, however clinicians will agree and produce a single report signed
by the consultant. There are some circumstances where this might be difficult to achieve. If there
is a single gate-keeper this should be a specialist learning disability consultant psychiatrist or an
Approved clinician.
A full list of identified gate-keeping assessors for the region is given in Appendix 4.
Assessors will normally operate within their own locality.
However, they can operate across
County boundaries if required.
4.3
The Gate Keeping Assessment
Clinicians working in an individual service are familiar with the role of deciding, as a result of
informal and formal processes, which patients are accepted into a service.
Whilst this may be considered a form of gate-keeping it differs from providing a gate-keeping role
on behalf of commissioners of services.
Most clinicians are familiar with:
Providing an assessment and treatment service for a defined number of inpatient beds or
occupied bed days(OBD) or contracted number of face to face contacts, outpatient(OPD)
contacts

Inpatient facilities under their own or a colleagues control
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Low secure LD care pathway and gate-keeping guidance and templates

Formal (and informal) operational practices and service strategy

Staff & resource skills/deficits at any particular time

Staff knowledge and strengths (e.g. autistic disorders, fire- setters etc)

Bed management issues

Existing inpatient populations & dynamics

Knowledge or experience of managing a particular patient
Independent Gate-keeping is a different process.
Gate-keeping is the process of managing / making recommendations to access scarce and expert
resources. It is reasonable to have clear structures and processes in place to ensure those most in
need receive the appropriate services. Gate-keeping will be needed to enter a service and for any
transition or exit from the service.
It should provide early indications of necessary treatment and markers of progress, or risk
milestones on a treatment plan. This should help an individual to maintain the achieved progress in
more local / less secure / less structured/staffed / less costly services.
4.4
Key Decision Points in the Gate-keeping Process
The decision points identified below are not altogether a linear process. They may be interactive
and are key in identifying appropriate levels and the type of service provision for the individual.
Decision point 1
Eligibility for access to specialised learning disability services should be ascertained noting that
wherever possible, practicable and appropriate mainstream (including forensic) services
with/without support should be accessed by all.
On assessment does the individual have:
known learning disability – this may require formal psychometric testing following the
assessment to assist in this.

recently assessed learning disability.

additional complex cognitive impairments such that they require a specialised earning
disability provision.
Decision point 2
Almost without exception for individuals presenting with offences or offending like behaviour the
first gate to be negotiated is:-
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Low secure LD care pathway and gate-keeping guidance and templates

Criminal Justice versus Healthcare provision, this is a very critical decision and may be
more prominent following the implementation of the recommendations from the Bradley
Report.
Decision point 3
For those individuals whose “behaviours” if convicted would attract a non-custodial sentence the
decision is:
No additional health provision

Community provision (including treatment as part of probation)

Residential hospital provision informal / detained
Decision point 4
For those individuals whose “behaviours” if convicted would attract a custodial sentence (or those
who are serving prisoners) the decision is: Hospital versus Prison
Note:Hospital provision can only be offered if the individual fulfils detention criteria under the Mental
Health Act (2007), otherwise intervention should be offered as in-reach to prison.
Decision point 5
If it is considered the individual should receive hospital provision the decision is: Locked rehabilitation services v low v medium v high secure services
Note:
For existing prisoners it is important to note that the security category of the detaining prison will
have a bearing on the level of security for hospital provision that will be acceptable to the Ministry
of Justice.
To identify anticipated level of hospital security

Security components need assessment to find best fit (consider use of structured tool e.g.
The Security Needs Assessment Profile (SNAP))

Current risk assessment of violence, sexual offending, further offending, vulnerability
(consider use of HCR-20, EPS, SVR-20, RSVP, etc)
Principles

Individuals should be placed in the least restrictive environment for their needs.
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Low secure LD care pathway and gate-keeping guidance and templates

There may be times when the complexity of intervention required may best be delivered
where there is the appropriate skill resource and historical patterns indicate worsening
patterns of behaviour when challenged.

An individual in crisis in custody acting out in distress may improve and stabilise very
quickly in the higher staffed hospital provision.
Additional considerations

At the time of assessment the treatment interventions likely to alleviate or prevent
deterioration in mental health should be identified. Not only do these assist in the selection
of the best fit placement but serve as initial care pathway targets and progress markers.

Reference should be made to geographic or other variables impacting on the suitability of
placement e.g. illicit drug free facility, geographically distant from victim.

Respectful suggestions of services known to fulfil provision criteria may be made but
referral to such remain the realm of the secure services commissioning team and
acceptance to individual services will remain the decision of the specific service.
4.5
The Gate-keeping Report
A single Gate-keeping report will provide a clinical picture of the individual and their possible
management issues.
It will clearly identify the level of security required to best meet the
individual’s needs and the level of risk posed.
The report should be based on a face to face interview with the person and take account of and
make reference to any appropriate background documentation.
Telephone calls to others involved with the person can assist in the assessment and should be
referenced in the report.
The report will identify the names and profession of assessors; with the final sign off by a
psychiatrist in learning disability. This person should be able to hold the status of an Approved or
Responsible Clinician. (NB only a medical practitioner can initiate detention).
The template for the report is attached in Appendix 6.
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Low secure LD care pathway and gate-keeping guidance and templates
5.
Model Pathway within Low Secure Services
The steps outlined are broadly sequential and are offered as guidance to commissioners and local
clinicians monitoring placements. Based on average length of admission data it is anticipated that
structured low secure admissions, with associated treatment and rehabilitation, may last up to 2
years duration (though this is dependent on the clinical rationale and individual circumstances).
Lengths of stay beyond this timescale are a variance from this model and may require repeat gatekeeping to re-assess treatment need / risk assessment in conditions of low security, as requested
by EMSCG case manager.
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Low secure LD care pathway and gate-keeping guidance and templates
Admission and Engagement
Max
Timeframe
Preadmission
Activity

Baseline Measurement

MDT assessment incorporating provisional care plans, risk management
strategies.
Identification of key named workers, RC and named nurse
1 week



Familiarisation
Health Action Plan
Communication plan
By first CPA
6-12 weeks
after
admission








Information gathering from all agencies, including social history
Clinical management of immediate risks
Understanding the person – development of an initial clinical formulation
Explore the needs and formulate joint actions for risk reduction and recovery
Person centred plan



Max
Timeframe
From initial
CPA
onwards to
18 months
Intervention, Rehabilitation and Recovery
Interventions and Outcomes











After 18
months




Implementation of CPA treatment plan, including accessible patient held
version.
Treatment interventions:

Psychotropic treatment

Insight related / mental health awareness work re psychosis

Drug/Alcohol misuse related therapy

Social problem solving skills

Interpersonal violence – focus on impulsivity, anger control

Development of social interaction / engagement, habilitation or
rehabilitation, and educational / vocational opportunities (OT
interventions)

Psychological approaches such as CBT, DBT or CAT (where
appropriate)

Specific offence related therapy – sex offending, arson (where
appropriate)

Structured Personality disorder assessment (where appropriate)
Risk assessment / management – graded risk testing linked to plans with clear
targets (in terms of changes in observation status, patient access levels,
nursing care plans and section 17 leave status)
Development of a care pathway beyond low secure conditions
Management of Transitional steps low to community
Consider use of Keep safe model
Ability to manage conflict
Focus on functional skill development and maturational tasks
Increasing independence and social integration
Development of non-institutional routines and structure to time management
Demonstration of acquired skills
Treatment Resistant
If likely clinical pathway trajectory is not towards step-down from low secure
conditions imminently
Treatment outcomes have not been achieved
There is a lack of sufficient change
Risk has not reduced sufficiently to progress
There should be a re evaluation to assess the balance between treatment/change
and quality of life
After 5
years

Cross area gate keeping from another area. Not the original gate keeper
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Completion of gate-keeping assessment
MDT have agreed admission plan
Development of a CPA Treatment Plan which
incorporates psychiatric, forensic nursing,
psychological, OT, SALT and general medical
treatment interventions or areas of ongoing need.
This should interlink with risk assessment tools.
Completion of HONOS Secure
HCR-20 in preparation; where appropriate relevant
consider other relevant risk assessment tools, e.g.
SVR-20 or RSVP for sex offending; actuarial tools
e.g. STATIC 99, RISK MATRIX 2000
Consideration of further assessment using tools.
These may include formal assessment of
intellectual functioning (such as WAIS) or others
areas of functioning e.g. GAF, BPRS, PANSS,
PASSAD, EPS
Outcome Measurement









Positive changes in Recovery Planning Tool Scores
Evidence of linking between CPA, Recovery plan
and PCP in accessible format and patient held
Positive changes in pre and post Model of Human
Occupation (MOHO) scores (when developed)
Completion of Assessment of Motor and Process
Skills (AMPS)
HONOS Secure and HCR-20 ratings reflect
reduced risk management strategies needed
Successful transfer. No return within 1 year.
At 18 months forensic case managers / throughcare clinicians should gather clinical evidence from
provider and request a gate keeping assessment
Consider quality of life indicators
Maintenance and Risk Management
Low secure LD care pathway and gate-keeping guidance and templates
6.
Equality Impact Assessment
EIA Initial Screening Template
PLEASE ENSURE EACH BOX IS COMPLETED OTHERWISE THE
SCREENING PROCESS WILL NOT BE VALIDATED
Directorate
East Midlands Specialised Commissioning Group
Department
Mental Health
Name of ‘activity’ being assessed
Name of document
Person completing this form
Ruth Sargent Head of Specialised Mental Health and
Learning Difficulties
Please indicate ( ) whether activity is Proposed
or Existing

Step One: Brief overview of aims and objectives of the Activity
Aim: To improve patient experience and quality
and cost of service
Objective: (intended benefits or outcomes)
Care closer to home. Reduce length of stay.
Step Two: Details of Consultation/Involvement – during the development of this activity?
All provider trusts and 9 PCTs have been involved in developing the guidance.
Confirm and Challenge Event 29th October 2010.
Step Three: Policy/Service Content: (A) SERVICE USERS
For each of the following checks is this ‘Activity’ sensitive to people of different age, ethnicity, gender,
disability, religion or belief, sexual orientation & transgender? The checklists below will help you to
identify any strength and / or highlight improvements required to ensure that the activity is compliant with
equality legislation.
(A) Check for DIRECT/INDIRECT discrimination against any minority group of SERVICE USERS:
Does your ‘Activity’ adversely impact people
from using the services :
Response
Yes
No

1.0
Age
1.1
Gender (Male, Female)

1.2
Sexual Orientation (Gay, lesbian)

14
Please justify your response for each
area and action to be undertaken
Low secure LD care pathway and gate-keeping guidance and templates
1.3
Transsexual/transgender

1.4
Disability including Learning Disability,
Mental Health, Sensory Impairment,
Physical or other (Check this link for further)

1.5
Race or Ethnicity

1.6
Religion or Belief (including other belief)

1.7
Gypsy/Roma/Traveller

1.8
Dependants/Family/Carers

1.9
Offenders and Ex offenders

Guidance covers all adults requiring
assessment for low secure care
Summary of actions required to remedy any adverse impact(s) identified above.
Action
Lead
Target date
Summary of actions required to remedy any adverse impact(s) identified above.
Action
Lead
Target date
Number of ‘Yes’ answers for Service users (A)
Number of ‘Yes’ answers for Employees.
(B)
Step Five: DETERMINATION QUESTIONS
Yes/ No
Is there any evidence that some groups are
affected differently?
No
Is there a need for external or user consultation?
No
If you have identified potential discrimination, are
any exceptions valid, legal and/or justifiable?
15
Comments (mandatory)
All current service users and carers
are currently being consulted
Low secure LD care pathway and gate-keeping guidance and templates
Is the impact likely to be negative?
Can we reduce the impact by taking different
action?
IMPACT(Please Tick)
High
Medium

Low
Step Six: Send copy of EIA Assessment to EIA Team
Attach any procedural document/s when submitted to the EDHR Team for validation. If you have
answered “Yes” to any of the questions in step five it is likely the function/activity will need a full EIA.
However if the action/s identified in step three mitigate the impact/s this will reduce likelihood of a full
EIA. It may be reasonable to review the activity in 12 months to determine the overall outcome of the
agreed actions. The EDHR team will be more than happy to discuss any concerns in this regard
Signatures author/reviewer of activity
Date for next review
7.
2
Review Date
2 years following approval
8.
Approval
Approval will be sought from EMSCG Board.
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Appendix 1
Description of high, medium and low secure services and locked rehabilitation services
High Secure Services
High secure provision provides a care and treatment environment for those individuals who would
pose a grave and immediate danger to others if at large. Security arrangements should be
capable of preventing even the most determined escape attempt or absconder.
The
comprehensive range of services, both recreational and clinical, acknowledges the severe
limitations for access to community services and facilities.
Medium Secure Services
Medium secure provision provides a care and treatment environment for individuals who present a
serious but less immediate danger to others. Physical security with security protocols and
procedures, supported by high levels of staff should be sufficient to deter all but the most
determined to escape or abscond. These environments should meet the needs of those who are
not yet ready for leave into the community, but with an emphasis on graduated use of community
facilities when possible.
As described in the Best Practice Guidance: Specification for adult
medium secure services. Health Offender Partnerships 2007 (DOH).
Low Secure Services
Low secure provision provides a care and treatment environment for individuals who present a
less physical danger to others. Security arrangements should impede rather than completely
prevent those who wish either to escape or abscond. Low secure provisions will have a greater
reliance on staff observation and support rather than physical security measures. Low Secure
Services are not Psychiatric Intensive Care Units. Low Secure services should emphasise access
to community services, and promote a philosophy of community integration.
(The National
Minimum Standards Low Secure Units (DH, 2002) should be consulted for more detailed guidance)
Each secure mental health provider will ensure, though the Care Programme Approach process
that each individual patient will receive high-quality care and treatment which meets their needs
and supports their recovery.
Locked and Unlocked Rehabilitation Services
Locked & Unlocked Hospital Rehabilitation (Psychiatric & Learning Disabilities) Service is a whole
systems approach to recovery from mental illness that maximises an individual’s quality of life and
social inclusion by enhancing skills, promoting independence and autonomy in order to give them
real opportunity for the future that may lead to successful community living through appropriate
support “
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Low secure LD care pathway and gate-keeping guidance and templates
The service provides high levels of therapeutic care underpinned by evidence-based practice in
keeping with industry norms, where this is published or is custom and practice. This will include a
comprehensive assessment of the needs of the individual in order to devise an individualised
treatment programme that will address social, physical, intellectual and mental health needs within
a specific and measurable care plan, regularly collated and reviewed through the CPA framework.
The maintenance of a safe, sound and secure environment for all is paramount. It is expected that
the level of security will be based on individual patient need, the responsibility to protect others,
and/or prevention of harm to self. Service delivery will take account of patient diversity, meeting the
needs of gender, cultural and religious diversity through policies and practices that positively
respect the patient’s gender, cultural, religious and spiritual preferences
(Taken from the regional specification for rehabilitation services)
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Appendix 2
The East Midlands Learning Disabilities Community Forensic Service Model
Introduction
This document outlines the aims, objectives and functions of a learning disability (LD) community
forensic team, which will be virtual in nature and will be purely advisory at this stage. It is
anticipated that each of the counties in the East Midlands will give strong consideration to enabling
the development of such a team.
Across the East Midland’s health communities the level of activity required is thought to be low,
hence there is little or no critical mass indicating the need for dedicated teams. This has resulted
in a gap in service with no specialist LD forensic service in place in the community for offenders
with LD. As part of the Towards Excellence LD low secure work stream an opportunity arose for
the development of a service model for this group of service users.
Survey work in Leicestershire indicated the following:
1. The community teams in learning disability services had a significant caseload of people
with forensic issues.
2. The community teams did not always have the necessary skills to an appropriate level to
manage this client group.
3. There was very little peer support and supervision could be enhanced in this area of
practice
4. There is difficulty in accessing the right service for these individuals.
The virtual team
The virtual community forensic learning disability team would consist of appropriately experienced
staff currently working within LD services. They are likely to come from various professional
backgrounds including psychology, psychiatry and nursing.
Aim
To provide an advisory community forensic services for people with learning disabilities in the East
Midlands.
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Low secure LD care pathway and gate-keeping guidance and templates
Objectives
1. To provide a community LD forensic service as a virtual team with no structural facilities.
2. To provide advice, supervision and training for community teams in managing service users
with LD and forensic risks and to undertake assessments and inform management
strategies where needed.
3. To provide advice, supervision and training for in-patient services (including locked
rehabilitation) staff in managing service users with LD and forensic risks and to undertake
assessments and inform management strategies where needed.
4. To undertake gate-keeping assessments locally and regionally, working in close
partnership with East Midlands Secure Commissioning Group (EMSCG) and other regional
gate-keepers to facilitate smooth transition of service users who step-down into low secure,
locked rehab facilities or to the community by supporting the relevant community teams.
5. To establish and maintain links with stakeholders in the clinical network such as, general
adult forensic services, the Criminal Justice System (police, prison, probation services,
courts, crown prosecution service) and to work in partnership to provide a LD forensic
service for individuals with LD who come into contact with other parts of the clinical network
and vice versa.
6. To consider developing an expert witness team service for the Legal Services Commission.
7. To consider developing and providing adapted treatment programmes (sex offending and
arson) in addition to providing a forensic angle to existing treatment strategies like anger
management, relationship work and stop and think groups.
The Virtual forensic team and its skill mix
The Core (virtual) team will consist of professionals with forensic experience working in LD
services drawn from the following disciplines:

psychiatry

nursing

psychology

speech and language therapy

occupational therapy

social work
The core team’s skills, in addition to basic competencies, will include expert assessment and
management of forensic risks, working with other professionals in the clinical network,
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Low secure LD care pathway and gate-keeping guidance and templates
administration of risk assessment scales relevant to the type of offence and providing support and
training for community teams.
The core team should be linked to clinical networks which consist of identified individuals from
relevant stakeholder organisations.
Eligibility
Principles to follow in assessing eligibility to service
1. To be as inclusive as possible. The team will also be involved in support, advice and
signposting.
2. The service user should have a learning disability as defined by the British Psychological
Society in 2001.
3. There should be an identified forensic issue.
Possible care pathway
An example of the care pathway that has been developed in Leicestershire detailed overleaf.
21
Low secure LD care pathway and gate-keeping guidance and templates
Leicestershire
Forensic Care Pathway (Process Map)
Primary Care
Trusts / Local
Authorities
LLR Community
Forensic
services
(General and
LD / Local,
Regional &
National)
East Midlands
Secure
Commissioning
Group
Criminal Justice
System (Prison,
Probation, Police,
MAPPA, LSC, CPS)
Community LD Teams
Community LD Forensic Team
Triage
Red = Immediate
Amber = 2-3 Weeks
Red
LDGreen
Forensic
Panel
meeting
= 5-6
Weeks
Fast track
Assessment
Advice / Signposting /
training / peer
support / supervision
/ involvement in
multiagency approach
In complex
cases, full
involvement
in
intervention
and
discharge
procedures
22
Gate-Keeping report
Expert witness
report
Low secure LD care pathway and gate-keeping guidance and templates
As can be seen from the above, these teams are a focussing and consolidation of the existing
expertise within local services, and do not entail additional resources for setting up. Consideration
of their training and developmental needs, however, should be undertaken by local services.
Authors
John Devapriam
Richard Lansdall-Welfare
Ruth Sargent
October 2010
Appendix 3
23
Low secure LD care pathway and gate-keeping guidance and templates
Current East Midlands Clinical Gate-Keepers – Low Secure Learning Disability (Dec 2010)
For a more recent list of Gate-keepers please contact EMSCG 0116 295 0898
Nottinghamshire
Derbyshire
Leicestershire
Northamptonshire
Lincolnshire
Identified Gatekeepers
Email Address
Dr Niraj Singh
Niraj.Singh@nottshc.nhs.uk
Dr Tapati Mukherjee
Tapati.mukherjee@nottshc.nhs.uk
John Robertson
John.Robertson@nottshc.nhs.uk
Dr Muhammad Qureshi
Muhammad.Qureshi@DerbysMHServices.nhs.uk
Pat Robinson
Pat.Robinson@DerbysMHServices.nhs.uk
Gaynor Ward
Gaynor.Ward@DerbysMHServices.nhs.uk
Rani Gosal
Rani.Gosal@DerbysMHServices.nhs.uk
Emma Hazel
Emma.Hazel@derbyshirecountyPCT.nhs.uk
Tania Moss
taniamoss@nhs.net
Jayne Stapleton
Jayne.Stapleton@derbyshirecountypct.nhs.uk
Dr Subash Mathews
Subash.mathews@derbyshirecountypct.nhs.uk
Sandra Twigg
Sandra.Twigg@derbyshirecountypct.nhs.uk
Dr John Devapriam
John.Devapriam@leicspart.nhs.uk
Lynne Moore
Lynne.moore@leicspart.nhs.uk
Dr Satheesh Kumar
Satheesh.kumar@leicspart.nhs.uk
Dr Raza Kiani
Raza.kiani@leicspart.nhs.uk
Dr Tonye Sikabofori
tonye.sikabofori@nht.northants.nhs.uk
Pily Maden
pily.maden@nht.northants.nhs.uk
Dr Peter Speight
Peter.Speight@lpt.nhs.uk
Dr Talib Abbas
Talib.Abbas@lpft.nhs.uk
Dr Enrique Bonell
Enrique.BonellPascual@lpft.nhs.uk
Dr Nicky Taylor
nickytaylor@nhs.net
Catherine Keay
Catherine.Keay@lpft.nhs.uk
Appendix 4
24
Low secure LD care pathway and gate-keeping guidance and templates
For Reference.
Assessment Tools and Outcome Measures
1. The Risk for Sexual Violence Protocol
RSVP
These factors relate to past information about an
Sexual Violence History
individual and their previous behaviour. They are
not amenable to reduction.
Chronicity of Sexual violence
Early onset of sexual offending is a
poor prognostic factor and a reliable
indicator of future offending:
Diversity of sexual violence
Range of victim selection and nature
of
assaults:
Greater
diversity
associated with increased risk:
Escalation of
sexual violence:
Refers to sexual violence which
increases in severity, frequency or
diversity over time; e.g. more direct
contact with victims, more serious
coercion, includes all activity not only
those resulting in arrest or conviction
Physical
coercion
in
sexual
violence: refers to actual, attempted
or threatened physical harm that
arises in the course of sexual
violence or that is intended to further
the commission of sexual violence.
Psychological coercion in sexual
violence: acts during the course of
or to further the commission of
sexual
violence
that
involve
threatened loss or promised gain of
25
Low secure LD care pathway and gate-keeping guidance and templates
status, privilege, power or affection.
Includes grooming, breach of trust,
abuse of power or entitlement. Not
causal
but
reflect
presence
of
attitudes condoning sexual violence,
self awareness difficulty and sexual
deviation.
Psychological Adjustment
Factors reflecting adjustment that have strong
and relatively specific conceptual link with
decisions to engage in sexual violence
Extreme minimisation or denial of
sexual violence: involves failure to
admit or accept responsibility for
acts of sexual violence and the
consequences
for
those
acts.
Includes displacement or projection
of responsibility and victim blaming
Attitudes that support or condone
sexual
political,
violence:
include
cultural,
socio-
sub-cultural
personal, attitudes or belief systems
and
patterns
of
behaviour
that
directly or indirectly encourage or
excuse coercive, violent sexual acts
or sex with minors (Andrews & Bonta
2003, Krug et al 2003 Mann & Beech
2003)
Problems with self awareness
refers to reasonable understanding
and evaluation of mental processes,
reactions, self knowledge (English &
English 1958) Perception of own risk
believed to correlate with recidivism
(Hanson & Harris 2000)
Problems with stress or coping:
linked empirically with overall risk of
26
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violence.
violence
In relation to sexual
some
evidence
that
stressful events precipitate deviant
sexual fantasies that may, in turn,
lead to the acting out of these
fantasies.
Problems
resulting
from
child
abuse: empirical evidence suggests
child abuse is a general risk factor
for criminality, non-sexual violence
and sexual violence.
It has been
reported that child abuse may lead
to
the
development
of
sexual
deviation or empathy problems and
in turn, to the increased risk of
perpetrating sexual violence.
Mental Disorder
Factors
reflecting
psychopathology.
fluctuating
in
presence
preference or arousal or behaviour
that
involves
a
focus
on
inappropriate persons or objects
(those that fall outside the realm of
what
is
considered
legal
or
conventional in consenting sexual
relationships)
Psychopathic personality
disorder: as assessed using a
standardised assessment schedule
such as PCL-R (Hare 1991, 2003) or
PCL-SV Hart et al 1995) Specifically
associated with diverse sexual
violence and increased risk of nonsexual violence
27
significant
All the factors are dynamic
nature
symptmatology over time
Sexual deviance: sexual interest,
of
and
severity
of
Low secure LD care pathway and gate-keeping guidance and templates
Major Mental Illness: refers to
presence of
mental illness and
“mental retardation” which may lead
to impulsive or irrational decisions to
act on a sexually violent manner or
interfere with the ability or motivation
to
comply
with
treatment
or
supervision
Problems with substance abuse:
may lead to impulsive or irrational
decisions to act in a sexually violent
manner. Some people with serious
sexual deviance deliberately use
substances to dis-inhibit themselves
when they are considering sexual
violence.
Substance abuse may
also interfere with the ability or
motivation to comply with treatment
and supervision
Violent or suicidal ideation:
reflects experience of thoughts,
impulses or fantasies about causing
or attempting to cause physical harm
to self or others.
Social Adjustment
Reflect problems relating to people and fulfilling
social roles and obligations.
dynamic in nature
Problems
with
intimate
relationships: involve the failure to
establish or maintain stable romantic
or sexual relationships with ageappropriate partners, whether due to
lack of desire, ability or opportunity.
Includes terms and concepts of
intimacy problems, poor dating skills,
and attachment difficulties.
28
Factors are all
Low secure LD care pathway and gate-keeping guidance and templates
Problems
with
relationships:
non-intimate
the
failure
to
establish or maintain positive social
support
network,
regardless
of
desire, ability or opportunity Includes
isolation, alienation, incompetence
or poor social skills
Problems
with
unemployment,
employment:
educational
or
vocational impairments. Associated
with risk of criminality and general
violence.
Non sexual criminality Marker of
presence of other risk factors. May
cause
negative
mood
and
interpersonal conflicts
Manageability
Reflect
problems
managing
violence in the community.
risk
of
sexual
Associated more
generally with risk of violence and criminality,
rather than specific sexual violence..
role in perpetration of sexual violence
Problems with planning: considers
making and implementing prosocial
life plans; poor self management,
unrealistic goals, impulsivity and
inability to delay gratification..
Problems with treatment: reflects
failure to benefit from rehabilitative
services
designed
to
address
identified deficits in the individuals
psychosocial adjustment
Problem with supervision: reflect
failure
to
benefit
from
services
designed to make it more difficult for
the individual to engage in further
sexual violence.
Also relevant are
29
Indirect
Low secure LD care pathway and gate-keeping guidance and templates
uncooperative, oppositional or antiauthority attitudes.
Other considerations
Evidence
30
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2. HCR-20
The HCR-20 (Webster, Douglas, Eaves & Hart, 1997) is a structured guide that is designed to
assess risk for violence in those with mental or personality disorders. Violence is defined as actual,
attempted or threatened physical harm that is deliberate and non-consenting. The HCR-20
facilitates the formation of informed decisions about an individual’s release plans and community
supervision based on a constellation of actuarial and clinical risk factors. These factors include the
individual’s past history (H), current clinical risk (C), and future risk (R). Support for the validity of
the HCR-20 in predicting general violence has been found in samples of civil and forensic
psychiatric patients and prison inmates (Douglas & Hart, 1996).
Historical Items
These factors relate to past information about an individual and their previous behaviour. They are
not amenable to reduction.
HCR-20
Historic Item
Evidence
H1 Previous Violence: The scoring scheme for this item is
intended to capture the density of previous violence. Therefore the
number of past violent acts is combined with their severity to
differentiate between a 2/1 score. A 1 score would be given if there
were one or two acts of moderately severe violence. Moderately
severe violence would include slapping, pushing, and other
behaviours unlikely to cause serious or permanent injury to victims. A
2 score would be given for three or more acts of serious previous
violence, or any acts of severe violence. Acts of severe violence
includes, but is not limited to, those that cause death or serious injury
to or maiming of the victim. All violence up to and including the time
of the assessment is included as “previous violence.” This would
include the index offence, violence during incarceration or
hospitalisation, or violence directed at the assessor during interview. A
NO would indicate no previous acts of violence.
H2 Young age of first violence: Age is established by
considering the date of the first known violent incident, which is not
necessarily the index offence. If there are no known acts of violence,
or the patient was 40 years and older at first known violent act, a 0
score is allotted. Between 20 and 39 a 1, and under 20 a 2 score is
allotted.
H3 Relational Instability: This refers only to “romantic,”
intimate, or non-platonic partnerships, and does not include
31
Low secure LD care pathway and gate-keeping guidance and templates
relationships with friends or family.
This item is geared toward
whether the individual is able to form and maintain long-term, stable
relationships given the opportunity. “Instability” would include many
short-term relationships; absence of any relationships or presence of
conflict within a long-term relationship. A 0 score would indicate a
relatively stable and conflict-free relationship pattern, a 1 possible/less
serious unstable and/or conflictual relationship pattern, and a 2 score
where there is evidence of definite/serious unstable and/or conflictual
relationship pattern or the absence of a relationships.
H4 Employment Problems: Individuals who warrant a 2
score on this item may refuse to seek legitimate employment, have a
history of many short-term jobs, or of frequently being sacked or
quitting. A 1 score is given for possible/less serious employment
problems; a reduction from 2 to 1 may be warranted if economic,
physical, or mental problems preclude employment but caution is
recommended as the item focuses on employment problems rather
than employability. Institutional work programmes may be considered.
A 0 should be given if there is no evidence of employment problems.
H5 Substance Misuse Problems: : Included in this item
is the misuse of prescription drugs and glue or solvents. Whilst
psychiatric diagnosis of substance abuse ought to be taken seriously
their mere presence does not warrant a 2 score without corroboration.
Focus on whether there exists impairment of functioning in areas such
as health, employment, recreation or interpersonal relationships that
are attributable to substances. Examples would include, (but are not
limited to): being late for work; irate with others; being severely hung
over; an inability to concentrate whilst working or driving or doing so
whilst under the influence; substance related arrests; having
difficulties within interpersonal relationships; and denying problems
despite strong evidence to the contrary. A 1 score should be given for
possible/less serious substance use problems and a 0 for no
substance use problems.
H6 Major Mental Illness: A diagnosis of major mental illness
should conform to an official nosological system such as DSM-IV or
ICD-10. The item is scored on the basis of past history and is
unaffected by whether the disorder is currently active or in remission.
A 2 score would be given when the evidence of major mental illness is
unequivocal; if the evidence is equivocal (e.g., course or severity is
unclear), then a 1 score is appropriate. Less serious mental illnesses,
such as anxiety disorders, somatoform disorders, paraphilias or sleep
disorders should be coded 0
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H7 Psychopathy: : It must be stressed that this rating is to be
made on the basis of an informed and trained psychopathy
assessment using the PCL-R or PCL:SV. The item is not to be used
until such a rating is available.
The item is scored according to the British Rating Scale as follows: 0
for a score of 14 or less, 1 for a score between 15 and 24 and YES for
a score equal to, or greater than 25.
H8 Early Maladjustment: Violence can be predicted through
childhood victimisation as well as through being a childhood victimiser
or delinquent.
A 2 score should be given if maladjustment has
occurred in at least two of the three domains of home, school, and
community. If the maladjustment was very severe in one domain
(e.g., severe and prolonged childhood abuse), then a 2 score is also
justified.
A 1 score should be given if there is evidence of
possible/less serious maladjustment. No early maladjustment is coded
0
H9 Personality Disorder: A diagnosis of personality
disorder should conform to an official nosological system such as
DSM-IV or ICD-10; this is scored on the basis of past history and is
unaffected by whether the disorder is currently active or in remission.
A 2 score would be given when the evidence of personality disorder is
unequivocal; A 1 score should be given if there is a diagnosis of
personality disorder traits but the full criteria have not been met. 0 is
given to indicate no personality disorder.
H10 Prior Supervision Failure: Failures during any
institutional or community placement are relevant here. A 2 score is
given if the act resulted in (re-) apprehension, (re-) institutionalisation
by a correctional or mental health agency, escape from a correctional
facility, elopement from a maximum secure hospital, abscondance
whilst on an escorted official visit (e.g., funeral/hospital attendance),
re-offence during probation, revocation of parole, or failure to attend
for psychiatric treatment as ordered by a court or tribunal. A 1 score
is given for less serious failures such as returning late when released
on pass, causing a disturbance, failing to take medication as
prescribed, or using alcohol or drugs whilst prohibited.
A 0 is given if the individual has never had a period of institutional, or
community supervision or if there are no prior supervision failures.
33
Low secure LD care pathway and gate-keeping guidance and templates
Clinical Items
These items relate to the current clinical presentation, including reference to the existing
therapeutic, remedial or activity programmes in place as well as general functioning.
Clinical Items
Evidence
C1 Lack of Insight: This item refers to the degree to which the
patient fails to acknowledge and comprehend his or her mental
disorder and its effect on others.
This lack of insight can be
expressed in many ways. Some patients may have clearly evident
signs of a major mental illness but are unable, or unwilling, to
acknowledge that they may act in a violent manner without regular
use of prescribed medication. Others may have difficulty realizing the
importance that a well-structured support group may have in averting
violence. Yet others may have little insight into their, generally, high
levels of anger and dangerousness. A score of 2 should be given for
definite/serious lack of insight, a 1 for a possible/less serious lack of
insight and a 0 for no lack of insight.
C2 Negative Attitudes: This item refers to recent evidence of
pro-criminal and antisocial attitudes connected to a higher propensity
for violence. Most people could be said to have negative attitudes of
some kind but this item is present to elucidate entrenched antisocial
attitudes and beliefs. Sadistic, homicidal, or paranoid attitudes which
do not stem from mental illness may be counted under this item as
can evidence of remorselessness, a current unwillingness to abide by
rules and regulations, evidence of splitting behaviour, boundary
pushing, callousness and lack of empathy. A 2 score is given for
definite/ serious negative attitudes, a 1 for possible/less serious
negative attitudes and a 0 given for no negative attitudes.
C3 Active Symptoms of Major Mental Illness:
Assessors should follow an official nosological system such as the
DSM-IV or ICD-10 for definitions of psychotic symptoms. 2 should be
given for definite/serious active symptoms of major mental illness, 1
for possible/less serious active symptoms of major mental illness, no
active symptoms of major mental illness should be coded 0.
C4 Impulsivity: Impulsivity refers to dramatic day-to-day, hourto-hour fluctuations in mood or presentation. It is an inability to remain
composed and directed when under the pressure to act. Impulsive
people are quick to (over-) react to real, or imagined slights, insults
and disappointments, when they do their action may appear to be
34
Low secure LD care pathway and gate-keeping guidance and templates
exaggerated or overdone. The item, therefore, measures behavioural
and affective instability and should be scored 2 in the case of
definite/serious impulsivity, 1 for possible/less serious impulsivity and
0 for no impulsivity.
C5 Unresponsive to Treatment: This item refers to any .
treatment designed to ameliorate criminal, psychiatric, psychological,
social, or vocational problems. It is vital to know if the individual has
sought help and accepted it, rejected it out of hand, or agreed to it
merely to speed their transfer or “look good” to a court, Mental Health
Review Tribunal or other authority. A 2 score is given to individuals
who respond poorly, or not at all, to treatment attempts. They may
lack motivation to begin or continue with treatment or merely pay lip
service to treatment or complete treatment but fail to benefit from it. A
1 score is given if there is possible/less serious unresponsiveness to
treatment and if the patient is responsive to treatment the item should
be coded 0..
Risk Managed Items
The risk management section considers how individuals will adjust to future circumstances. The
intention is to stimulate the development of appropriate risk management plans. The assessment
of risk will depend heavily upon the context within which the subject is placed. The following
comments reflect the possibility of Mr ……….. being freed from detention in the near future.
Risk Management Items
Evidence
R1 Plans Lack Feasibility: Lack of feasibility may be due to
the fact that community agencies/RSU’s are unwilling (due to the
patient’s behaviour) or unable (due to lack of resources) to provide
assistance. Alternatively, the patient may have played no role in
making plans or be uninvolved with peers or family. Finally, family and
peers may be unable or unwilling to help. Score 2 for a high
probability that plans will not succeed, 1 for a moderate probability
that plans will not succeed and a 0 indicates that there is a low
probability that plans will not succeed.
R2 Exposure to Destabilizers: This term appertains to
risk increasing factors. In the majority of cases the patient may be
exposed to destabilizers because of inadequate professional
supervision. Assessors should consider whether the patient would be
attending specialized support programmes such as alcohol or
substance use sessions for assistance with abstaining from
destabilizers. A 2 score should be given if there is a high probability of
35
Low secure LD care pathway and gate-keeping guidance and templates
exposure to destabilizers a 1 for a moderate probability and a 0
indicates that there is a low probability of exposure to destabilizers.
R3 Lack of Personal Support: A 2 score on this item
would appertain to an individual who would lack emotional, financial,
or physical support from friends or family, or if such support is
available but the individual is unwilling to accept it. It is important to
look beyond “good intentions” of friends and family and ensure that
they are not just being “used” to secure release. A 1 score is given if
there is a moderate probability of lack of personal support and a 0
should indicate that the individual will have appropriate support.
R4 Non-Compliance with Remediation Attempts:
This item should be construed broadly to include remediation attempts
in both therapeutic and supervision/management realms. A 2 score on
this item should be given to individuals who it is felt have little
motivation to succeed and unwillingness to comply with medication or
therapy, or refuse to follow rules in the future. A 1 score should be
given if the probability of non-compliance with remediation attempts is
judged to be moderate and a 0 indicates that there is a low probability
of noncompliance with remediation attempts.
R5 Stress: This item can be coded as 2 if the individual is likely to
be exposed to serious stressors, or if the individual has been judged
to cope poorly with stressful situations. A 1 score would indicate a
moderate probability of stress, and a 0 indicates a low probability of
stress.
3. HoNOS
Information relating to HoNOS, HoNOS secure and HoNOS LD is available at the following:
http://www.rcpsych.ac.uk/quality/honos/secure.aspx
36
Low secure LD care pathway and gate-keeping guidance and templates
Appendix 5
Gate Keeping Assessment Template
Front sheet
NHS number:
Name: 1
DOB:
Current Placement:
R.C:
Date of Assessment:
Place of Assessment:
Referral Source:2
Referral Date:
Legal Status: 3
Mental Health Act Section:
4
Differential Diagnoses: 5
Index Offence/Behaviour:
Previous Convictions:
1 Include any known aliases.
2 Name of case manager at East Midlands Specialised Commissioning Team.
3 Include stage of the legal process.
4 Give details of Mental Health Act section currently applicable.
5 Please give current and previous diagnosis.
37
First Report

Return to secure service

New Problem

Low secure LD care pathway and gate-keeping guidance and templates
Assessed by:
1.
2.
MAPPA Links:
Sources of information:6
1
Introduction
2
Summary and Opinion 7
3.
Recommendations
Low secure
yes/no
Treatment needs
Progress markers
6 Interview persons present, location, duration; records; reports; files; documents.
7 Include risks, clinical opinion and a brief rationale for recommendation.
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Low secure LD care pathway and gate-keeping guidance and templates
4. Patient History
Personal History:
Pre-morbid Personality:
Intellectual and Adaptive Functioning (inc Education & Employment):
Psychosexual History:
Family History:
Substance & Alcohol Use:8
Physical Health:
Current medication:
Behavioural & Forensic History:9
5.
At Interview:
Presentation:
Mental state examination:
Areas of Need:
8 Give details of use of illicit substances and use of alcohol.
9 Give details of circumstances of and attitude to index offence/behaviour, progress in hospital/custody, circumstances leading to admission.
39
Low secure LD care pathway and gate-keeping guidance and templates
Therapeutic Issues identified:
Behavioural issues identified:
Attitude to treatment:
Recommendations re Medication:
6.
Clinical Opinion on Risk
7. Consideration for Low Secure Services10
Background Information Appendices
Previous reports11
In preparing this report I read and considered the following reports.
Note:
Risk Considerations:12
Consideration has been given to the risks presented by Mr …………… using the frameworks for
structured clinical risk judgements provided for violent and sexual offending using both the “Risk of
Sexual Violence Protocol” (RSVP) and “HCR20” schedules, which identify and describe factors
associated with the repetition of sexual or violent offending respectively and indicate areas of
potential intervention which might manage the behaviour and/or modify any perceived risks. Each
of these frameworks examines the chronicity, diversity, escalation and historical pattern of key
10 Additional Placement Considerations
Reference should be made to geographic or other variables impacting on the suitability of placement e.g.
illicit drug-free facility
media / local interest
geographically distant from victim
Interventions likely to alleviate or prevent deterioration in mental health and reduce risk should be identified. Initial care pathway targets and progress markers.
11 Please state authors and dates.
12 If you have used a structured clinical framework you could consider using the following text.
40
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criminogenic factors of the identified behaviours to date, considers current interactions and
attitudes which contribute to the assessment of anticipated motivation, engagement and
compliance with intervention strategies to reduce further risks of re-offending.
Each of the risk factors is rated on a three-point assignment of ‘0’, ‘1’, ‘2’ or ‘no’, ‘maybe’, ‘yes’. A
rating of ‘0’ or ‘no’ indicates that the item is definitely absent; a rating of ‘1’ or ‘maybe’ indicates that
the item is possibly present or present in a less serious form; a rating of ‘2’ or ‘yes’ indicates that
the item is definitely present in a more pervasive or serious form. These “values” are not additive
and do not give a “risk score”. Risk for future offending and the development of plans to manage
this risk are based on the risk factors identified as relevant for each individual. Clinical and Risk
factors are dynamic, situation specific subject to change and therefore should be reviewed on a
regular basis.
RSVP, SNAP and HCR20 available at Appendix 4.
41
Low secure LD care pathway and gate-keeping guidance and templates
Appendix 6– Steering Group Attendees
Lisa Cresswell
Derby City PCT
David Gardner
Derbyshire County PCT
Diane Smith
Derbyshire County PCT
Dr Edward De Saram
Derbyshire County PCT
Gaynor Ward
Derbyshire Mental Health Services NHS Trust
Dr Muhammad Qureshi
Derbyshire Mental Health Services NHS Trust
Ruth Sargent
East Midlands Specialised Commissioning Group
Dr Sateesh Kumar
Leicestershire Partnership NHS Trust
Dr John Devapriam
Leicestershire Partnership NHS Trust
Lynne Moore
Leicestershire Partnership NHS Trust
Dr Peter Speight
Lincolnshire Partnership NHS Foundation Trust
Pily Maden
Northamptonshire Healthcare NHS Trust
Dr Tonye Sikabofori
Northamptonshire Healthcare NHS Trust
Gregory Payne
Nottingham City NHS
Nick Judge
Nottingham City PCT
Dr Jaspreet Phull
Nottinghamshire Healthcare NHS Trust
Dr Adarsh Kaul
Nottinghamshire Healthcare NHS Trust
Dr Mark Taylor
Nottinghamshire Healthcare NHS Trust
Martine Lascelles
Nottinghamshire Healthcare NHS Trust
Dr Richard Lansdall-Welfare
Nottinghamshire Healthcare NHS Trust
Dr Sue Johnston
Nottinghamshire Healthcare NHS Trust
42