Care and Treatment Planning/CPA in The State Hospital:
violence risk assessment and management planning:
how you can make a difference
Clare Neil
Before we start…
Evaluation
 Your feedback is invaluable as it help us identify what
we are doing well and what we can develop and
improve upon
 We will be comparing pre- and post-training evaluation
forms to see whether we have met our aims and
objectives
 We would appreciate it if you could complete the
evaluation forms and return them to us – thank you!
Overview of training
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Aims and objectives
Background to violence risk assessment and
management planning in TSH – why do we do it?
The violence risk assessment and management planning
process – how do we do it?
Violence risk assessment and management planning –
what and how you can contribute
Using the Violence Risk Assessment and Management
Plan Profile (VRAMP)
Aims and objectives

Have a general overview of the process of violence risk
assessment and management planning within TSH

Be able to identify and pass on to the clinical team
information you know about a patient that would be
relevant for their risk assessment and management plan

To know about the violence risk assessment and
management plan profile (VRAMP) and be able to use
it in your care and treatment of patients
Background to violence
risk assessment and
management planning in
TSH – why do we do it?
Why do we assess risk of violence…?
Exercise:
 In pairs, consider why we assess risk of violence in
TSH.
Why would the following groups of people think risk
assessment was important?
1. The clinical team?
2. Scottish ministers?
3. The public?
4. Patients?
 Why would risk assessment be important for you in your
job?

Legislation and political drivers

In the past…
Individuals who committed acts of violence were not
properly assessed
 Individuals who were risky were not properly
managed
 Staff who were noticing issues indicative of
increasing risk of violence struggled to be heard –
poor documentation and lines of communication

Legislation and political drivers cont.

As a result…
 Offenders repeated patterns
of offending - including
violence with significant
harm

Several high profile cases
Legislation and political drivers cont.
Legislation and political drivers cont.
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
Memorandum of Procedure (MoP)
Care Programme Approach (CPA)
Risk Management Authority (RMA)
Mental Health (Care and Treatment) (Scotland) Act
2003
Multi Agency Public Protection Arrangements
(MAPPA)
High profile cases where things have gone wrong – e.g.
MWC inquiry (Mr L and Mr M)
Lessons learnt…
Violence risk assessment and management planning should
be…
 Systematic using standardised tools for assessing risk
 Consistent and use standardised documentation
 Based on comprehensive and detailed information about
the patients background, treatment and progress
 Multi-disciplinary
 All staff involved in patient’s care and treatment should be
aware of the assessment and management plan and should
highlight areas of concern – it is everyone’s responsibility
 Information should be shared between disciplines and
agencies
The violence risk
assessment and
management planning
process – how do we do
it?
Care and treatment planning in TSH
How violence risk assessment and management planning used to be
done in TSH…
 No agreed format across the hospital for reviewing
patients (care and treatment planning)
 No agreed formal assessment of future risk of
violence
 Risk assessment and management planning not
always linked with care and treatment planning
 Different practices and documentation were used by
different clinical teams
Care and treatment planning in TSH

The new Care and Treatment Planning process and documentation…
 All wards are now following the same process and using
the same documentation
 This meets the requirements for CPA
 Aim is for all patients to have a completed violence risk
assessment and management plan which is reviewed
regularly by the clinical team
 Violence risk assessment and management planning is
now part of the care and treatment planning process
 The Violence Risk Assessment and Management Profile
(VRAMP) forms part of the care and treatment plan

Violence risk assessment and
management planning
Violence risk assessment and management planning involves:
 RISK ASSESSMENT (RISK FACTORS) - Assessing an
individual’s risk of committing a violent act by looking for
evidence of established risk factors which have been shown in
research to be linked with future violence
 FORMULATION - Considering how these risk factors are
relevant for the individual being assessed and understanding
why an offence happened
 SCENARIO PLANNING - Making an assessment of the
likelihood of future violence and the circumstances that this is
likely to occur
 WARNING SIGNS - Identifying warning signs that would
indicate an increase in the risk of violence
 RISK MANAGEMENT PLANNING - Developing
strategies to manage this risk - including intervention and
treatment, monitoring, supervision and victim safety planning
Thinking about risk…
Exercise:
Imagine a situation where you are
driving in adverse weather and have
a car accident…
In 3 groups:
1.
What factors would make driving in adverse weather risky
(risk assessment)?
2.
Why did the accident happen (formulation)?
3.
What might happen in the future (scenario planning)?
Thinking about risk…cont.

What signs would indicate that the risk was
increasing (warning signs)?

What could you do to reduce the risk or
minimise the harm (risk management planning)?
Violence risk assessment and
management planning

Violence risk assessment and management planning involves:
 RISK ASSESSMENT (RISK FACTORS) - Assessing an
individual’s risk of committing a violent act by looking for
evidence of established risk factors which have been shown in
research to be linked with future violence
 FORMULATION - Considering how these risk factors are
relevant for the individual being assessed and understanding
why an offence happened
 SCENARIO PLANNING - Making an assessment of the
likelihood of future violence and the circumstances that this is
likely to occur
 WARNING SIGNS - Identifying warning signs that would
indicate an increase in the risk of violence
 RISK MANAGEMENT PLANNING - Developing
strategies to manage this risk - including intervention and
treatment, monitoring, supervision and victim safety planning
Violence risk assessment in TSH – risk
factors


In TSH the risk assessment tool most commonly used is the
HCR-20
The HCR-20 is a structured clinical judgment tool used to assess
risk of violence.


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Other tools are available to assess different types of violence (e.g. sexual
violence, stalking, spousal violence)
The HCR-20 defines violence as… “actual, attempted, or
threatened harm to a person or persons”
The HCR-20 contains 20 items (or risk factors)
 10 Historical items
 5 Clinical items
 5 Risk Management items
Violence risk assessment in TSH cont.



Clinical teams collect evidence of the various risk
factors identified in the HCR-20 for the patient
being assessed. The evidence is presented in a draft
evidence document and discussed by the clinical
team
The clinical team decide whether there is evidence
that the item is present (rating of definite, possible
or no evidence)
The evidence in the HCR-20 evidence document
for the C and R items is updated and reviewed
every year
THE STATE HOSPITAL
EARN CLINICAL TEAM
NAME: Mr Joe Bloggs
DOB: 12.12.65
HOSP. NO.: 65/1234
WARD: EARN
HCR-20 PREPARED BY: Earn Clinical Team
DATE PREPARED: 4.05.07
HCR-20
The Historical Clinical Risk 20 protocol (HCR-20; Webster et al, 1997) is a guide to
forming a structured clinical judgement regarding future risk of committing a violent
act. This involves investigation of factors which are known to correlate with violent
recidivism. It should however be born in mind that much of the research that has
investigated the ability of these factors to predict recidivism has been conducted in
North America, and so there is limited evidence at present to validate their use on a
mentally disordered population in Scotland. In addition, although this is a useful
guide to making clinical judgement, no risk assessment can be completely reliable.
This tool contains 20 items: 10 based upon historical factors; 5 based upon clinical
factors; and 5 based upon future risk management factors. No final score is provided,
and instead the information from this has been used to anchor and inform the clinical
team’s view about Mr Bloggs’s level of risk based on the guidelines provided. Each
item is rated both for its presence and its relevance. Presence indicates that the risk
factor is present to some degree while the relevance rating indicates the importance of
the risk factor for risk management. Relevance ratings reflect whether the risk factor
plays a causal role in the individual’s violence and/or the extent to which it could
impair risk management strategies.
N.B. This document should only be read in conjunction with the Treatment Plan
Report from 4.05.07
H5. Substance use problems
Assessor is interested in whether there exists impairment of functioning in areas of
health, employment, recreation, and interpersonal relationships, which is attributable
to substances. Include neurological damage as a result of substance use. Include
misuse of prescription drugs, as well as solvents and glue.
SOURCE
SUPPORTING INFORMATION
Patient
Notes, Mr Bloggs first tried alcohol at the age of 15 and remembers
19.09.02,
drinking with his friends every weekend and would continue
Psychology File 1 of drinking until he was drunk. He reports first taking drugs when
2.
he was 14.
File
Review, Mr Bloggs reports using whatever drugs were available to him,
Psychology File
and the quantities as being largely dependent on the money
available to him. He admits to using a wide variety of drugs
including Speed, Smack, LSD, Cannabis, and Heroin.
Social
History, Mr Bloggs would become violent towards his sister, brother
14.07.91, Medical and mother threatening to kill them whilst under the influence
File A1, Volume 1.
of drugs or alcohol.
Admission History, Mr Bloggs had been taking drugs and drinking alcohol for
25.07.91, Medical some time prior to his index offence. On the night before the
File A1, Volume 1.
alleged offence he had taken around 10 joints of cannabis and
pain killers for a headache. He had also taken alcohol – beer,
wine and whisky.
Mr Bloggs describes having “frightening thoughts” when
taking drugs and when coming off drugs, and reports having
had visual and auditory hallucinations when taking drugs.
RATING
RATING
There is clear evidence that this risk factor is present
This risk factor is clearly relevant to risk management
H6. Major mental illness
This item is scored on the basis of past history and is unaffected by whether the
disorder is currently active or in remission.
Include illnesses involving disturbances of thought and affect (e.g. psychotic illnesses,
manic mood illnesses, organic illnesses, learning difficulties). Include even when
diagnosis is unclear.
SOURCE
Psychiatric Report,
18.06.91, Medical
File A1, Volume 1.
SUPPORTING INFORMATION
“…his conversation became more bizarre and he began to
express a mass of rather poorly systematised delusional
beliefs.” These included references to various rock groups,
punk singers, abortions and terrorists.
Admission History, Delusional thoughts and beliefs around the time of admission
25.07.91, Medical to The State Hospital include ideas about holocausts, bombs
File A1, Volume 1.
and the end of the world; pop groups and pop songs; belonging
to the Ninja Religion; the earth as an alien experiment;
The HCR-20

1.
2.
3.
4.
5.
Historical items:
Previous violence
Young age at first
violent incident
Relationship instability
Employment problems
Substance use problems
6.
7.
8.
9.
10.
Major mental illness
Psychopathy
Early maladjustment
Personality disorder
Prior supervision failure
The HCR-20 cont.

Clinical items
1. Lack of insight
2. Negative attitudes
3. Active symptoms of major mental illness
4. Impulsivity
5. Unresponsive to treatment
The HCR-20 cont.

Risk Management items:
1. Plans lack feasibility
2. Exposure to destabilizers
3. Lack of personal support
4. Noncompliance with remediation attempts
5. Stress
Violence risk assessment
and management
planning – what and how
you can contribute
Contributing to the risk assessment

Nursing and PARS staff spend a significant amount of
time in contact and interacting with patients

It is therefore likely that you will know things about
your patient or have observed things which would be
useful evidence for the risk assessment
Contributing to the risk assessment – what
do you know?
Exercise:
 In two groups think about the Clinical and Risk
Management items of the HCR-20
 What information could nursing or
PARS staff have through their contact
with patients that would be evidence
for or against the presence and relevance of these
items?
 How would you have obtained this information?
How the best Index links with the C&R items of
the HCR-20 (Walker & Kettles)
BEST – Index (scale - items)
HCR-20
Risk – 2, 3, 4, 5, 6, 7; Insight – 1, 2, 3, 15,16, 17, 18, 19, 20
H1 – previous violence
Insight – 1, 2, 3, 15, 16, 17, 18, 19, 20; Work and Rec – 1, 2, 3,
4, 5
H4 – employment problems
Risk – 19; Insight - 1, 2, 3; Empathy – 1, 2, 3, 14
H5 – substance use problems
Risk – 20; Insight – 1, 2, 3, 5, 16, 17, 18, 19
H6 – major mental illness
Insight – 1, 2, 3; Empathy – 1, 3, 14
C1 – lack of insight
Insight – 15, 16, 19; Empathy – 1, 3, 14, 19
C2 – negative attitudes
Risk – 2, 3, 19, 20; Insight – 1, 2, 15, 20; Work and Rec – 1
C3 – active symptoms of MMI
Insight – 16, 17, 18, 19, 20; Work and Rec – 1, 2, 4, 5
C4 – impulsivity
Insight – 16, 17, 18
C5 – unresponsiveness to Tx
Insight – 19
R4 – noncompliance with remediation
attempts
Violence risk assessment and
management planning

Violence risk assessment and management planning involves:
 RISK ASSESSMENT (RISK FACTORS) - Assessing an
individual’s risk of committing a violent act by looking for
evidence of established risk factors which have been shown in
research to be linked with future violence
 FORMULATION - Considering how these risk factors are
relevant for the individual being assessed and understanding
why an offence happened
 SCENARIO PLANNING - Making an assessment of the
likelihood of future violence and the circumstances that this is
likely to occur
 WARNING SIGNS - Identifying warning signs that would
indicate an increase in the risk of violence
 RISK MANAGEMENT PLANNING - Developing
strategies to manage this risk - including intervention and
treatment, monitoring, supervision and victim safety planning
Understanding a person’s offending
behaviour

Why do people commit offences?

People commit offences for different reasons – the
same type of offence may be motivated by very
different reasons…
Understanding a person’s offending
behaviour cont.
Offender A – Serious Physical Assault
 At the time of the offence…they are intoxicated, become
involved in an argument…unable to manage their anger they lash
out at victim…
Offender B – Serious Physical Assault
 At the time of the offence…they have been a victim of domestic
abuse for a number of years…unable to cope any longer, they
retaliate and assault their partner…
Understanding a person’s offending
behaviour cont.
What might we find in TSH?

Some external motivators for offending may be
controlled by the security of TSH

Some internal motivators for offending may remain but
they may be expressed or evident in different ways in
the different environment of TSH

Within the TSH we may see offence-related behaviours:
these behaviours are similar to past offending
behaviour in that they are driven by similar motivators
and indicate an increase in risk of violence.
Understanding a person’s offending behaviour cont.
What might we find in TSH? cont.
Observed behaviours in TSH
Offence information
Noted to drink excessive amounts of
milk. Causes other patients to become
annoyed with him when none left for
teas/coffees. [Motivation: delusional
beliefs.]
Index offence involved stabbing family
member whom he believed was trying to
poison him with an out of date carton of
milk. Psychosis includes delusional beliefs
and a belief that drinking milk will make
him God.
Noted to be reluctant to engage with
keyworker. Also became extremely angry
when she advised him that outing has had
to be rescheduled. [Motivation: negative
attitudes towards females.]
Index offence involved murder of
girlfriend. Extensive history of physical
abuse towards intimate partner.
Reporting to select members of staff that
he is being targeted by other patients on
the ward; bullied and made to buy
tobacco, confectionary. [Motivation: need
for control and to assert self.]
Index offence involved significant control
and violence. Extensive history of
childhood sexual abuse.
Understanding a person’s offending
behaviour cont.

Understanding a person’s offence helps us to make sense
of behaviours we might see in TSH and think about how
these link with risk of violence

Understanding a person’s past offending behaviour is
crucial for effective violence risk assessment and
management:
 It helps us think about what violence that individual may
perpetrate in the future and how this might come about
 It highlights potential warning signs that could indicate
increasing risk of violence
 It can also help identify areas for intervention
What we might find in TSH –
motivating factors and offence-related
behaviours.

Exercise:
Think of a patient you know and their offence
 Describe their background to your group

Describe their offence in as much detail as
possible

Ask your group to predict what kinds of
behaviour you might see in this person in TSH
Information about a person’s
offences

In order to be able to identify offence-related
behaviours, we need to…



Know details about an individual’s past offending behaviour
Understand why an individual’s past offending behaviour
occurred (the formulation)
Information on patients offending can be found in
the…



File review
Case summary
HCR-20 evidence document
Name: Joe Bloggs
Patient Number: 65/1234
DOB: 12.12.65
Current Location/Address: The State Hospital
Date of admission: 30/07/2003
Current Section: Section 57 (2)(A)(B) of the Criminal Procedure (Scotland) Act 1995
Index Offence: Assault to injury, breach of the peace
Current Diagnosis: Paranoid Schizophrenia
 Previous Inpatient Admissions (note date of admission, hospital and length of time spent)
 Prison Remands (note date, prison, length of sentence, time served and to which offence it was related)
19/11/99 – 23/06/00 – Psychiatric Admission (Clinical notes available from 19/11/99 – 23/06/00, however
no admission or discharge dates are available)
5/06/2003 – 16/06/2003 – Psychiatric Admission (Source Admission History, Dr Peter Jones, 19/09/2003, A1)
16/06/2003 – 18/06/2003 – IPCU (Source Admission History, Dr Peter Jones, 19/09/2003, A1)
24/06/2003 – Re-admitted to IPCU after index offence before transfer to The State Hospital (Source Social
Work Report, Tom David, 15/09/2003, A1)
12 (i) Previous Violence (community)
12 (i) PREVIOUS VIOLENCE (community)
List any convictions for violent offences (this will inevitably repeat some of Q11)
 With dates and age of person at the time
 Include offences as a juvenile
 Note and recorded triggers and/ or motivation behind the offences
 Note sentences, fines imposed, diversion from custody or sections under the Mental Health Act
20/06/2003 (INDEX OFFENCE) – Mr Bloggs entered the office from the elevator
by smashing through the locked internal door and ran towards his boss’s
desk, where he began to shout at his boss for planning to dismiss him. He
then jumped onto her desk in an attempt to grab her, and when she ran JB
pursued her through the open plan office. A witness then tripped JB so that
he fell to the floor, and the witness then restrained him whilst calling for
the assistance of the other male staff in the office. Mr Boggs continued to
struggle whilst face down on the floor before producing a black handled
kitchen knife and slashing one of the men restraining him repeatedly on the
back of his left hand.
12 (ii) Previous Violence (other hospital admissions)
12 (ii) PREVIOUS VIOLENCE (other hospital admissions)
 List any other records of violence during other inpatient admission (including other hospitals and any
previous State Hospital admissions) where criminal charges were not pursued.
 For each incident give some indication of the severity of the incident to victim or self (was medical
treatment or hospitalisation required of either party?)
 Did the authorities involved take any action?
At the IPCU the incidents were as follows:
17/07/2003 – Mr Bloggs banged and kicked doors and windows
19/07/2003 – He broke through external doors from the exercise area and had
to be brought back from the hospital grounds
Source & date
Police Report printed on
11/08/2003, A1
Source & date
Letter from David Ball to
Dr Dowling dated
29/07/2003, A1
MULTIDISCIPLINARY TREATMENT PLAN
ANNUAL REVIEW & CPA MEETING
CASE SUMMARY
Patient
Joe Bloggs
Section
CP (Scot) Act 95, s57
Admission date
30.07.03
Ethnic origin
British
Hospital number
65/1234
Restricted/non restricted
Restricted
Admitted from
HMP Barlinnie
First Language
English
DOB
12.12.65
Date applied
30.07.03
REASON FOR ADMISSION
Diagnosis Paranoid Schizophrenia
Other problems Antisocial Personality Disorder
MENTAL STATE ON ADMISSION
Mr Bloggs was admitted to The State Hospital in July 2003 when transferred from HMP
Barlinnie where he was serving a 6 year sentence for the serious assault of a man whom he
met in a public house. On admission he was noted to be suspicious and paranoid and reluctant
to engage with staff. There was evidence of paranoia and he was involved in several physical
assaults on other patients whom he believed were going to harm him.
ADDITIONAL INFORMATION
Personal & family history
Mr Bloggs grew up in the Paisley area with his mother, father and younger brother. His
mother and father divorced when he was 12 years old and he had no subsequent contact with
his father his mother has a history of mental health problems and was admitted frequently for
hospital care during Mr Blogg’s childhood.
Alcohol & drug history
Mr Bloggs has a history of dug and alcohol misuse from the age of 12. He has admitted to
using cannabis on a regular basis and Heroin. He continued to use Heroin whilst in prison. His
cannabis use is associated with a deterioration in his mental health and subsequent increase in
paranoia.
Forensic history
Mr Bloggs has a significant forensic history with convictions for theft, burglary, and driving
offences from the age of 16. He was three convictions for assault dating back to 1985. All
appear to have occurred in the context of increase alcohol consumption and cannabis use.
Psychiatric history
Mr Bloggs was admitted to Leverndale hospital in 1999 and diagnosed with drug induced
psychosis. He has no other formal contact with psychiatric services until the index o ffence in
2002.
How do you communicate what you
know?



If you observe something which you think may
be related to an individual’s risk of violence
and/or important for the risk assessment and
management plan it is essential that you pass
this on effectively
The next step is to make sure the clinical team
gets the information so it can be incorporated
into the risk assessment – you may also want
to discuss it with a colleague or line manager
If writing notes or a report – make sure this is
accurate and descriptive
 Try to avoid phrases like “sexually
inappropriate” or “abusive” – we need
details!
Using the Violence
Risk Assessment and
Management Plan
Profile (VRAMP)
Violence risk assessment and
management planning

Violence risk assessment and management planning involves:
 RISK ASSESSMENT (RISK FACTORS) - Assessing an
individual’s risk of committing a violent act by looking for
evidence of established risk factors which have been shown in
research to be linked with future violence
 FORMULATION - Considering how these risk factors are
relevant for the individual being assessed and understanding
why an offence happened
 SCENARIO PLANNING - Making an assessment of the
likelihood of future violence and the circumstances that this is
likely to occur
 WARNING SIGNS - Identifying warning signs that would
indicate an increase in the risk of violence
 RISK MANAGEMENT PLANNING - Developing
strategies to manage this risk - including intervention and
treatment, monitoring, supervision and victim safety planning
The Violence Risk Assessment and
Management Profile (VRAMP)

The VRAMP can be found within the care and
treatment/CPA plan

The VRAMP includes:
Summary of risk factors
 Formulation of offending behaviour
 Scenario planning
 Warning signs
 Recommendations for risk management strategies

RISK ASSESSMENT AND MANAGEMENT PROFILE
Violence risk assessment
Is there a completed violence risk assessment?
Yes/No
YES
HCR-20 prepared and discussed by Earn
Clinical team on 8.05.07
C & R items review on 9.05.08
If yes, note type of assessment and date
completed:
Is the assessment attached to this treatment
plan?
Yes/No
YES
Possible living situation in next
year or likely future transfer
plan.
Rowanbank Medium Secure Hospital
Description of locality/victim
issues (if applicable)
Edinburgh city centre – victim of index offence lives in
area.
SUMMARY (9.05.08)
HCR-20
Historical Items
Definite evidence
H1 – previous
violence
H2 – young age at
first violent incident
H5 – substance use
problems
H6 – major mental
illness
H8 – early
maladjustment
Clinical Items
Risk management
Items
High probability
R2 – exposure to
destabilisers
R5 - stress
Possible evidence
H3 – relationship
instability
H4 – employment
problems
H10 – prior
supervision failure
No evidence
H7 – psychopathy
H9 – personality
disorder
C1 – lack of insight
C2 – negative
attitudes
C3 – active
symptoms of MMI
C4 – impulsivity
C5 – unresponsive to
treatment
Low Probability
R3 – lack of personal
support
Moderate probability
R1 – plans lack
feasibility
R4 noncompliance
with remediation
attempts
Add summary of previous HCR-20 findings (see end of HCR-20 Evidence document)
Possible Definite
st
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ss
su
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or
t
co
m
pl
ia
nc
e
pl
an
s
de
st
ab
iliz
er
s
en
t
at
m
tre
M
I
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lsi
vi
ty
M
im
ne
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at
tit
ud
es
None
9.05.07
9.05.08
in
si
gh
t
Evidence
Changes in C & R items
Item
VIOLENCE RISK FORMULATION AND SCENARIO PLANNING
(This will be drafted but amended at the MDCT discussion)
1.
FORMULATION OF OFFENDING BEHAVIOUR:
Describe and
highlight the most important known causal factors in the person’s history that
have made them more likely to commit acts of violence (e.g. mental illness,
substance abuse, social isolation, violent sexual fantasies etc). Include use of
weapons or interest and/or expertise in weapons.








Psychosis – including command hallucinations related to violence and
paranoia relating to personal safety
History of child sexual abuse by male neighbour
Poor problem solving leading to increased stress, anger and difficulties coping
Anti-authoritarian attitudes
Pro-violent attitudes towards those he believes have committed sexual
offences
Substance misuse – mainly alcohol and cannabis use used to self-medicate and
cope with stress.
Weapon use – including improvised weapon use (e.g. furniture)
History of failing to attend psychiatric services for follow up when in
community
2
SCENARIO PLANNING: The team should at a minimum consider the patient’s risk
of violence in the State Hospital. However if onward moves or access to the community is
being considered then the patient’s risk of violence should be considered in these situations as
well. For each potential scenario consider the following and the relevant context:
THE STATE HOSPITAL
Describe the nature or kind of violence or aggression (if any) the
patient may commit along with the context or situation this may
occur. Who are likely victims? What would be the level of physical
or psychological harm caused? Also, consider behaviours that
approximate or mirror previous offending.
Most likely form of violence would be verbal aggression
Most
directed towards a member of staff if he perceived his needs
Likely
as not being met quick enough. Most likely to occur in the
context of increasing stress (e.g. around significant
anniversaries) and likely to result in psychological harm.
Most serious would be a serious physical assault result in
Most
Serious physical injury. Most likely to be towards a peer whom he
believes has committed a sexual assault in the context of
deterioration in mental health, ongoing disagreements or
tension with the victim, and or/a deterioration in his
relationship with staff.
May use improvised weapon.
Unlikely in TSH as Mr Bloggs is more likely to speak with a
member of staff regarding.
Other
possible
scenario
(e.g.
specific
victim)
Estimate
chances of this
behaviour
occurring. *
Low.
Very Low.
*HIGH: High chance of committing a violent act in situation described
MEDIUM: Some chance of committing a violent act in situation described
LOW: Little chance of committing a violent act in the situation described
VERY LOW: Almost no chance of committing a violent act in the situation described
OTHER SITUATION ……………Rowanbank Medium Secure Hospital……….
Consider any additional risk situation(s) the person is likely to be in, over the next
year. For example grounds access for the first time, outings, family or other visits,
transfers to other hospitals.
Describe the nature or kind of violence or aggression (if any) the
patient may commit along with the context or situation this may
occur. Who are likely victims? What would be the level of physical
or psychological harm caused?
Also, consider behaviours that
approximate or mirror previous offending.
As in TSH – verbal aggression towards staff.
Most
May be more likely in medium security if has access to
Likely
alcohol or drugs which he may be more likely to use in the
context of increasing stress.
How likely is it
that this
behaviour will
occur? *
Medium.
Most
Serious
As in TSH – physical assault towards peer believes has Very low.
committed sexual offence.
May find it more difficult to engage with new staff whom he
Other
possible has yet to develop trust with.
scenario
(e.g.
specific
victim)
Warning signs
What warning signs would indicate that this person’s risk is increasing or that a
violent act may be imminent? List all possible factors.




Isolating self from peers and staff
Reluctant to attend placements
Fidgeting and pacing (indicating increasing anxiety)
Reduced appetite
Recommendations for risk management (to form part of care and treatment
plan)
 Complete Social Problem Solving skill group
 Monitor interactions with peers known to have committed sexual offences
 Monitor stress and coping particularly around significant anniversaries (e.g.
date of index offence)
(See objectives 4 and 5 of treatment plan for the setting of management
strategies)
Date of multidisciplinary discussion 9 / 5 / 08
Signed on behalf of
MDCT…………………………………………………………………
Using the VRAMP

Exercise
Spend some time reading Adam Brown’s case
summary. Whilst reading this think about:

What might be the important factors in Adam’s
background

Why Adam committed the offence

What Adam might be like in TSH
Using the VRAMP cont.

The clinical team have completed a risk assessment
and prepared a VRAMP for Adam Brown. Spend
some time reading over the VRAMP.

What would you be looking out for in his
behaviour in TSH that would indicate increasing
risk of violence?
Using the VRAMP cont.

Now spend some time reviewing reports about
Adam’s current functioning and presentation in the
hospital.
1. Is there anything standing out in the reports that
concerns you? Why?
2. Is there anything you would like to find out more
about or investigate further? How would you do
this?
3. Is there anything that you would want to pass on
to the clinical team? What would you tell them?
What will you do differently…?
What have you taken from today’s training…
 Take a few minutes to think about what you will do
differently when you return to your ward or
department.
 What changes will you make to your practice?
 What responsibilities do you have in relation to
violence risk assessment and management
planning?
Aims and objectives
Have we covered our aims and objectives…?
 Have a general overview of the process of violence risk
assessment and management planning within TSH
 Be able to identify and pass on to the clinical team
information you know about a patient that would be
relevant for their risk assessment and management plan
 To know about the violence risk assessment and
management plan profile (VRAMP) and be able to use
it in your care and treatment of patients
Before we finish…
Evaluation
 Your feedback is invaluable as it help us identify what
we are doing well and what we can develop and
improve upon
 We will be comparing pre- and post-training evaluation
forms to see whether we have met our aims and
objectives
 We would appreciate it if you could complete the
evaluation forms and return them to us – thank you!
Care and Treatment Planning/CPA in The State Hospital:
violence risk assessment and management planning:
how you can make a difference
2009
Clare Neil
Trainee Forensic Psychologist
Claire Hamill
Specialist Psychological Practitioner