Memorandum of Procedure on Restricted Patients

3 RISK ASSESSMENT AND MANAGEMENT

3.1 The risk of harm to others is an important concern when making decisions about the treatment care and recovery of restricted patients. Patients who present a risk to others are likely also to be vulnerable to other forms of risk, e.g. self harm, self neglect or exploitation by others ³⁴. Good clinical care must include good risk assessment and management.

3.2 Risk assessment and management is an overarching principle in the management of restricted patients; it is an ongoing and dynamic process throughout the patient journey. The risk that a patient may present can vary over time and with the patient's condition. Good clinical care should involve a multidisciplinary approach of structured risk assessment and management within the Care Programme Approach (" CPA"). The Scotland Government Health Directorate (" SGHD") expect reassessment of the risk that a patient might present at 6 monthly intervals or at appropriate points and, in particular:

• before transfer involving a drop in the level of security;
• prior to a MAPPA referral and
• prior to consideration by the Tribunal.

3.3 A balance needs to be struck; risk aversion can be detrimental to a patient's rehabilitation. A multidisciplinary approach that appropriately engages the patient and has a focus on victim safety is required for effective management of the risk patients pose to others.

3.4 It is understood that there is inherent uncertainty in the processes of risk assessment and risk management. The goal is not to predict adverse events, nor to have overly risk-averse practice which can be counter-productive. Risk assessment is useful in identifying conditions where the risk of harm to others is increased and to inform measures to manage that risk. It is important to emphasise that risk can be reduced and managed but never eliminated.

3.5 The fuller the risk assessment provided by the multi-disciplinary team, the speedier the response officials are able to provide to recommendations for suspension of detention from hospital (granted under section 224 of the 2003 Act for restricted patients) (" SUS"), and transfer. In addition, full risk assessment improves input to Tribunal cases. Scottish Ministers need to be satisfied that the multidisciplinary team have properly identified and evaluated any risk to the public and that sound measures have been taken to manage it.

3.6 It is essential that each of the decision points for multidisciplinary teams, the Scottish Ministers and the Tribunal are supported by good quality risk assessments and risk management plans which are regularly updated within the CPA every 6 months and updated as circumstances change.

3.7 The Risk Management Authority (" RMA") guidance on risk management planning ³⁵ indicates that good quality risk management relies upon the following areas.

Collaborative Working

3.8 Risk Management for restricted patients requires a multi-disciplinary and multi-agency approach. This will require the multidisciplinary team to develop, communicate, implement and review the measures adopted to manage risk. With the introduction of MAPPA for restricted patients, the police are an integral part of the process. There may be separate risk assessments undertaken by Criminal Justice agencies with regard to the patient. Teams should be aware of these, their meaning and impact on communication of risk between agencies.

3.9 Formal assessment of risk should take place at a number of stages in the patient's progress and will be reviewed and updated as circumstances change. It is therefore important that all relevant information on a patient is shared with the Mental Health Officer. as well as other members of the multidisciplinary team on a need-to-know basis. All restricted patients must be managed via the CPA³⁶. The dissemination of information may be broadened to include external agencies such as local authority housing departments, care providers and the police. Equally, the CPA process may offer opportunities for gathering additional information, e.g. local police intelligence at pre- CPA meetings. The introduction of Multi Agency Public Protection Arrangements (" MAPPA") for restricted patients reinforces the requirement for multi-agency information sharing. Decisions on how and when to share information outside of the CPA and MAPPA meetings, and who with, will be taken on a case-by-case basis and should take account of patient confidentiality considerations.

Risk Assessment

3.10 The treatment plan for a restricted patient will necessarily include measures to manage the risk that the patient poses to others. The foundation of risk management planning is risk assessment. A 'risk assessment document' as a contributor to the planning process under CPA is recommended ³⁷. Risk assessment informs management planning, which in turn informs subsequent assessment and planning in a continuous and dynamic process.

3.11 Risk assessment will demonstrate:

• a thorough review of the available information;
• personal and family history;
• criminal history and history of violence;
• substance misuse;
• psychiatric history;
• assessment of personality; and
• other relevant risk factors ( e.g. sex offender risk factors).
• the use of appropriate risk assessment tools for the case in hand; to assist in:
• the application of structured professional judgement to help identify relevant risk and protective factors; and to provide a framework for
• a formulation of risk that includes the nature, severity, imminence, frequency and likelihood of re-offending; and
• an examination of a number of possible future scenarios that risk management strategies will seek to avert, or in the case of 'best-case' scenarios; support.

3.12 In order that the risk assessment may contribute to the treatment plan for the patient, it is not recommended that multidisciplinary teams undertake a solely statistical (or actuarial) assessment but attempt to place the risk the patient presents in context using Structured Professional Judgement. However, use of appropriate protocols or assessment tools ( e.g. suitable for mentally disordered offenders, sexual offenders or violent offenders) may contribute to the risk assessment and can be useful in framing the risk assessment in a systematic way. The RMA has evaluated the commonly used risk assessment tools for general offending, risk of violence and risk of sexual violence. This evaluation is published in Risk Assessment Tools Evaluation Directory ( RMA 2007) ³⁸

3.13 Risk Assessment should be clearly indicated and should clearly document:

• the likely impact of the harm posed by the patient;
• an indication of those to whom the patient poses a risk of harm;
• all relevant risk factors;
• active protective factors; and
• early warning signs and relapse indicators.

3.14 Risk assessment will be a continuous process in the implementation and review of the plan as implemented through the CPA.

CPAand risk management

3.15 In response to the risk assessment, the multidisciplinary team will document preventive actions and contingency actions (traffic light section) in the documentation for CPA, alongside mental health considerations that may or may not be linked to the risk to others. The plan will outline clear lines of accountability and responsibility and timeframes for delivery.

3.16 The CPA treatment plan will set out risk management strategies to:

• address the identified risk factors; and
• support and enhance protective factors.

3.17 The contingency action plan (traffic light section) will set out planned responses to:

• the appearance of early warning signs;
• the weakening or breakdown of protective factors; and
• the weakening or breakdown of the risk management strategies set out in the treatment plan.

Risk Management Strategies

3.18 The multidisciplinary team must ensure that they don't over-rely on one type of strategy in their plan to manage risk. The RMA in their Standards and Guidelines³⁹ suggest that a risk management plan should map multi-layered risk management strategies to each identified risk factor and to each active protective factor. This ensures that multiple strategies, delivered by multiple means, are applied to address each identified risk and protective factor.

3.19 The CPADocumentation must set out the arrangements for the supervision and monitoring of the patient, must detail the treatments or interventions to be carried out and must address victim safety planning.

3.20 Risk management strategies will represent the principles of effective practice and each strategy should be:

• sufficient to manage the risk posed;
• appropriate to the patient and the patient's situation;
• relevant to the risk factor(s);
• evidence-based; and
• the least restrictive necessary.

Accommodation

3.21 The multidisciplinary team should ensure that appropriate accommodation is identified for patients in both secure and community settings. However, it is perhaps most important in the community setting. Suitable housing should be identified prior to discharge of a patient into the community.

3.22 Identified accommodation must be subject to an evaluation of the risk posed by the patient; and those risks posed to the patient. Police and other agencies should be involved in assessing the suitability of identified accommodation.

3.23 For those restricted patients who are sexual offenders, multidisciplinary teams should refer to the National Accommodation Strategy for Sexual Offenders and its associated guidance.

3.23 At the stage of planning conditional discharge and once accommodation has been identified and vetted by the police, a MAPPA referral should be made.

Responding To Change

3.24 To ensure the continuing suitability of the plan, and the ability to respond timeously and effectively to any material change in the risk that the patient presents, the multidisciplinary team should engage in ongoing assessment and evaluation of the risk management strategies implemented and review the patient's progress.

3.25 Revisions of the strategies must be recorded in the CPA documentation and communicated to the appropriate parties in a timely manner.