Risk Assessment

By London Deanery | September 24, 2018

Risk assessment is an essential component of every psychiatric assessment. It is imperative that you ask specifically about each of the key domains of risk listed in the box below. Your trust is likely to have both a risk assessment protocol and mandatory forms that need to be completed on each client. Please take some time to familiarise yourself with both.

In this section, we will only briefly cover the key domains of risk that you need to enquire about and then look a little more closely at assessing self harm as this is a common clinical presentation. Trainees are advised to undertake further reading and request supervision on this topic.

Risk Assessment Key Domains:

To ensure a competent risk assessment, in addition to or incorporated within your history and MSE you must enquire about risk in the following categories:

  • Self Harm: e.g. Suicidal Ideas / Plans / Attempts; Self-harm / Injury e.g. cutting, poisoning, burning; Substance Misuse
  • Self Neglect: e.g. Poor nutrition and personal hygiene; unable to cook / feed self; unable to wash / dress self; poor budgeting, not taking medication
  • Harm to others (dangerousness): e.g. Aggression / violence / abuse to others and animals; including sexual/domestic/other abuse (including touching /exposure); command hallucinations; arrests/conviction for violent or sexual offence; preoccupation/obsession with weapons; arson / fire setting; hostage taking; violence/aggression/abuse to staff; threats to kill; stalking / harassment; risk to children; risk to vulnerable adults; exploitation of others (financial/emotional); risk to escape/abscond
  • Harm from others (vulnerability): e.g. neglect by carers; sexual exploitation; bullying; risk of unlawful restrictions e.g. locks on doors, physical restraints; risk of physical harm; and risk caused by medical/services/treatment
  • Risk to children: Please consider: Is the patient in contact with any children, related or unrelated? If yes, consider if there are any risks to children (e.g. neglect, abuse).
  • There are some other areas of risk you may also want to consider - for example: accidents; driving; road safety; incidents involving police; damage to property; theft; phone calls; correspondence; disengagement from mental health services; pregnancy etc.
  • Assess for protective factors: e.g. religion, family, previous good response to treatment

ASSESSING RISK

Remember risk assessment must include risk to others, risk from others, vulnerability as well as risk to self (not just self-harm but also neglect, non-compliance and substance misuse).

Risk assessment to predict suicide by any clinician is difficult as there are multiple variables to take into account. Published research has however identified some risk factors, which should alert all clinicians to an increased risk of an adverse outcome.

NOTE: A risk assessment is only useful if it leads to a carefully constructed management plan to address all risks identified.

SUICIDE RISK FACTORS

It is important to recognise some important risk factors for suicide. These include:

  • Male gender and increasing age
  • Single, widowed, divorced
  • Social isolation
  • Suicidal intent or ideation
  • Pervasive feelings of hopelessness
  • Recent adverse life events
  • History of previous attempted self-harm
  • Depressive illness and other psychiatric disorders (non-compliance)
  • Presence of physical illness and chronic pain
  • History of substance misuse
  • Recent discharge from hospital

ASSESSING A PATIENT WHO HAS SELF HARMED

As a core trainee, you may be asked frequently to assess patients who have harmed themselves and to make a judgment on the level of risk that they pose to themselves. To determine this, you will want to consider the details of the episode of self-harm including the premeditation and intent. You may find it useful to use the questions in either the Beck’s or Pierce suicide intent rating scales. A sample of the Pierce suicide intent scale has been given at the end of this page.

DO NOT FORGET TO ASK ABOUT:

  • Trigger for episode of self harm
  • Ongoing thoughts of self harm, any suicide intent or plans
  • Psychiatric history
  • History of self harm
  • Alcohol/Drug misuse (also in relation to self harm episode)
  • Protective factors and support network

A FULL HISTORY AND MSE SHOULD IDENTIFY CO-MORBID DEPRESSION OR PSYCHOSIS

Here is Pierce Suicide Intent Scale

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Further Reading

by Dr Chloe Pickup

A risk assessment is a core part of any psychiatric assessment and is usually done towards the end of the assessment, or where it naturally arises during the history taking. There are many aspects to a clear risk assessment, and it is not only risk to self as is commonly thought. Risk to self is a very important aspect of psychiatry, specifically assessing a suicidal patient, however risk to self occurs in more than just depression. Also patient’s who are depressed may also have more than just risk to self which needs to be explored.

It is important to understand the patient’s thoughts on the risk within their own narrative. You should also make clear the confines of confidentiality and be open with the patient about why you are asking about certain aspects of risk

It is likely you will need to gain collateral information from family, friends or carers to get a fuller picture of the risk profile.

Often aspects of risk can be assessmed within a mental state examination, such as when reviewing for command hallucinations, delusions of control, delusions of jealousy as well as passivity experiences.

It is always important to consider past risk as this can be a predictor for future risk. Certain areas such as forensic history should be fully established within this section of history taking, as well as past psychiatric admissions. It is important to be aware of if the patient has required to be nursed on a PICU or has community orders on going.

Main areas of a risk assessment:

  1. Risk to self
    1. this would include current thoughts, plans and intent. Protective factors. Past attemepts. Current home situation. Guilt/anger/hopelessness. (Further covered within suicide assessments)
  2. Risk to others
    1. including domestic violence. Physical/emotional or psychological harm towards children or vulnerable adults in the home or who being cared for
  3. Risk from others
    1. this includes from gangs
  4. Risk due to vulnerability
    1. such as from exploitation from others, finacially, emotionally or due to own vulnerability due to poor compliance/concordance with both drugs and MH teams
  5. Risk of neglect

Other areas of risk include:

  1. risk from physical health factors
  2. risk from substances
  3. risk of radicalisation
  4. risk due to access to weapons
  5. risk of hoarding
  6. risk from environment
    1. this can include from current housing, friends, family, work or school

Risk factors needing to be assessed and considered:

  1. These include drugs and alcohol and how this impacts the risk
  2. supportive relationships or if there has been a breakdown of them
  3. current work and social situation
  4. financial situation
  5. past triggers for relapse or increase of risk
  6. current concordance with treatment, including engagement with services
  7. potential changes which could affect the risk
  8. recent loss/stressors/threats

Risk formulation

It is important to be clear what the plan from the risk assessment is. Such as admission, either informally or under section, or referral to Home Treatment Teams or referral to other services. These can include local MH services, drug and alochol services and social services.

It should be able to summarise from the history, mental state and specific risk factors as well as demonstate understanding of how the risk could be dynamic and what factors are of concern and the management of them.

All risk assessments must be clearly documented in the notes

It is key that any risks idenitfied be recored and then acted upon as necessary, such as by communication with seniors, other teams or those at risk who need to be informed.

References

www.rcpsych.ac.uk/usefulresources/managingandassessingrisk www.medistudents.com/en/learning/osce-skills/psychiatry/suicide-risk-assessment

Form to sign off the Competency

Note: You can either fill this PDF form on a computer (preferably together with your assessor) and print it out for the assessor to sign, or you can just print the page and fill it out by hand together with the assessor. In any case after the form is signed, you will need to scan it to upload to your portfolio, just like you would with any paper-based evidence form. If you fill the form on your computer you need to SAVE it with a different name - so that the text you typed into the form gets preserved. A form filled on a computer probably, will be easier to read.

If the form opens directly in your browser you probably will not be able to type in the form fields - for that you need to open the form with your system PDF viewer - which likely will be Adobe Reader.

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