CP 92 Risk Assessment and Management of Patients/Service Users [Version 2] Author: Medical Director 1
Hampshire Partnership NHS Foundation Trust POLICIES AND PROCEDURES PROFORMA CP 92 Subject and Version of Document: Author: Persons/Committees etc consulted whilst document in draft: Risk Assessment and Management of Patients/Service Users Version 2 Medical Director P&PC Date agreed: Version 1 - May 2010 Version 2 By whom agreed: P&PC Date of next review/up date and by whom: June 2013 Medical Director Copy obtainable from: Trust website Date document issued: Version 1 - October 2008 Update 41 Version 2 Update 61 Responsibility for dissemination to new staff: Principal Target Audience Training Implications Equality Impact Assessment Completed? Policy Statement: Key Words All Clinical/Social Care Department Heads All Clinical/Social Care Staff Ward/Dept/Team Managers to brief staff No The principles in this policy apply to all Directorates within the Trust who provide a service directly to patients, or arrange a service to be provided by another provider where contact is maintained. Harm, Suicide, Violence, Care, Planning Amendments Summary: Amend. No. Issued Page Subject 1, V2 This document has been completely re-written Author: Medical Director 2
1. INTRODUCTION Risk Assessment and Management of Patients 1.1 Risk assessment should be a core component of any mental health or learning disability assessment, in any setting. The Department of Health Guidance, Best Practice in Managing Risk (DOH 2007) provides a framework based on the principle that modern risk assessment should be structured, evidence-based and as consistent as possible across settings and across service providers. The assessment of Clinical Risk and subsequent management of the identified risk, is integral to Care Planning and in particular, the management of patient safety in Hampshire Partnership Foundation Trust 1.2 Although it is accepted that most practitioners will consider risk during an assessment, this may not be explicitly documented. The need for clarity and transparency in the assessment of risk and sharing this information with other relevant clinicians, teams and agencies, has been highlighted in a number of critical incident reviews and independent inquiries. 1.3 Recurring themes from these reviews and inquiries have included the need for clinical information to be communicated and shared so that it follows the patient throughout their treatment. 1.4 The Department of Health Guidance, Best Practice in Managing Risk (DOH 2007), states that a consistent approach to risk assessment will enable better communication between agencies and professionals and will contribute to improved care. 1.5 This policy describes the processes the Trust uses to ensure risks relating to the clinical presentation of patients and their care and support are assessed and managed. It should be read in conjunction with the Practice Guidance for Managing Clinical Risk Document (CP 92.1) which supports the implementation of this policy. 1.6 The risks covered by this policy and the associated guidance can be grouped into one of four over-arching categories: 1) Risk of harm to the patient including deliberate self harm, self neglect or the potential for abuse by others, including, physical abuse, the potential for actively or passively leaving the unit/department/scheme/care home without the knowledge and agreement of staff or financial exploitation. 2) Risk of harm to others including physical violence or harm, sexual violence, verbal or psychological abuse, harassment, potential harm to others through passive or active unsafe actions including fire setting or other dangerous acts - to include the potential for actively or passively leaving the unit/department/scheme/care home, without the knowledge and agreement of staff Author: Medical Director 3
3) Risk of damage to property including damage to fabric or structure of buildings or objects, including as a result of passive or active fire setting - to include the potential for actively or passively leaving the unit/department/scheme/care home, without the knowledge and agreement of staff 4) Risk to the Trust reputation and/or business profile if the Trust is shown to have failed to have robust systems and processes in place to identify and manage these risks The Trust has a range of polices relating to specific clinical risk and care and support issues which provide in-depth guidance and should be referred to where relevant risks are identified. These include but are not limited to; CP 22 Prevention and Management of Violence and Aggressive Incidents at Work Policy CP 85 Self Harm: Policy for the Assessment and Management of Self Harm CP 91 Slips, Trips and Falls Policy CP 11 Observation Policy and Procedure CP 24 Patients Missing or Absent Without Leave Policy CP 15 & CP 39 Safeguarding adults and children CP 46 & NCP 46 Moving and Handling NCP 16 Incident Reporting, Recording and Reviewing Policy CP17 Search Policy CP98 Care Planning Policy 2. SCOPE 2.1 The principles in this policy apply to all Directorates within the Trust who provide a service directly to patients, or arrange a service to be provided by another provider where contact is maintained. 2.2 The following principles are adapted from Justifying Risk Decisions by Dr David Carson & Rethinking Risk to Others (RCPsych, 2008) and apply to this Policy. By definition, it is inevitable that harm will sometimes occur from risk taking, even with the highest quality decisions. When judging a risk decision both the assessment of the risk and the management of its implementation should be considered. The quality of risk decisions made by all staff in HPFT will not be measured by whether harm does or does not result. Risk assessment is an assessment of a current situation, not itself a predictor of a particular event. Although accurate prediction is never possible in individual patients, some negative outcomes can be reduced in frequency by sensible contingency planning. Author: Medical Director 2
Mental health, learning disability and Adult Services (Social Services) professionals in HPFT must ensure that they have the necessary competencies to make risk decisions, including using approved relevant structured tools. Organisational contributions to poor quality risk decisions will always be considered along with the contribution of individual decision makers. 3. RESPONSIBILITIES 3.1 Chief Executive The Chief Executive has overall responsibility for the management of clinical risk. 3.2 Medical Director The Medical Director is responsible for: Ensuring that the Managing Clinical Risk Policy, Guidance and Training are regularly reviewed and are in line with best practice. Ensuring that the Patient Safety Group considers reports regarding clinical risk assessment and management practices and initiates appropriate actions to address concerns. Ensuring that the policy and related guidance is audited across the Trust and the results are acted upon Ensuring that reports regarding risk management are provided to the Assurance Committee and the Board as required 3.3 Directors of Operations and Area and Locality Managers Are responsible for: Ensuring that staff receive the necessary training to enable them to carry out risk assessments and manage risk as per the policy. Ensuring that staff receive clinical supervision and support to enable them to be competent at following the policy in their practice. Ensuring that the clinical risk management audit is undertaken. That good practice is celebrated. That action plans are developed and implemented to improve practice where required and that lessons are shared. 3.4 Ward and Team Managers Are responsible for: Ensuring that staff receive the necessary training to enable them to carry out risk assessments and manage risk as per the policy. Ensuring that staff receive clinical supervision and support to enable them to be competent at following the policy in their practice. Author: Medical Director 3
Ensuring that the clinical risk management audit is undertaken. That good practice is celebrated. That action plans are developed and implemented to improve practice where required and that lessons are shared. 3.5 Care Co-ordinator/Consultant/Responsible Clinician (Depending on the location of the patient) Are responsible for: Ensuring that a Risk Assessment has been carried out in line with this Policy for all patients under their care. Ensuring that the Risk Assessment is reviewed in line with this Policy, for all patients under their care. Ensuring that the Risk Assessment is recorded in line with this Policy. 3.6 Individual Clinical Staff Are responsible for: Reading the policy and guidance documents and following the procedures for undertaking risk assessments and managing risk. Recording all risk assessments and risk management activities in line with the policy and related guidance document. Accessing agreed training and supervision to ensure their competence is current. Ensuring that they have read the current Care Plan and Risk Assessment 3.7 Sources of Information for Risk Assessments When staff are assessing patients for the first time, they are responsible for ensuring that they access all available sources of information to formulate the risk assessment. These should include: Patient Relatives and carers Previous contacts with other mental health and learning disability services (whether internally within the Trust or externally to the Trust) Primary Care Records Other health professionals involved Other health or social services involved. Criminal Justice Service agencies, including Police and Probation. The information sources used should be recorded in the patient records. Author: Medical Director 4
4. RISK ASSESSMENT 4.1 Risk Assessment should be a core component of any Mental Health Assessment in any setting. The Practice Guidance Notes for Managing Clinical Risk (CP92.1) and the Department of Health Best Practice Guidance both emphasise that Risk Assessment should be structured and evidence based. 4.2 The agreed Risk Assessment Tool for HPFT is the RiO Risk Assessment Tool which will be the standard Risk Assessment Tool to be used (Appendix 1). 4.3 Other specialist Risk Assessment tools are used, this includes SVR 20 in the Learning Disability directorate and HCR-20 and Savry tools in the Specialised Services Directorate. Specialised tools such as these will only be used where they have been agreed by the relevant Directorate Service Board and they should only be completed by those with appropriate training and practice. 4.4 A new Risk Assessment must be completed in the following situations; As part of the initial assessment by any Clinical Team in all Service Directorates. At the beginning of each new episode of care for patients, Following admission to hospital. It will be countersigned by the patient s Consultant/Responsible Clinician at the first Inpatient Multi Disciplinary Ward Review If, following a Review of the Risk Assessment, there is a significant change in the patient in any of the following area; o Behaviour, especially known risk behaviours. o Mental state. o Any other third party information from carers/relatives/other informants suggesting changes in risk. o Significant life events o Following a Serious Untoward Incident As a minimum, annually, as part of CPA/Care Plan Reviews, if a new Risk Assessment has not been completed in the previous 6 months. 4.5 Risk Assessments should be completed after multi-disciplinary discussion with the whole Team, but if there is an urgent need to complete the Risk Assessment, this should be done by a qualified Mental Health Professional and agreed with the Multi-Disciplinary Team at the next opportunity. 4.6 All items in the Risk Assessment Tool must be completed including free text boxes. If there is no relevant information, this should be indicated. The name, date and job title of the person completing the tool must be completed. Author: Medical Director 5
4.7 The Clinician responsible for ensuring that a Risk Assessment has been carried out will be; In the case of community patients, the Care Co-ordinator. In the case of inpatients, patients on Community Treatment Orders or patients on Section 17 Leave, the relevant Consultant/Responsible Clinician. 5. REVIEW OF RISK ASSESSMENT 5.1 Community Patients For all community patients, the current Risk Assessment should be reviewed as part of all clinical assessments/reviews, in the following circumstances; At each CPA/Care Plan Review. If there is evidence of a change in the presentation of the patient as shown in the following areas; o Behaviour, especially known risk behaviours o Mental state. If there is information from a third party, including, carers, family members or other informants which suggests that the patients risk has changed. Significant change in life events. Following a Serious Untoward Incident. As part of the clinical assessment of the patient s suitability for transfer to another team. Within four weeks of transition, eg. between Community Teams. Within 7 days of discharge from an inpatient service or within 48hrs if the patient had been assessed as a high risk of suicide during the admission 5.2 Inpatients For all inpatients, the current Risk Assessment will be reviewed in the following circumstances; At each Multi-Disciplinary Ward Review/CPA/Care Plan Review. Prior to decisions about change in the leave status of the patient. Before each episode of leave. By the Responsible Clinician (for detained patients) or by the Inpatient Consultant, prior to discharge planning. This must include due consideration to the risk to any actual or potential victims in the community. It should also take into account the heightened risk of suicide in the first three months after discharge. Prior to transfer between inpatient wards or inpatient units. Evidence of change in the presentation of the patient as shown by their; o Behaviour, especially known risk behaviours. o Mental state Significant change in life events. Author: Medical Director 6
Following a Serious Untoward Incident. Evidence from information from a third party, including, carers, family members or other informants, which suggests that risk has changed. On the day of discharge from an inpatient ward 6. RECORDING OF RISK ASSESSMENT 6.1 Completion of the RiO Risk Assessment Tool will be recorded directly into the patients RiO record where RiO is live. In situations where RiO is not yet deployed the paper based version will be used. 6.2 Whenever the Risk Assessment Tool is completed, it will be either validated on the patient s RiO record or in the case of the paper based version, signed and dated with the person s job title. 6.3 Whenever a new paper based Risk Assessment is completed, a copy will be sent to all other relevant staff and/or Teams. 6.4 The fact that a new Risk Assessment has been completed will be noted in the patient s progress notes and recorded as a risk related progress note. All reviews of Risk Assessment must be recorded in the progress notes, even if there has not been a change to the risk assessment. This should be recorded as a risk related progress note. 7. USE 0F STRUCTURED RISK ASSESSMENT TOOLS FOR RISK OF VIOLENCE 7.1 If the standard Risk Assessment Tool and subsequent analysis of risk factors indicates a high risk to others, Practitioners must consider referring the patient to the Forensic Psychiatry Services for a detailed Risk Assessment, which could include the use of a structured Risk Assessment Tool, such as the HCR20. 7.2 The Protocol for referrals to the Wessex Forensic Psychiatry Service makes clear that one of the reasons for referrals states; For advice, including Risk Assessment, on the management of patients who are either in the community or in other mental health services. 7.3 Referral to the Wessex Forensic Psychiatry Service should also be considered for patients who have previously been under the care of either the Trust s Forensic Psychiatry Services or Forensic Psychiatry Services of other Trusts, who have been readmitted to hospital or are being considered for discharge from inpatient care. Author: Medical Director 7
7.4 Structured Risk Assessment Tools such as the HRC20 must only be completed by clinical staff who have received appropriate training in their completion. 8. MANAGEMENT OF IDENTIFIED RISK 8.1 Effective management of risk requires appropriate plans to reduce the level of risk. The Practice Guidance Notes for Managing Clinical Risk (CP92.1) contains detailed advice on Risk Management. Risk Assessment will inform the Risk Management Plan and contribute to the clinical care and meeting the needs of patients. 8.2 If the standard RiO Risk Assessment Tool indicates a significant risk of harm to self or others, then reference must be made to the Risk Assessment Section of the Practice Guidance Notes for Managing Clinical Risk (CP92.1), in particular, the Risk Factors for violence and for suicide which are listed in that section. Practitioners should identify the Dynamic Risk Factors and use those to draw up the Risk Management Plan. Patients with a significant level of risk will inevitably come within the Care Programme Approach (Care Planning Policy CP 98). Therefore the Risk Management Plan must be integrated and form an essential part of the patient s Care Plan/CPA Care Plan. 9. MANAGEMENT OF PATIENTS AT HIGHER RISK OF SUICIDE 9.1 Patients who have been assessed as being at high risk of suicide during an inpatient admission may present a higher risk to themselves immediately following discharge from an inpatient unit. These patients must be contacted within 48 hours of discharge and the risk assessment should be reviewed. Any increase in risk that is identified, must be addressed in the patient s care plan. 10. MANAGEMENT OF PATIENTS AT HIGHER RISK OF VIOLENCE TO OTHERS 10.1 Inpatients who have shown the following higher risk behaviours to others, either prior to their admission to hospital or during their current admission to hospital, are likely to present a high risk to others. Assault to others, including sexual assault. Use of weapons. Fire setting, where there is a risk to others. Focused animosity, including threats to kill, to identified potential victims. 10.2 For high risk patients, consideration should therefore be given to referral to the Wessex Forensic Psychiatry Service for a more detailed Risk Assessment which could include a structured Risk Assessment Tool such as the HCR20. If discharge is being considered, then referral to the relevant Assertive Outreach Team should be considered as part of the Discharge Plan. Author: Medical Director 8
10.3 High risk patients should be managed using the Care Programme Approach (Care Planning Policy CP 98). Higher risk patients should be followed up within 48 hours of discharge from inpatient care (whether on Community Treatment Order or Section 12 Leave or not), by a qualified member of the Team responsible for their care in the community. This should preferably be the patients Care Co-ordinator. In addition, their mental state should be reviewed by the Community Consultant Psychiatrist/Community Responsible Clinician and their Risk Assessment reviewed within two weeks of their discharge from hospital. 11. TRANSITION POINTS 11.1 It is generally accepted that transition points in a patient s care can be times of increased risk. For example, when a patient is discharged from inpatient care to the community, there will be a decrease in the protective factors associated with being in hospital and an increase in the potential risk factors associated with a move to less supervised accommodation in the community. 11.2 Transition points include; Discharge from inpatient setting to the community. Transfer from one level of security to another (e.g. from PICU ward to Acute Inpatient ward). Transfer from one Team to another. Transfer from a Forensic Psychiatry Service to General Adult Psychiatry Service. Release from Prison to the community. 11.3 Risk Assessment, Risk Management and Care Planning, must be considered at any of these transition points, to ensure that continuity of care is maintained and information is shared with Teams and Services who may be involved in providing care to the patient following transition. 11.4 The patient s current Risk Assessment and Risk Management Plan must be reviewed within four weeks of the point of transition to consider the impact of the transition on the previously identified risks and to put in place Risk Management Plans. 11.5 The Risk Assessment and Risk Management Plan must be reviewed in conjunction with the Team who will be responsible for the patient s care following the transition. This is to ensure that both Teams are clear about the potential risks, management strategies, contingency plans and their clinical responsibilities. A Transfer CPA Meeting must be held and this will form an essential part of the transition planning process. It will allow clinical teams to consider and review the Risk Assessment, Risk Management Plans and Contingency Plans and ensure that the patient is clear about the transition plans. Author: Medical Director 9
12. COMMUNICATING RISK INFORMATION 12.1 The Practice Guidance Notes for Managing Clinical Risk (CP92.1) contains detailed advice on communicating risk information. This makes clear that once a Risk Management Plan has been developed or reviewed, it must become a live document and be communicated to the patient and all those involved in providing their care. 12.2 Communication of risk information is essential for the following reasons; To assist in effective team working. Because of the fact that all Practitioners have a duty of care to the wider public, especially to carers/family members of patients. 12.3 Staff must make reference to the HPFT Policy on Information Sharing (CP12.1 and NCP5.1). 12.4 The Practice Guidance Notes also gives information on Multi Agency Public Protection Arrangements (MAPPA) 13. RECORDING RISK INCIDENTS 13.1 Whenever a member of HPFT staff becomes aware that a patient has been harmed (including when they have caused harm to themselves) or caused harm to others, the details should be recorded in the primary patient record. The entry should clearly be identified as Risk Information. The entry should include the following: The source of the information, whether it was witnessed by Trust staff. An accurate account of the circumstances of what happened, including the events leading up to it and a description of the patient s behaviour. The outcome of the incident, including, if harm resulted to the patient or any other person as a result of it. The consequences of the incident, including any legal proceedings. An assessment of how this relates to the patient s mental illness. 13.2 This should enable a history of risk incidents to be built up to help inform the risk assessments and management plans. In addition, an incident form should be raised in line with the Trust Incident Reporting, Recording and Reviewing Policy (NCP 16). 14. RISK ASSESSMENT TOOL 14.1 The Trust has adopted the RiO Risk Assessment tool for use in all services. For services which have adopted the use of RiO, this tool is automatically available for use within the electronic system. A paper version is available for all other services to use in prior to the availability of RiO. This is included as appendix 1. Author: Medical Director 10
15. TRAINING REQUIREMENTS 15.1 All clinical staff will receive training in Risk Assessment and Positive Risk Management to ensure that they are competent to fulfil their responsibilities under this policy. All clinical staff should refer to the Trust s Essential Training Manual, to establish the type of training that is required. Clinical staff who are new to the Trust will receive this training during organisational induction. The training is also provided as part of the Trust s essential training programme. 16. MONITORING COMPLIANCE WITH THE REQUIREMENTS OF THIS POLICY 16.1 Compliance with this policy will be monitored through an audit of the completion of the risk assessment and risk management process. Author: Medical Director 11
Risk Management Planning Undertake Clinical Review With Multi-Disciplinary Team Regularly as part of Care Planning At times of crisis If evidence of change in presentation of patient Before and after transition Include relevant agencies Review crisis management plan Assess Risk Review Risk Information from all sources Discuss Risk Assessment with Multi-Disciplinary Team Identify Risk Factors using Practice Guidance Notes Take account of any Substance Misuse problems Record using RiO Risk Assessment Tool Document in Patient Record Draw up Risk Management Plan Use Dynamic Risk Factors to inform Risk Management Plan Include a Crisis Management Plan and actions to be taken when warning signs are apparent Integrate with Care Plan Evaluate Outcome of Risk Management Plan Review effectiveness of Risk Management Plan Take account of both positive and negative outcomes for the patient Ensure Risk Management Plan is Carried Out Provide effective treatment, including for Substance Misuse problems. Ensure monitoring of risk Ensure effective supervision Refer to relevant policies & procedures Consider use of Mental Health A ct when required Communicate Risk Management Plan Discuss with the patient Include in Care Plan With other agencies if appropriate Consider issues of Privacy and Dignity Consider any Safeguarding issues Author: Medical Director 12