High Risk Patients - Their Management at Broadmoor Hospital

Policy: H4 High Risk Patients - Their Management at Broadmoor Hospital Version: H4/03 Ratified by: Broadmoor SMT Date ratified: December 2013 Title of originator/author: Clinical Director High Secure Services Title of responsible Director Executive Director of High Secure Services Date issued: 19 th May 2014 Review date: December 2015 or earlier if directions require Target audience: All staff at Broadmoor Hospital Disclosure Status B Can be disclosed to Patients and the Public Embedded Documents EIA/Sustainability Implementation Plan N/A G:\Trust Policies and Procedures\2011 & 20 West London Mental Health NHS Trust Page 1 of 22

Equality & Diversity statement The Trust strives to ensure its policies are accessible, appropriate and inclusive for all. Therefore all policies will be required to undergo an Equality Impact Assessment and will only be approved once this process has been completed Sustainable Development Statement The Trust aims to ensure its policies consider and minimise the sustainable development impacts of its activities. All policies are therefore required to undergo a Sustainable Development Impact Assessment to ensure that the financial, environmental and social implications have been considered. Policies will only be approved once this process has been completed West London Mental Health NHS Trust Page 2 of 22

H4 - High Risk Patients - Their Management at Broadmoor Hospital Version Control Sheet Version Date Title of Author Status Comment H4/01 Sep 11 Clinical Director High Secure Services H4/02 Nov 11 Clinical Director - High Secure Services Draft Revised Policy to be presented to SMT Sep 2011 for approval to go to consultation. Revised following consultation process Ratified at Broadmoor SMT 25 November 2011 11 th July 2013 Re-issued to reflect Organisation and Department name changes. No changes to content. H4 / 03 October 2013 Clinical Director High secure Services Revised and updated as per periodic review For consideration at Broadmoor SMT October 2013 and subsequently consultation if required Approved at Broadmoor SMT, Dec 2013 subject to minor amendments. Issued on the Exchange 19.05.14. West London Mental Health NHS Trust Page 3 of 22

H4 - High Risk Patients - Their Management at Broadmoor Hospital Content Page 1. Flowchart 5 2. Introduction 9 3. Scope 10 4. Definition 11 5. Responsibilities 12 6. Systems & Recording 13 7. The process for identifying high risk patients 11 8. Managing high risk patients 12 9. Monitoring telephone calls 12 10. Locking a high risk patient in his room at night 12 11. Reviewing patients High Risk status 13 12. Incompatible patients 13 13. Monitoring and review 15 14. Training 15 15. References 15 16. Glossary of Terms/Acronyms 16 17. Appendices: 1 High Risk Identification algorithm 2 Decision Tree & Management strategies 3 Procedure for identification 4 Notification form 5 Discontinuation form 17 19 20 21 22 West London Mental Health NHS Trust Page 4 of 22

H4 - High Risk Patients - Their Management at Broadmoor Hospital 1.0 DECISION TREE FOR RISK MANAGEMENT OF HIGH RISK PATIENTS (including decisions about locking them in their rooms at night to manage risk) West London Mental Health NHS Trust Page 5 of 22

Management Strategies Supporting the Decision Making for the Risk Management of High Risk Patients Box 1 High Risk Suicide / Self Harm specific treatment focussed on suicide/self harm for the individual reduced access to risk items enhanced levels of observation (refer to the enhanced engagement & observation policy) enhanced emotional support occasionally a suicidal/self harming patient is also violent and assaultative and in this situation the patient may be locked in their room at night in conjunction with enhanced levels of observation 3 Box 2 High Risk of Being Assaulted enhanced levels of observation (refer to the hospital s observation policy) geographical manipulation i.e. consider moving the patient away from individual(s) posing risk or restrict access to such individual(s) voluntary locking into room for periods of day or night. Many of these patients will co-operate with measures to enhance their safety, including agreeing to remain in their rooms for specified periods. But consideration must be given to the patient s ability / willingness to protect themselves. Voluntary exit from rooms should be maintained if possible but locking into room for identified high risk periods only (e.g. night time) 3 may be considered Box 3 High Risk of Escape locking into room for identified high risk periods (e.g. night time) 2 3 geographical manipulation i.e. consider moving the patient to a higher staffed location, or restrict access to a more confined area of the ward1 enhanced monitoring of visits (including closed visits) or temporary suspension of visits1 enhanced monitoring of mail and telephone calls 1 enhanced precautions for leave of absence from hospital (refer to policy) 1 enhanced escorting (to be specified precisely) for movement within hospital s secure perimeter 1 enhanced levels of observation 1 (refer to the hospital s observation policy) enhanced restrictions on access to risk items enhanced search/drug screening procedures 1 1,2,3 etc: see notes page 8 West London Mental Health NHS Trust Page 6 of 22

Box 4 High Risk of Immediate Harm to Others (continued) locking into room until judged safe to end such locking in in accordance with seclusion policy locking into room for identified high risk periods only (e.g. night time) 2 3 Longer term segregation should be considered if the risk is continuous and other management strategies are not considered sufficient to manage the risk geographical manipulation i.e. consider moving the patient to a higher staffed location or away from provocation, or restrict access to a more confined area of the ward 1 enhanced levels of observation 1 (refer to the enhanced engagement & observation policy) enhanced restrictions on access to risk items enhanced search/drug screening procedures 1 enhanced monitoring of visits (including closed visits) or temporary suspension of visits 1 Box 5 High Risk of Subverting Security locking into room for identified high risk periods (e.g. night time) 2 3 geographical manipulation i.e. consider moving the patient to a higher staffed location, or restrict access to a more confined area of the ward1 enhanced monitoring of visits (including closed visits) or temporary suspension of visits 1 enhanced monitoring of mail and telephone calls 1 enhanced precautions for leave of absence from hospital (refer to policy) 1 enhanced escorting (to be specified precisely) for movement within hospital s secure perimeter1 enhanced levels of observation 1 (refer to the hospital s observation policy) enhanced restrictions on access to risk items enhanced search/drug screening procedures 1 Box 6 Corridor Supervision at Night Corridor supervision can be enhanced by the use increased levels of staff and this should be considered as part of risk management. Consideration should also be given to deploying technology to enhance corridor supervision. Appropriate technology would include CCTV monitoring of corridors, Video motion detectors, infra red detectors, and door alarms. These can all be used to give early warning of untoward patient movement. West London Mental Health NHS Trust Page 7 of 22

(continued) NOTE 1 if these measures do not reduce the risk of escape in the view of the clinical team and security department, then locking in for high risk periods will be necessary (see Broadmoor Hospital Night Time Confinement Policy and paragraph 33 & 35 of the Directions). NOTE 2: a decision not to lock a patient in his room at night in accordance with the protocol should be clearly documented in the notes. NOTE 3: locking patients in their rooms at night should be supervised (see Broadmoor Hospital Night Time Confinement Policy ) West London Mental Health NHS Trust Page 8 of 22

2. INTRODUCTION 2.1 The High Security Psychiatric Services (Arrangements for Safety & Security in Ashworth, Broadmoor and Rampton Hospitals) Directions 2013 recognise there is a group of patients in the High Security Hospitals who may pose a higher risk than the majority and therefore, require increased levels of security. The Directions require that increases in both physical and procedural security be considered for those patients identified as high risk. 2.2 This policy provides a structured algorithm for the identification and management of patients identified as significantly higher risk than the majority of high secure patients. 2.3 The purpose of this document is to describe the procedures whereby these High Risk patients are identified and the enhanced procedural security arrangements that they may be subject to. 3. SCOPE This policy is applicable to all clinical staff working in Broadmoor High Security Hospital. 4. DEFINITIONS 4.1 For the purposes of this specific policy the term ' "High Risk" patients' refers to those patients who have been assessed as High Risk in accordance with direction 33 of The High Security Psychiatric Services (Arrangements for Safety & Security in Ashworth, Broadmoor and Rampton Hospitals) Directions 2013 (herein referred to as the Directions ). 4.2 This policy will be applied to all patients, enabling the identification of those who present high levels of risk in specific areas and the safe management of the risks they present. 5. RESPONSIBILITIES 5.1 Chief Executive The Chief Executive is responsible for ensuring that the Trust has policies in place and complies with its legal and regulatory obligations. 5.2 Executive Director of High Secure Services The Executive Director of High Secure Services is the responsible Director for this policy and has overall responsibility for ensuring that policy and practice within the High Secure Service adheres to the legislative requirements of the High Security Psychiatric Services Directions (2013) and the Clinical Security Framework. West London Mental Health NHS Trust Page 9 of 22

5.3 Clinical Director High Secure Services The Clinical Director is accountable to the Director of High Secure Services in relation to this policy for ensuring that the effectiveness of the policy is monitored through the High Risk Monitoring Group and for conducting annual audits of compliance with the policy and its effectiveness. The Clinical Director is also responsible for ensuring the maintenance of a contemporary High Risk Register of identified patients as defined by this policy. 5.4 Responsible Clinicians / Clinical Teams Clinical Teams are responsible for ensuring that every patient under their care is appropriately assessed using the prescribed tools in this policy and in line with the minimum time intervals described in this policy (or more frequently as indicated), and where those patients are identified as high risk that appropriate management plans are documented and followed in order to address the identified areas of risk. 5.5 All Staff This policy applies to all staff working within Broadmoor Hospital 6. SYSTEMS & RECORDING When patient assessed and decision is high risk Notification form completed Where recorded on High Risk database maintained by PA to Clinical Director Recorded by - Security Liaison Nurse When recorded notified when decision made Circulated to: - Clinical lead Site management Control room Clinical director Deputy Director of Nursing Director of Security West London Mental Health NHS Trust Page 10 of 22

7. THE PROCESS FOR IDENTIFYING "HIGH RISK" PATIENTS 7.1 Clinical Teams will use the operational pro-forma (Appendix 1) to identify those patients who should be considered as high risk. As a minimum, this should be undertaken before admission, (or within 6 hours of admission if it is not practicable to do so before) at every CPA, on transfer between wards and when a significant untoward incident* requires reassessment of risk. *including: Where a patient commits or threatens to commit an act of self harm, Where a patient is the victim of actual or threatened violence, Where a patient has used or threatened violence towards another patient, or a member of staff, Any act, or the receipt of any intelligence, relating to escape or unauthorised absence of the patient, or Any action, or threat of action, by the patient which would subvert security, In relation to a risk management plan, by the dates specified in the plan 7.2 A comprehensive multi-disciplinary risk assessment will be undertaken and recorded to ensure that all risks are identified. These fall into five main categories: Immediately harming others Committing suicide or self harming; Being assaulted Escaping Subverting safety and security, or organizing action to subvert safety or security 7.3 Any type of risk may range in magnitude from minimal to high We have attempted to operationalise the identification of high risk using the pro-forma at appendix 1. This has a scoring system which is inclusive of both historical and current evidence to improve consistency in identifying the level of risk in each category (see embedded presentation document below, for further details on use). IDENTIFYING.ppt 7.4 The Clinical Team (including the Security Liaison Nurse) must consider whether each patient presents an identified risk of harmful behaviour which is greater than can be managed by the ward s regime which normally contains or manages the risk(s) presented by its other patients. 7.5 Associated management strategies (appendix 2) have been designed to standardise the development of risk management plans for each identified risk. The use of this and the decisions made will be documented in the patient s MDT notes. 7.6 Appendix 3 of this policy outlines the procedure for notifying relevant parties of the identification of "high risk" patients and appendix 4 contains the appropriate notification form. West London Mental Health NHS Trust Page 11 of 22

8. MANAGING "HIGH RISK" PATIENTS 8.1 The management of the identified high risk patients must include the development of a multi-disciplinary High Risk management Plan (this is incorporated in the assessment tool at Appendix 1), as a key component of risk reduction is the effective treatment of the patient s mental disorder. Management strategies to support the decision making for the care and management of high risk patients are contained in Appendix 2. 8.2 The management plan for each identified risk may include enhanced security procedures e.g. enhanced mail monitoring (refer to policy M6 Patients Mail & Postal Packets), increased supervision of visits, stricter monitoring (recording) of telephone calls (refer to T2 Telephone Calls by Patients), locking the patient in their room at night (refer to Broadmoor Hospital Night Time Confinement Policy). 8.3 Where a patient is identified as high risk in one or more of the above categories the Security Liaison Nurse must be present in the meeting drawing up the resulting risk management plan(s). 9 MONITORING TELEPHONE CALLS 9.1 If a patient is assessed, by the clinical team to be at high risk of escaping or subverting safety and security or organising action to subvert safety or security, or where there is a need to protect the safety of the patient (or others), the Clinical Team shall consider including in the risk management plan, arrangements to monitor the patient s telephone calls. 9.2 Details of the procedures to be followed for recording and monitoring patients telephone calls and the patient s right to have the decision reviewed are included in the Trust s policy Telephone Calls by Patients. 10 LOCKING A "HIGH RISK" PATIENT IN HIS ROOM AT NIGHT 10.1 One of the enhanced security procedures that may be appropriate for managing high risk patients is to lock them in their room for identified high-risk periods only (e.g. at night). The decision to authorise locking-in must be recorded in the High Risk management plan and any period of locking in will be recorded in accordance with the Broadmoor Hospital Night Time Confinement Policy which includes Procedural Guidelines for the care of a "high risk" patient locked in their room. 11 REVIEWING PATIENTS' "HIGH RISK" STATUS 11.1 For Each Individual Patient Review dates will be agreed and documented for each identified risk and its associated management plan. In some instances the review frequency will be determined by the policies governing the specific interventions deployed. West London Mental Health NHS Trust Page 12 of 22

11.2 The risk assessment protocol (appendix 1) will be used to assess the patient before, or on admission and, thereafter, as a minimum at each CPA review but frequencies must be set for individual patients in the light of their clinical condition and security intelligence. A further risk assessment will be required when a significant incident* occurs and similarly, events leading to a change of ward will also trigger a review of risk acknowledging either reduced risk if the ward move has been progressive or increased risk if the move has been retrogressive. *including: Where a patient commits or threatens to commit an act of self harm, Where a patient is the victim of actual or threatened violence, Where a patient has used or threatened violence towards another patient, or a member of staff, Any act, or the receipt of any intelligence, relating to escape or unauthorised absence of the patient, or Any action, or threat of action, by the patient which would subvert security, In relation to a risk management plan, by the dates specified in the plan 11.3 In implementing any enhanced security procedures for a high risk patient, it is important to have clearly prescribed periods for them, and agreed review dates. However, it is necessary for the Clinical Team to define, and be alert to, any triggers that may indicate the need for a review, in advance of the agreed date. 11.4 As good practice, details of all enhanced security measures should be shared (as far as is appropriate) with the patient, ensuring they understand the reasons for their implementation and the arrangements and timescales for their review. 11.5 If it is deemed upon review the patient no longer requires "high risk" status then the "discontinuation of high risk status" form must be completed by the Clinical team (Appendix 5). When the "high risk" status has been reviewed and discontinued all other agencies that were aware of the patients "high risk" status must be informed. 12. INCOMPATIBLE PATIENTS 12.1 On occasion Clinical Teams may identify that two (or more) patients are incompatible. Meaning that, at the present time, they pose such a risk / are at such risk to / from identified individual(s) within the Hospital that the Clinical Team(s) decide that contact between the identified individuals must be prevented, or safely managed*. (*requiring interventions that extend beyond the normal operational procedures of a ward/area) 12.2 Placing a patient(s) on the incompatibility list must not be viewed as a resolution of the identified problem and must prompt interventions designed to address the identified issue(s). 12.3 The process for signposting individuals incompatibility with each other is to add their names to the incompatibility list. In order to do this the Responsible Clinician, Clinical Nurse Manager, or Security Liaison Nurse should inform the Security West London Mental Health NHS Trust Page 13 of 22

Intelligence Office, by submitting a Security Information Report detailing the reasons why the patient(s) need to be added to the list and if contact between the patients can be managed or should be prevented. 12.4 In some cases (i.e. where a patient has disclosed fear of another patient or having been victimised), whether the patient explicitly requests it or not, the CTM may decide that the information should be kept confidential from the third party identified by the patient. In this case this must be clearly indicated in the SIR that is submitted, in order that the Security Intelligence Office can annotate the incompatibility list indicating that this information is not to be disclosed. 12.5 The Security intelligence Office maintains a contemporary list of all incompatibilities within the Hospital. The list is published on the exchange. 12.6 Possible reasons for patients to be added to the incompatibility list include the following: Threats of violence to an identified other Actual violence Evidence of having collaborated to subvert safety or security, or information that suggests collaboration Information that suggests others are at risk Bullying Predatory behaviour Inappropriate sexual activity 12.6.1 It should be noted that the above list is, by no means, exhaustive. It should also be noted that evidence of the above behaviours does not mean that a patient should be automatically added to the incompatibility list, but it is an option that the Clinical Team may wish to consider as a short term measure for managing the identified risk(s). 12.7 When incompatibility issues are identified Clinical Teams must consider all aspects of the patients care and management including High Risk assessment / management, care planning and where appropriate, safeguarding vulnerable adults. 12.8 Once a patient has been added to the incompatibility list Clinical Teams should seek to identify appropriate methods for resolution, i.e. mediation, 1-1 support, safeguarding vulnerable adults interventions, High Risk management plan, etc. 12.9 The decision to place a patient on the incompatibility list must be made by the Clinical Team and reviewed as a minimum at each CPA where the default is that the incompatibility lapses unless actively reinstated by the Team. The Team must ensure that appropriate steps are made to remove patients from the list wherever the risks have been mitigated to levels that can be managed by the clinical teams. The Security Intelligence Office must be informed of any changes in order that the incompatibility list may be updated. Where it is decided to remove a patient from the incompatibility list a Security Information Report should be submitted detailing how the original issue has been resolved. 12.10 Where patients from different wards have been placed on the incompatibility list, all of the appropriate Clinical Teams must be in agreement for the names to be removed from the list. West London Mental Health NHS Trust Page 14 of 22

13. MONITORING AND REVIEW 13.1 The High Risk Register will be reviewed monthly in the Directorate Management Team meetings by the Service Director and the Clinical Lead who may seek assurance from the Responsible Clinician, Ward Manager and Security Liaison Nurse regarding the status of any patient. 13.2 The High Risk Monitoring Group will meet quarterly to review the number of patients within the Hospital who are (or have been, during the period in question) designated High Risk, and a summary of the risk(s) they pose (or have posed). The group will have oversight take an overview of the distribution of high risk patients around the hospital and consider any new security information which has a bearing on the safe management of wards. 13.3 The Clinical Director will report to the Performance Manager at NTDA in accordance with the performance review framework for High Secure Hospitals. 13.4 The High Risk Identification Framework will be subject to monitoring across the three High Secure Hospitals at the Clinical and Security Practice Forum. 13.5 The High Risk Monitoring Group will also consider any patients classified at exceptionally high risk of escape or causing harm to others for all Leave of Absences. - See Leave of Absence Policy L2 paragraph 6.1.1 (j). Depending on the nature of the leave of absence, Thames Valley Police may deploy and manage police resources in addition to those identified within the patient High Risk Management Plan. 13.6 Compliance with this policy is subject to external audit on an annual basis by the National Offender Management Service (NOMS) audit team. 14. TRAINING Role Specific training is provided for Responsible Clinicians and Security Liaison Nurses as part of Secondary Induction 15. REFERENCES This policy should be read in conjunction with the following: The High Security Psychiatric Services (Arrangements for Safety & Security in Ashworth, Broadmoor and Rampton Hospitals) Directions 2013 (and accompanying Guidance) National & Local Clinical Security Frameworks Leave of Absence Policy L2 (paragraph 6.1.1 (j) Telephone Calls by Patients at Broadmoor T2 Night Time Confinement Broadmoor N5 Patients Mail at Broadmoor M6 West London Mental Health NHS Trust Page 15 of 22

16. GLOSSARY OF TERMS/ACRONYMS ACRONYMS CPA MDT CCTV NOMS CTM NHS SMT SIR NTDA DESCRIPTION Care Plan Approach Multidisciplinary Team Closed-circuit Television National Offenders Management Service Clinical Team Manager National Health Service Senior Management Team Security Incident Report National trust Development Authority West London Mental Health NHS Trust Page 16 of 22

HIGH SECURE HOSPITAL HIGH RISK REGISTER Appendix 1 PATIENT NAME: RIO NUMBER: MHA SECTION: WARD: DATE: REASON FOR UPDATE: DOB: NHS NUMBER: DOA: RC: CPA / WARD TRANSFER / RECENT EVENT / ADMISSION A patient should be placed on the high risk register if there is historical evidence (scoring 1) as well as current evidence (scoring 1), i.e. in the last six months, of significant risk. Current evidence of risk may be due to (a) chronic risks that have not reduced (e.g. because pharmacological or psychological interventions have not been effective) or (b) new behaviours. In exceptional circumstances current evidence alone, if sufficiently serious, may warrant inclusion on to the high risk register by scoring 2. IMMEDIATELY HARMING OTHERS1 (consider: sex offending; arson, hostage taking; harm to children; weapon use) Historical Evidence: Score (0,1) Current Evidence: Score (0,1,2) TOTAL HIGH RISK REGISTER (I.E. A TOTAL CATEGORY SCORE OF 2 OR MORE)? YES NO IF YES PLEASE DETAIL HIGH RISK MANAGEMENT PLAN COMMITTING SUICIDE OR SELF-HARM Historical Evidence: Current Evidence: Score (0,1) Score (0,1,2) TOTAL HIGH RISK REGISTER (I.E. A TOTAL CATEGORY SCORE OF 2 OR MORE)? YES NO IF YES PLEASE DETAIL HIGH RISK MANAGEMENT PLAN 1 If a patient is held under terrorist legislation or detained under suspicion of terrorist activity, they are automatically placed on the high risk register (i.e. scoring 2) as immediate harm to others. Such patients are kept on the high risk register until the clinical team are directed otherwise. West London Mental Health NHS Trust Page 17 of 22

BEING ASSAULTED / RISK FROM OTHERS (consider: very high profile patients) Historical Evidence: Current Evidence: Score (0,1) Score (0,1,2) TOTAL HIGH RISK REGISTER (I.E. A TOTAL CATEGORY SCORE OF 2 OR MORE)? YES NO IF YES PLEASE DETAIL HIGH RISK MANAGEMENT PLAN ESCAPING (consider: escaping and absconding) Historical Evidence: Current Evidence: Score (0,1) Score (0,1,2) TOTAL HIGH RISK REGISTER (I.E. A TOTAL CATEGORY SCORE OF 2 OR MORE)? YES NO IF YES PLEASE DETAIL HIGH RISK MANAGEMENT PLAN SUBVERTING SECURITY (includes: concerted indiscipline) Historical Evidence: Current Evidence: Score (0,1) Score (0,1,2) TOTAL HIGH RISK REGISTER (I.E. A TOTAL CATEGORY SCORE OF 2 OR MORE)? YES NO IF YES PLEASE DETAIL HIGH RISK MANAGEMENT PLAN Review Date Changes or Amendments Signed by Responsible Clinician on behalf of MDT West London Mental Health NHS Trust Page 18 of 22

APPENDIX 2 "HIGH RISK" PATIENTS THEIR MANAGEMENT IN BROADMOOR HOSPITAL PROCEDURE FOR IDENTIFYING "HIGH RISK" PATIENTS The following procedure will be applied in identifying all high risk patients within the hospital. 1 Introduction 1.1 The Clinical Team should review all patients as part of the regular Clinical Team Meeting and identify those patients who pose a high risk (see Policy Section 2). These fall into 5 main categories: Risk of harm to self (suicide or self injury) Risk of harm to others Risk of escape Risk of being assaulted (ie high vulnerability) Risk of subverting safety and security, or organizing action to subvert safety or security 1.2 The purpose of this document is to set out the process of notification to relevant parties of any patient identified as "high risk" as per this policy in order to ensure there is an up-to-date central record of all high risk patients in the hospital. 2 Notification 2.1 When a patient has been assessed as high risk by their Clinical Team. This decision will be Recorded in the patient s clinical notes Communicated by e-mail to the Clinical Lead Site Management Control Room Clinical Director 2.2 The Responsible Clinician (or delegated member of the clinical team) will complete the attached notification form (appendix 3) and send it to the: Clinical Lead Site Management Control Room Clinical Director 2.3 The P.A to the Medical Director will maintain a hospital-wide list of "high risk" patients, which will be maintained up-to-date as amendments occur. This information will be copied to the Director of High Secure Services and the Director of Security. West London Mental Health NHS Trust Page 19 of 22

Appendix 3 "HIGH RISK" PATIENTS THEIR MANAGEMENT IN BROADMOOR HOSPITAL "HIGH RISK" PATIENTS NOTIFICATION FORM Ward Responsible Clinician Patient Identified risk category(s) Care plan(s) in place to address identified risk(s)? yes / no Telephone monitoring required? yes / no Patient's room to be locked at night? yes / no Review date When completed, please forward to Clinical Director Site Management Control Room Security Liaison Mental Health Act Office MDT Notes West London Mental Health NHS Trust Page 20 of 22

Appendix 4 DISCONTINUATION OF "HIGH RISK" STATUS FORM Ward Responsible Clinician Patient Commencement date of High Risk Status Date discussed at CTM Date Discontinued Form Completed by RC or appointed Deputy: Signature: Name (PRINT): Date: When completed please forward to: Clinical Director Site Management Office Control Room MDT File (Section 4) Service Director Mental Health Act Office West London Mental Health NHS Trust Page 21 of 22

APPENDIX 5 POLICY / PROCEDURE: MONITORING TEMPLATE H4 - High Risk Patients - their Management at Broadmoor Hospital. MONITORING TEMPLATE WHO (which staff/team/dept) National Offender Management Service (NOMS) - external High Risk Monitoring Group (HRMG) - clinical director, dep dir nursing, director of security WHAT / TYPE (Audit/process/report - list details) AUDIT - standards and baseline targets to be agreed by the 3 HSHs Review the number & distribution of patients who have been placed on the high risk register, including a review of a summary of the risks they do/have posed. HOW MANY (No of records/%) No. of records to be agreed by 3 HSHs Summaries of all patients currently on the high risk register FREQUENCY (monthly/quarterly/annual) Annual Monthly WHERE REVIEWED (which meeting/committee) Security Committee HSS SMT Trust Board Safety & Safeguarding Governance Group OUTCOME OF REVIEW / ACTION TAKEN (Action plan / escalate to higher meeting) Action plans are prepared by the Director of Security / Director of High Secure Services and submitted to the Trust Board HRMG may recommend action where the identification of patients appears anomalous, where distribution of high risk patients needs to be addressed, or where policy is being inconsistently applied. West London Mental Health NHS Trust Page 22 of 22