Care and Treatment Planning/CPA in The State Care and Treatment Planning/CPA in The State Hospital:Hospital:

violence risk assessment and violence risk assessment and management planning: management planning:

how you can make a differencehow you can make a difference

Before we start…Before we start…

Evaluation Evaluation Your feedback is invaluable as it help us Your feedback is invaluable as it help us

identify what we are doing well and what identify what we are doing well and what we can develop and improve upon we can develop and improve upon

We will be comparing pre- and post-We will be comparing pre- and post-training evaluation forms to see whether training evaluation forms to see whether we have met our aims and objectiveswe have met our aims and objectives

We would appreciate it if you could We would appreciate it if you could complete the evaluation forms and return complete the evaluation forms and return them to us – thank you!them to us – thank you!

Overview of trainingOverview of training

Aims and objectivesAims and objectives Background to violence risk assessment and Background to violence risk assessment and

management planning in TSH – why do we do management planning in TSH – why do we do it?it?

The violence risk assessment and management The violence risk assessment and management planning process – how do we do it?planning process – how do we do it?

Violence risk assessment and management Violence risk assessment and management planning – what and how you can contributeplanning – what and how you can contribute

Using the Violence Risk Assessment and Using the Violence Risk Assessment and Management Plan Profile (VRAMP)Management Plan Profile (VRAMP)

Aims and objectivesAims and objectives

Have a general overview of the process of Have a general overview of the process of violence risk assessment and management violence risk assessment and management planning within TSHplanning within TSH

Be able to identify and pass on to the clinical Be able to identify and pass on to the clinical team information you know about a patient that team information you know about a patient that would be relevant for their risk assessment and would be relevant for their risk assessment and management planmanagement plan

To know about the violence risk assessment and To know about the violence risk assessment and management plan profile (VRAMP) and be able management plan profile (VRAMP) and be able to use it in your care and treatment of patientsto use it in your care and treatment of patients

Background to Background to violence risk violence risk

assessment and assessment and management management

planning in TSH – planning in TSH – why do we do it?why do we do it?

Why do we assess risk of Why do we assess risk of violence…?violence…?

Exercise:Exercise: In pairs, consider why we assess risk of In pairs, consider why we assess risk of

violence in TSH. violence in TSH. Why would the following groups of people Why would the following groups of people

think risk assessment was important?think risk assessment was important?1.1.The clinical team?The clinical team?2.2.Scottish ministers?Scottish ministers?3.3.The public?The public?4.4.Patients?Patients? Why would risk assessment be important Why would risk assessment be important

for you in your job?for you in your job?

Legislation and political driversLegislation and political drivers

In the past…In the past… Individuals who committed acts of Individuals who committed acts of

violence were not properly assessedviolence were not properly assessed Individuals who were risky were not Individuals who were risky were not

properly managedproperly managed Staff who were noticing issues Staff who were noticing issues

indicative of increasing risk of violence indicative of increasing risk of violence struggled to be heard – poor struggled to be heard – poor documentation and lines of documentation and lines of communicationcommunication

Legislation and political drivers Legislation and political drivers cont.cont.

As a result…As a result… Offenders repeated Offenders repeated

patterns of offending patterns of offending - including violence - including violence with significant harmwith significant harm

Several high profile Several high profile casescases

Legislation and political drivers Legislation and political drivers cont.cont.

Legislation and political drivers Legislation and political drivers cont.cont.

Memorandum of Procedure (MoP)Memorandum of Procedure (MoP) Care Programme Approach (CPA)Care Programme Approach (CPA) Risk Management Authority (RMA)Risk Management Authority (RMA) Mental Health (Care and Treatment) Mental Health (Care and Treatment)

(Scotland) Act 2003(Scotland) Act 2003 Multi Agency Public Protection Multi Agency Public Protection

Arrangements (MAPPA)Arrangements (MAPPA) High profile cases where things have gone High profile cases where things have gone

wrong – e.g. MWC inquiry (Mr L and Mr M)wrong – e.g. MWC inquiry (Mr L and Mr M)

Lessons learnt…Lessons learnt…

Violence risk assessment and management planning Violence risk assessment and management planning should be…should be…

Systematic using standardised tools for assessing riskSystematic using standardised tools for assessing risk Consistent and use standardised documentationConsistent and use standardised documentation Based on comprehensive and detailed information Based on comprehensive and detailed information

about the patients background, treatment and progressabout the patients background, treatment and progress Multi-disciplinaryMulti-disciplinary All staff involved in patient’s care and treatment should All staff involved in patient’s care and treatment should

be aware of the assessment and management plan and be aware of the assessment and management plan and should highlight areas of concern – it is everyone’s should highlight areas of concern – it is everyone’s responsibilityresponsibility

Information should be shared between disciplines and Information should be shared between disciplines and agenciesagencies

The violence risk The violence risk assessment and assessment and

management management planning process – planning process – how do we do it?how do we do it?

Care and treatment planning in Care and treatment planning in TSHTSH

How violence risk assessment and management How violence risk assessment and management planning used to be done in TSH…planning used to be done in TSH… No agreed format across the hospital for No agreed format across the hospital for

reviewing patients (care and treatment reviewing patients (care and treatment planning)planning)

No agreed formal assessment of future risk No agreed formal assessment of future risk of violenceof violence

Risk assessment and management planning Risk assessment and management planning not always linked with care and treatment not always linked with care and treatment planningplanning

Different practices and documentation were Different practices and documentation were used by different clinical teamsused by different clinical teams

Care and treatment planning in Care and treatment planning in TSHTSH

The new Care and Treatment Planning process and The new Care and Treatment Planning process and documentation…documentation… All wards are now following the same process and All wards are now following the same process and

using the same documentationusing the same documentation This meets the requirements for CPAThis meets the requirements for CPA Aim is for all patients to have a completed violence Aim is for all patients to have a completed violence

risk assessment and management plan which is risk assessment and management plan which is reviewed regularly by the clinical teamreviewed regularly by the clinical team

Violence risk assessment and management Violence risk assessment and management planning is now part of the care and treatment planning is now part of the care and treatment planning processplanning process

The Violence Risk Assessment and Management The Violence Risk Assessment and Management Profile (VRAMP) forms part of the care and Profile (VRAMP) forms part of the care and treatment plantreatment plan

Violence risk assessment and Violence risk assessment and management planningmanagement planning

Violence risk assessment and management planning involves:Violence risk assessment and management planning involves: RISK ASSESSMENT (RISK FACTORS)RISK ASSESSMENT (RISK FACTORS) - Assessing an - Assessing an

individual’s risk of committing a violent act by looking for individual’s risk of committing a violent act by looking for evidence of established risk factors which have been shown evidence of established risk factors which have been shown in research to be linked with future violence in research to be linked with future violence

FORMULATION FORMULATION - Considering how these risk factors are - Considering how these risk factors are relevant for the individual being assessed and relevant for the individual being assessed and understanding why an offence happenedunderstanding why an offence happened

SCENARIO PLANNING SCENARIO PLANNING -- Making an assessment of the Making an assessment of the likelihood of future violence and the circumstances that this likelihood of future violence and the circumstances that this is likely to occuris likely to occur

WARNING SIGNS WARNING SIGNS -- Identifying warning signs that would Identifying warning signs that would indicate an increase in the risk of violenceindicate an increase in the risk of violence

RISK MANAGEMENT PLANNINGRISK MANAGEMENT PLANNING - Developing strategies - Developing strategies to manage this risk - including intervention and treatment, to manage this risk - including intervention and treatment, monitoring, supervision and victim safety planningmonitoring, supervision and victim safety planning

Thinking about risk…Thinking about risk…Exercise: Exercise:

Imagine a situation where you are Imagine a situation where you are driving in adverse weather and have driving in adverse weather and have a car accident…a car accident…

In 3 groups:In 3 groups:1.1. What factors would make driving in adverse What factors would make driving in adverse

weather risky (weather risky (risk assessmentrisk assessment)?)?2.2. Why did the accident happen (Why did the accident happen (formulationformulation))??3.3. What might happen in the future (What might happen in the future (scenario scenario

planningplanning))??

Thinking about risk…cont.Thinking about risk…cont.

What signs would indicate that the What signs would indicate that the risk was increasing (risk was increasing (warning signswarning signs)?)?

What could you do to reduce the risk What could you do to reduce the risk or minimise the harm (or minimise the harm (risk risk management planningmanagement planning)?)?

Violence risk assessment and Violence risk assessment and management planningmanagement planning

Violence risk assessment and management planning Violence risk assessment and management planning involves:involves: RISK ASSESSMENT (RISK FACTORS)RISK ASSESSMENT (RISK FACTORS) - Assessing - Assessing

an individual’s risk of committing a violent act by an individual’s risk of committing a violent act by looking for evidence of established risk factors which looking for evidence of established risk factors which have been shown in research to be linked with future have been shown in research to be linked with future violence violence

FORMULATION FORMULATION - Considering how these risk factors - Considering how these risk factors are relevant for the individual being assessed and are relevant for the individual being assessed and understanding why an offence happenedunderstanding why an offence happened

SCENARIO PLANNING SCENARIO PLANNING -- Making an assessment of Making an assessment of the likelihood of future violence and the the likelihood of future violence and the circumstances that this is likely to occurcircumstances that this is likely to occur

WARNING SIGNS WARNING SIGNS -- Identifying warning signs that Identifying warning signs that would indicate an increase in the risk of violencewould indicate an increase in the risk of violence

RISK MANAGEMENT PLANNINGRISK MANAGEMENT PLANNING - Developing - Developing strategies to manage this risk - including intervention strategies to manage this risk - including intervention and treatment, monitoring, supervision and victim and treatment, monitoring, supervision and victim safety planningsafety planning

Violence risk assessment in Violence risk assessment in TSH – risk factorsTSH – risk factors

In TSH the risk assessment tool most commonly In TSH the risk assessment tool most commonly used is the HCR-20used is the HCR-20

The HCR-20 is a structured clinical judgment tool The HCR-20 is a structured clinical judgment tool used to assess risk of violence. used to assess risk of violence. Other tools are available to assess different types of Other tools are available to assess different types of

violence (e.g. sexual violence, stalking, spousal violence)violence (e.g. sexual violence, stalking, spousal violence) The HCR-20 defines violence as… “actual, The HCR-20 defines violence as… “actual,

attempted, or threatened harm to a person or attempted, or threatened harm to a person or persons”persons”

The HCR-20 contains 20 items (or risk factors)The HCR-20 contains 20 items (or risk factors) 10 10 HHistorical itemsistorical items 5 5 CClinical itemslinical items 5 5 RRisk Management itemsisk Management items

Violence risk assessment in Violence risk assessment in TSH cont.TSH cont.

Clinical teams collect evidence of the Clinical teams collect evidence of the various risk factors identified in the various risk factors identified in the HCR-20 for the patient being assessed. HCR-20 for the patient being assessed. The evidence is presented in a draft The evidence is presented in a draft evidence document and discussed by the evidence document and discussed by the clinical teamclinical team

The clinical team decide whether there is The clinical team decide whether there is evidence that the item is present (rating evidence that the item is present (rating of definite, possible or no evidence)of definite, possible or no evidence)

The evidence in the HCR-20 evidence The evidence in the HCR-20 evidence document for the C and R items is document for the C and R items is updated and reviewed every yearupdated 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, 19.09.02, Psychology File 1 of 2. File Review, Psychology File Social History, 14.07.91, Medical File A1, Volume 1. Admission History, 25.07.91, Medical File A1, Volume 1.

Mr Bloggs first tried alcohol at the age of 15 and remembers drinking with his friends every weekend and would continue drinking until he was drunk. He reports first taking drugs when he was 14. Mr Bloggs reports using whatever drugs were available to him, 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. Mr Bloggs would become violent towards his sister, brother and mother threatening to kill them whilst under the influence of drugs or alcohol. Mr Bloggs had been taking drugs and drinking alcohol for some time prior to his index offence. On the night before the 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 There is clear evidence that this risk factor is present RATING 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 SUPPORTING INFORMATION Psychiatric Report, 18.06.91, Medical File A1, Volume 1. Admission History, 25.07.91, Medical File A1, Volume 1.

“…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. Delusional thoughts and beliefs around the time of admission to The State Hospital include ideas about holocausts, bombs and the end of the world; pop groups and pop songs; belonging to the Ninja Religion; the earth as an alien experiment;

The HCR-20The HCR-20

Historical items:Historical items:

1.1. Previous violencePrevious violence

2.2. Young age at first Young age at first violent incidentviolent incident

3.3. Relationship Relationship instabilityinstability

4.4. Employment Employment problemsproblems

5.5. Substance use Substance use problemsproblems

6.6. Major mental Major mental illnessillness

7.7. PsychopathyPsychopathy

8.8. Early Early maladjustmentmaladjustment

9.9. Personality Personality disorderdisorder

10.10. Prior supervision Prior supervision failurefailure

The HCR-20 cont.The HCR-20 cont.

Clinical itemsClinical 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.The HCR-20 cont.

Risk Management Risk Management items:items:1. Plans lack feasibility

2. Exposure to destabilizers

3. Lack of personal support

4. Noncompliance with remediation attempts

5. Stress

Violence risk Violence risk assessment and assessment and

management management planning – what planning – what and how you can and how you can

contributecontribute

Contributing to the risk Contributing to the risk assessmentassessment

Nursing and PARS staff spend a Nursing and PARS staff spend a significant amount of time in contact and significant amount of time in contact and interacting with patientsinteracting with patients

It is therefore likely that you will know It is therefore likely that you will know things about your patient or have things about your patient or have observed things which would be useful observed things which would be useful evidence for the risk assessmentevidence for the risk assessment

Contributing to the risk Contributing to the risk assessment – what do you assessment – what do you

know?know?Exercise:Exercise:

In two groups think about the Clinical and In two groups think about the Clinical and Risk Management items of the HCR-20Risk Management items of the HCR-20 What information could nursing or What information could nursing or

PARS staff have through their contactPARS staff have through their contact

with patients that would be evidence with patients that would be evidence

for or against the presence and relevance for or against the presence and relevance of these items?of these items?

How would you have obtained this How would you have obtained this information?information?

How the best Index links with the How the best Index links with the C&R items of the HCR-20 (Walker & C&R items of the HCR-20 (Walker &

Kettles)Kettles)BEST – Index (scale - items)BEST – Index (scale - items) HCR-20HCR-20

Risk – 2, 3, 4, 5, 6, 7; Insight – 1, 2, 3, 15,16, Risk – 2, 3, 4, 5, 6, 7; Insight – 1, 2, 3, 15,16, 17, 18, 19, 2017, 18, 19, 20

H1 – previous violenceH1 – previous violence

Insight – 1, 2, 3, 15, 16, 17, 18, 19, 20; Work Insight – 1, 2, 3, 15, 16, 17, 18, 19, 20; Work and Rec – 1, 2, 3, 4, 5and Rec – 1, 2, 3, 4, 5

H4 – employment problemsH4 – employment problems

Risk – 19; Insight - 1, 2, 3; Empathy – 1, 2, 3, Risk – 19; Insight - 1, 2, 3; Empathy – 1, 2, 3, 1414

H5 – substance use problemsH5 – substance use problems

Risk – 20; Insight – 1, 2, 3, 5, 16, 17, 18, 19Risk – 20; Insight – 1, 2, 3, 5, 16, 17, 18, 19 H6 – major mental illnessH6 – major mental illness

Insight – 1, 2, 3; Empathy – 1, 3, 14Insight – 1, 2, 3; Empathy – 1, 3, 14 C1 – lack of insightC1 – lack of insight

Insight – 15, 16, 19; Empathy – 1, 3, 14, 19Insight – 15, 16, 19; Empathy – 1, 3, 14, 19 C2 – negative attitudesC2 – negative attitudes

Risk – 2, 3, 19, 20; Insight – 1, 2, 15, 20; Work Risk – 2, 3, 19, 20; Insight – 1, 2, 15, 20; Work and Rec – 1and Rec – 1

C3 – active symptoms of MMIC3 – active symptoms of MMI

Insight – 16, 17, 18, 19, 20; Work and Rec – 1, Insight – 16, 17, 18, 19, 20; Work and Rec – 1, 2, 4, 52, 4, 5

C4 – impulsivityC4 – impulsivity

Insight – 16, 17, 18Insight – 16, 17, 18 C5 – unresponsiveness to TxC5 – unresponsiveness to Tx

Insight – 19Insight – 19 R4 – noncompliance with R4 – noncompliance with remediation attemptsremediation attempts

Violence risk assessment and Violence risk assessment and management planningmanagement planning

Violence risk assessment and management planning Violence risk assessment and management planning involves:involves: RISK ASSESSMENT (RISK FACTORS)RISK ASSESSMENT (RISK FACTORS) - Assessing an - Assessing an

individual’s risk of committing a violent act by looking for individual’s risk of committing a violent act by looking for evidence of established risk factors which have been evidence of established risk factors which have been shown in research to be linked with future violence shown in research to be linked with future violence

FORMULATION FORMULATION - Considering how these risk factors are - Considering how these risk factors are relevant for the individual being assessed and relevant for the individual being assessed and understanding why an offence happenedunderstanding why an offence happened

SCENARIO PLANNING SCENARIO PLANNING -- Making an assessment of the Making an assessment of the likelihood of future violence and the circumstances that likelihood of future violence and the circumstances that this is likely to occurthis is likely to occur

WARNING SIGNS WARNING SIGNS -- Identifying warning signs that would Identifying warning signs that would indicate an increase in the risk of violenceindicate an increase in the risk of violence

RISK MANAGEMENT PLANNINGRISK MANAGEMENT PLANNING - Developing - Developing strategies to manage this risk - including intervention and strategies to manage this risk - including intervention and treatment, monitoring, supervision and victim safety treatment, monitoring, supervision and victim safety planningplanning

Understanding a person’s Understanding a person’s offending behaviouroffending behaviour

Why do people commit offences?Why do people commit offences?

People commit offences for different People commit offences for different reasons – the same type of offence may be reasons – the same type of offence may be motivated by very different reasons…motivated by very different reasons…

Understanding a person’s Understanding a person’s offending behaviour cont.offending behaviour cont.

Offender A – Serious Physical AssaultOffender A – Serious Physical Assault At the time of the offence…they are intoxicated, At the time of the offence…they are intoxicated,

become involved in an argument…unable to become involved in an argument…unable to manage their anger they lash out at victim…manage their anger they lash out at victim…

Offender B – Serious Physical AssaultOffender B – Serious Physical Assault At the time of the offence…they have been a At the time of the offence…they have been a

victim of domestic abuse for a number of years…victim of domestic abuse for a number of years…unable to cope any longer, they retaliate and unable to cope any longer, they retaliate and assault their partner…assault their partner…

Understanding a person’s Understanding a person’s offending behaviour cont. offending behaviour cont.

What might we find in TSH?What might we find in TSH? Some external motivators for offending may Some external motivators for offending may

be controlled by the security of TSHbe controlled by the security of TSH

Some internal motivators for offending may Some internal motivators for offending may remain but they may be expressed or remain but they may be expressed or evident in different ways in the different evident in different ways in the different environment of TSHenvironment of TSH

Within the TSH we may see offence-related Within the TSH we may see offence-related behaviours: these behaviours are similar to behaviours: these behaviours are similar to past offending behaviour in that they are past offending behaviour in that they are driven by similar motivators and indicate an driven by similar motivators and indicate an increase in risk of violence.increase in risk of violence.

Understanding a person’s offending Understanding a person’s offending behaviour cont. behaviour cont.

What might we find in TSH? cont.What might we find in TSH? cont.Observed behaviours in Observed behaviours in TSHTSH

Offence informationOffence information

Noted to drink excessive Noted to drink excessive amounts of milk. Causes other amounts of milk. Causes other patients to become annoyed patients to become annoyed with him when none left for with him when none left for teas/coffees. [Motivation: teas/coffees. [Motivation: delusional beliefs.]delusional beliefs.]

Index offence involved stabbing Index offence involved stabbing family member whom he family member whom he believed was trying to poison believed was trying to poison him with an out of date carton him with an out of date carton of milk. Psychosis includes of milk. Psychosis includes delusional beliefs and a belief delusional beliefs and a belief that drinking milk will make him that drinking milk will make him God.God.

Noted to be reluctant to engage Noted to be reluctant to engage with keyworker. Also became with keyworker. Also became extremely angry when she extremely angry when she advised him that outing has had advised him that outing has had to be rescheduled. [Motivation: to be rescheduled. [Motivation: negative attitudes towards negative attitudes towards females.]females.]

Index offence involved murder Index offence involved murder of girlfriend. Extensive history of girlfriend. Extensive history of physical abuse towards of physical abuse towards intimate partner.intimate partner.

Reporting to select members of Reporting to select members of staff that he is being targeted staff that he is being targeted by other patients on the ward; by other patients on the ward; bullied and made to buy bullied and made to buy tobacco, confectionary. tobacco, confectionary. [Motivation: need for control [Motivation: need for control and to assert self.]and to assert self.]

Index offence involved Index offence involved significant control and violence. significant control and violence. Extensive history of childhood Extensive history of childhood sexual abuse. sexual abuse.

Understanding a person’s Understanding a person’s offending behaviour cont.offending behaviour cont.

Understanding a person’s offence helps us to make Understanding a person’s offence helps us to make sense of behaviours we might see in TSH and think sense of behaviours we might see in TSH and think about how these link with risk of violenceabout how these link with risk of violence

Understanding a person’s past offending behaviour Understanding a person’s past offending behaviour is is crucialcrucial for effective violence risk assessment and for effective violence risk assessment and management:management: It helps us think about what violence that It helps us think about what violence that

individual may perpetrate in the future and how individual may perpetrate in the future and how this might come aboutthis might come about

It highlights potential warning signs that could It highlights potential warning signs that could indicate increasing risk of violenceindicate increasing risk of violence

It can also help identify areas for interventionIt can also help identify areas for intervention

What we might find in TSH – What we might find in TSH – motivating factors and offence-motivating factors and offence-

related behaviours.related behaviours.

Exercise:Exercise: Think of a patient you know and their offenceThink of a patient you know and their offence

Describe their background to your groupDescribe their background to your group

Describe their offence in as much detail as Describe their offence in as much detail as possiblepossible

Ask your group to predict what kinds of Ask your group to predict what kinds of behaviour you might see in this person in behaviour you might see in this person in TSHTSH

Information about a Information about a person’s offencesperson’s offences

In order to be able to identify offence-In order to be able to identify offence-related behaviours, we need to…related behaviours, we need to… Know details about an individual’s past Know details about an individual’s past

offending behaviouroffending behaviour Understand why an individual’s past offending Understand why an individual’s past offending

behaviour occurred (the formulation)behaviour occurred (the formulation)

Information on patients offending can be Information on patients offending can be found in the…found in the… File reviewFile review Case summaryCase summary HCR-20 evidence documentHCR-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) Source & date 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.

Police Report printed on 11/08/2003, A1

12 (ii) Previous Violence (other hospital admissions) 12 (ii) PREVIOUS VIOLENCE (other hospital admissions) Source & date 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

Letter from David Ball to Dr Dowling dated 29/07/2003, A1

MULTIDISCIPLINARY TREATMENT PLAN

ANNUAL REVIEW & CPA MEETING

CASE SUMMARY

Patient Joe Bloggs

Hospital number 65/1234

DOB 12.12.65

Section CP (Scot) Act 95, s57

Restricted/non restricted Restricted

Date applied 30.07.03

Admission date 30.07.03

Admitted from HMP Barlinnie

Ethnic origin British

First Language English

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 offence in 2002.

How do you communicate How do you communicate what you know?what you know?

If you observe something which you think If you observe something which you think may be related to an individual’s risk of may be related to an individual’s risk of violence and/or important for the risk violence and/or important for the risk assessment and management plan it is assessment and management plan it is essential that you pass this on effectivelyessential that you pass this on effectively

The next step is to make sure the clinical The next step is to make sure the clinical team gets the information so it can be team gets the information so it can be incorporated into the risk assessment – you incorporated into the risk assessment – you may also want to discuss it with a colleague may also want to discuss it with a colleague or line manageror line manager

If writing notes or a report – make sure this If writing notes or a report – make sure this is accurate and descriptiveis accurate and descriptive Try to avoid phrases like “sexually Try to avoid phrases like “sexually

inappropriate” or “abusive” – we need inappropriate” or “abusive” – we need details!details!

Using the Using the Violence Risk Violence Risk

Assessment and Assessment and Management Management Plan Profile Plan Profile (VRAMP)(VRAMP)

Violence risk assessment and Violence risk assessment and management planningmanagement planning

Violence risk assessment and management planning Violence risk assessment and management planning involves:involves: RISK ASSESSMENT (RISK FACTORS)RISK ASSESSMENT (RISK FACTORS) - Assessing an - Assessing an

individual’s risk of committing a violent act by looking for individual’s risk of committing a violent act by looking for evidence of established risk factors which have been evidence of established risk factors which have been shown in research to be linked with future violence shown in research to be linked with future violence

FORMULATION FORMULATION - Considering how these risk factors are - Considering how these risk factors are relevant for the individual being assessed and relevant for the individual being assessed and understanding why an offence happenedunderstanding why an offence happened

SCENARIO PLANNING SCENARIO PLANNING -- Making an assessment of the Making an assessment of the likelihood of future violence and the circumstances that likelihood of future violence and the circumstances that this is likely to occurthis is likely to occur

WARNING SIGNS WARNING SIGNS -- Identifying warning signs that would Identifying warning signs that would indicate an increase in the risk of violenceindicate an increase in the risk of violence

RISK MANAGEMENT PLANNINGRISK MANAGEMENT PLANNING - Developing - Developing strategies to manage this risk - including intervention and strategies to manage this risk - including intervention and treatment, monitoring, supervision and victim safety treatment, monitoring, supervision and victim safety planningplanning

The Violence Risk Assessment The Violence Risk Assessment and Management Profile and Management Profile

(VRAMP)(VRAMP) The VRAMP can be found within the The VRAMP can be found within the

care and treatment/CPA plancare and treatment/CPA plan

The VRAMP includes:The VRAMP includes: Summary of risk factorsSummary of risk factors Formulation of offending behaviourFormulation of offending behaviour Scenario planningScenario planning Warning signsWarning signs Recommendations for risk management Recommendations for risk management

strategiesstrategies

RISK ASSESSMENT AND MANAGEMENT PROFILE

Violence risk assessment

Yes/No Is there a completed violence risk assessment? YES

If yes, note type of assessment and date completed:

HCR-20 prepared and discussed by Earn Clinical team on 8.05.07 C & R items review on 9.05.08

Yes/No Is the assessment attached to this treatment plan?

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 Definite evidence Possible evidence No evidence Historical Items H1 – previous

violence H2 – young age at first violent incident H5 – substance use problems H6 – major mental illness H8 – early maladjustment

H3 – relationship instability H4 – employment problems H10 – prior supervision failure

H7 – psychopathy H9 – personality disorder

Clinical Items C1 – lack of insight C2 – negative attitudes

C3 – active symptoms of MMI C4 – impulsivity C5 – unresponsive to treatment

High probability Moderate probability Low Probability Risk management Items

R2 – exposure to destabilisers R5 - stress

R1 – plans lack feasibility R4 noncompliance with remediation attempts

R3 – lack of personal support

Add summary of previous HCR-20 findings (see end of HCR-20 Evidence document)

Changes in C & R items

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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.

Estimate chances of this behaviour occurring. *

Most Likely

Most likely form of violence would be verbal aggression directed towards a member of staff if he perceived his needs 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.

Low.

Most Serious

Most serious would be a serious physical assault result in 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.

Very Low.

Other possible scenario (e.g. specific victim)

*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.

How likely is it that this behaviour will occur? *

Most Likely

As in TSH – verbal aggression towards staff. May be more likely in medium security if has access to alcohol or drugs which he may be more likely to use in the context of increasing stress.

Medium.

Most Serious

As in TSH – physical assault towards peer believes has committed sexual offence.

Very low.

Other possible scenario (e.g. specific victim)

May find it more difficult to engage with new staff whom he has yet to develop trust with.

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 VRAMPUsing the VRAMPExerciseExercise

Spend some time reading Adam Brown’s Spend some time reading Adam Brown’s case summary. case summary. Whilst reading this Whilst reading this think about:think about:

What might be the important factors in What might be the important factors in Adam’s backgroundAdam’s background

Why Adam committed the offenceWhy Adam committed the offence

What Adam might be like in TSHWhat Adam might be like in TSH

Using the VRAMP cont.Using the VRAMP cont.

The clinical team have completed a risk The clinical team have completed a risk assessment and prepared a VRAMP for assessment and prepared a VRAMP for Adam Brown. Spend some time reading Adam Brown. Spend some time reading over the VRAMP.over the VRAMP.

What would you be looking out for in What would you be looking out for in his behaviour in TSH that would his behaviour in TSH that would indicate increasing risk of violence?indicate increasing risk of violence?

Using the VRAMP cont.Using the VRAMP cont.

Now spend some time reviewing reports Now spend some time reviewing reports about Adam’s current functioning and about Adam’s current functioning and presentation in the hospital. presentation in the hospital.

1.1. Is there anything standing out in the Is there anything standing out in the reports that concerns you? Why?reports that concerns you? Why?

2.2. Is there anything you would like to Is there anything you would like to find out more about or investigate further? find out more about or investigate further? How would you do this?How would you do this?

3.3. Is there anything that you would Is there anything that you would want to pass on to the clinical team? What want to pass on to the clinical team? What would you tell them?would you tell them?

What will you do What will you do differently…?differently…?

What have you taken from today’s What have you taken from today’s training…training… Take a few minutes to think about what Take a few minutes to think about what

you will do differently when you return you will do differently when you return to your ward or department.to your ward or department. What changes will you make to your What changes will you make to your

practice?practice? What responsibilities do you have in What responsibilities do you have in

relation to violence risk assessment relation to violence risk assessment and management planning?and management planning?

Aims and objectivesAims and objectives

Have we covered our aims and objectives…?Have we covered our aims and objectives…? Have a general overview of the process of Have a general overview of the process of

violence risk assessment and management violence risk assessment and management planning within TSHplanning within TSH

Be able to identify and pass on to the clinical Be able to identify and pass on to the clinical team information you know about a patient that team information you know about a patient that would be relevant for their risk assessment and would be relevant for their risk assessment and management planmanagement plan

To know about the violence risk assessment and To know about the violence risk assessment and management plan profile (VRAMP) and be able management plan profile (VRAMP) and be able to use it in your care and treatment of patientsto use it in your care and treatment of patients

Before we finish…Before we finish…

Evaluation Evaluation Your feedback is invaluable as it help us Your feedback is invaluable as it help us

identify what we are doing well and what identify what we are doing well and what we can develop and improve upon we can develop and improve upon

We will be comparing pre- and post-We will be comparing pre- and post-training evaluation forms to see whether training evaluation forms to see whether we have met our aims and objectiveswe have met our aims and objectives

We would appreciate it if you could We would appreciate it if you could complete the evaluation forms and return complete the evaluation forms and return them to us – thank you!them to us – thank you!

Care and Treatment Planning/CPA in The State Care and Treatment Planning/CPA in The State Hospital:Hospital:

violence risk assessment and violence risk assessment and management planning: management planning:

how you can make a differencehow you can make a difference

20092009

Clare NeilClare NeilTrainee Forensic PsychologistTrainee Forensic Psychologist

Claire HamillClaire HamillSpecialist Psychological PractitionerSpecialist Psychological Practitioner