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Quality in Health Care 1995;4:122-128

Clinical risk management in psychiatry

Maurice Lipsedge

This paper deals with suicide and violence toothers, which constitute the topics of greatestcurrent concern in risk management in themental health services. Most of the psychiatricclaims managed by the Risk ManagementFoundation of the Harvard Medical Insti-tutions over a twelve year period involved casesin which suicide, attempted suicide, or violenceto self or others occurred.'

Psychiatric disorder and dangerousnessPsychiatric disorder, especially schizophrenia,is associated with a significant risk of violencebefore admission to hospital.2 Patients withschizophrenia in a recent large scale Swedishlongitudinal study committed four times asmany violent offences as the general popu-lation.3 Among inpatients, those with schizo-phrenia are also disproportionately more likelyto be violent.4

Taylor found that the vast majority of thepsychotic offenders on remand at BrixtonPrison whom she examined had symptoms atthe time of the index offence. Schizophrenia isalso overrepresented among men remanded forhomicide: 11% in Taylor's series.5 Recent crosssectional surveys show an association betweenself reported violent behaviour and either adiagnosis of schizophrenia or current psychoticsymptoms.6 Thus violence is most likely tooccur when patients have active symptoms ofpsychosis, and the risk significantly diminishesafter treatment.7 The risk of violence in mentalillness is greatest when the patient hasdelusions and passivity experiences,8 and thereis a well recognised association of violence withdelusional belief, as in the "pathologies ofpassion" such as morbid jealousy anderotomania.5

Predicting dangerousnessPredicting dangerousness in any individualcase is known to be an uncertain exercise, andpsychiatrists tend to overestimate the likeli-hood of violence by patients considered forrelease from secure institutions.9

Methodological problems have vitiatedattempts to research the accuracy of psy-chiatrists' prediction of dangerousness.Difficulties include overinclusive diagnosticgroupings (for example, "psychotic"), failureto recognise the importance of the situationalcontext (for example, violence within thefamily), lack of data on aftercare arrangementsand compliance with treatment, and failure todefine violence clearly (for example, arrestrates, conviction rate, or self reported anti-social behaviour).' A major problem lies in thedesign of studies purporting to validate riskassessment, since those patients predicted tobehave violently will tend to be admitted to

hospital and be given preventive treatment andonly those considered unlikely to be violent inthe near future will be released into thecommunity.11The predictive power of decisions based on

actuarial data can be substantially increased byusing a more realistic, shorter time frame andby considering the environment into which apatient with a history of violence is to bedischarged, since violent acts by psychiatricpatients are known to be more likely to occurwithin a family setting. The confidentialenquiry into homicide found that most of thevictims were family members or were alreadyacquainted with the attacker."2 Although theview that the best predictor of future violenceis a history of physically aggressive behaviour'3has become axiomatic, the individual person'smental state is a crucial variable, which, sur-prisingly, has been omitted from predictiveresearch on violence. Gunn enumerated theimportant variables involved in predictingdangerous behaviour.'4 He emphasised theimportance of those elements which are subjectto change, such as family support and personalrelationships and the availability of potentialvictims. A recent prospective study of physicalassaults in a psychiatric intensive care unitshowed that both a criminal record andprevious drug misuse have predictive value, sothat a urine test for drugs and attention toforensic and violent history will help'to identifythose patients who are most likely to becomeaggressive. 15

Other critical factors include the patient'sdeclared intentions and attitudes to bothprevious and potential victims and to caringstaff, and his or her mental state, includingdelusions, command hallucinations, jealousy,depression, and proneness to angry outbursts.Schizophrenic delusions, especially of poison-ing or of a sexual nature, are more likely to leadto deliberate personal violence than imperativehallucinations.2 Detailed discussion should beheld with the patient about his or her thoughtsand feelings at the time of specific offences,supplemented by documentary evidence onthese events from the police depositions andwitness statements.

Information about the patient's history, psy-chiatric condition, likely compliance with treat-ment, ability for taking responsibility for his orher behaviour, and modes of responding tostress, as well as an assessment of relationships,provide a basis on which to predict thosecircumstances in which violence might occur'4and permit interventions designed to modifythese situations. A flexible plan might includeprescribing antipsychotic drugs for commandhallucinations; counselling for substancemisuse; marital therapy for potentially

Guy's Hospital,London SEl 9RTMaurice Lipsedge,consultant psychiatrist

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Risk management in psychiatry

explosive domestic relationships; and an angermanagement programme run on cognitive-behavioural lines or admission to a range ofhospital facilities with appropriate levels ofsupervision and security (from locked wards toregional secure units), or both.Although clinical judgment adds to pre-

dictive accuracy,'4 Gunn warns that predic-tions about violent behaviour can be safelymade only for fairly short periods, hence theneed for careful supervision, vigilant moni-toring, and the development of supportivetherapeutic relationships. Those providingsuch support require their own supervision andsupport and an awareness of transferenceissues.'4 (Transference refers to the way apatient's relationship with mental healthprofessionals is coloured and shaped by theirown earlier relationships and by the projectionof images derived from the formativeexperience of close contact with others in thepast.)

Managing potentially dangerouspsychiatric patientsThe Ritchie inquiry into the care ofChristopher Clunis, a young man with schizo-phrenia who killed a stranger in 1992,concluded that this patient's care and treat-ment "was a catalogue of failure and missedopportunity" over the five years of hospital andcommunity care before he stabbed his victim."6The report of the inquiry refers to the fact thatmany others with severe chronic mental illnessin the community, especially in poor inner cityareas, are a risk either to themselves or toothers. Most mentally abnormal offenders whocommit serious offences are already wellknown to the psychiatric services.'7 Since 1992there have been further incidents of grave actsof violence committed by patients with severemental illness.'8

Factors predicting violence inpsychiatric patients: summaryAntecedents: A previous history of violence

Diagnosis: SchizophreniaMorbid jealousy and erotomaniaIllicit drug use or alcohol misuse,or both

Loss of family support anddeterioration in personalrelationshipsLoss of accomodation

Clinical: Patient's declared intentions andattitudes to previous andpotential victimsThreats of violencePresence of active symptomsincluding delusions, especiallyregarding poisoning and sexualmatters, passivity experiences,command hallucinations, jealousy,depression, and angry outburstsSigns and symptoms of relapseLoss of contact with mentalhealth servicesPoor compliance with medication

Social ordomesticfactors:

Management:

The inquiry found a significant failure inpassing on information between psychiatrists,nurses, general practitioners, social workers,hostel staff, and Christopher Clunis's family.Other deficiencies in care which might haveultimately contributed to the death of hisvictim Jonathan Zeto included failure toobtain an accurate history and to considerChristopher Clunis's past history of violenceand to assess his propensity for furtherviolence. Doctors, nurses, and social workersfailed to make adequate contemporaneousrecords of important events, and violent inci-dents were either minimised or even omittedfrom records, correspondence, and dischargesummaries and were not picked up byclinicians and social workers from the nursingnotes. 16

In considering violent incidents whichoccurred three years before the fatal stabbing,the inquiry concluded that the medical pro-fessionals had tended to minimise the gravityof a series of attempts by Christopher Clunisto stab people, on the grounds that little actualphysical damage was caused in that particularcluster of incidents: "We feel there is a realdanger of looking too much at the conse-quences of an action without looking at theaction itself' (paragraph 2616).The inquiry also disclosed a failure to

provide and coordinate adequate aftercareaccording to section 1 17 of the Mental HealthAct 1983 by both medical and social servicesand a failure to act on warning signs to preventa relapse. (Section 117 of the act requireshealth services and social services to provideaftercare for patients on discharge fromhospital after compulsory detention under themental health act.) Throughout, the reportrefers to a tendency to overlook or minimiseviolent incidents and to ignore reports ofviolence made by members of the public anda failure to ensure continuity of care when thepatient had left a particular health district(paragraph 10916).The report of the Independent Panel of

Inquiry examining the case of MichaelBuchanan, a man with chronic schizophreniaand personality disorder who abused cocaineand who murdered a stranger in 1992, foundmany failures of care which resembled those inthe Clunis case.'8 These included inadequateaftercare planning, failure to allocate akeyworker according to section 117 of theMental Health Act 1983, lack of recording ofnumerous violent episodes, failure to assessrisk of dangerousness, and premature removalof the patient from the caseload of thecommunity psychiatric nurse. As with Clunis,these failures led to a potentially dangerouspatient slipping out of the aftercare system.To prevent patients with serious mental

illness falling through the net of care in this waythe Ritchie inquiry reiterates the need forimplementation of section 117 of the mentalhealth act and of the care programme approachso that the aftercare needs of each patient aresystematically assessed by both health andsocial services before discharge and anindividual plan of care is formulated by the

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multidisciplinary team.'9 This plan should bediscussed with and given to the patient and toall team members. The consultant psychiatristand the team must assess the risk of the patientharming himself or herself or others. Akeyworker or "care coordinator" has to beappointed and a regular review of the patientarranged. The keyworker should have directaccess to the responsible medical officer. Thereshould be contingency plans if the patient failsto engage in treatment and an assertiveapproach to maintaining patient contact. If acrisis develops and a request is made for anurgent mental health act assessment, thisshould be carried out within three hours. Non-urgent requests should be met within threeworking days. The foreword to the revisedcode of practice emphasises that the mentalhealth act can be used to admit patients notonly to prevent harm to self or to others butalso to forestall deterioration in a patient'shealth.20

All team members should be aware of thesigns of an impending relapse and reactpromptly. The preliminary report on homicidefrom the confidential inquiry into homicideand suicide of mentally ill people'2 states thatin over half the cases some reduction in atten-dance for treatment or some failure to takeprescribed medication had occurred. Non-compliance with treatment is often animportant pointer to relapse.2' Other circum-stances which increase the risk of dangerousbehaviour include drug or alcohol misuse in apatient with major mental disorder,2' as in thecase of Michael Buchanan,'8 the occurrence ofa potentially dangerous personal situation suchas marriage in a patient with a history ofmorbid jealousy, or disappearance from hostelor bed and breakfast accommodation, as in thecase of both Buchanan and Clunis. Identifyingall relevant factors in past violent behaviour isessential. '9When a patient who is subject to aftercare

under section 117 moves out of his or herarea, responsibility remains with the multi-disciplinary team until the aftercare has beeneffectively transferred to a new team. If thereis a risk of harm to self or others, all thoseproviding a service to the patient in terms ofhousing or occupational therapy need to beinformed of the risk. Information about anyviolent or potentially violent incident and a

thorough assessment of the risk of dangerous-ness should be included in the dischargesummary. The Ritchie inquiry seems torecommend (paragraph 48) that the need totransmit information about the risk ofdangerousness transcends considerations ofprofessional confidentiality.'6 This is sup-ported by the judgment inW versus Egdell andothers,22 which prompted a legal comment that"whenever a doctor perceives a patient to be aserious danger to his family or the public atlarge, his duty of confidence to that patient willbe reduced."23 The guidelines of the RoyalCollege of Psychiatrists on the aftercare ofpotentially violent or vulnerable patientsindicate that considerations of public safetyshould give exemption from absolute pro-

fessional confidentiality, but recommends(paragraph 44) that when such a disclosureoccurs the reasons for the decision should bedocumented.24 The clinician should alsorecord the steps taken before disclosure, suchas attempting to persuade the patient toauthorise the disclosure, and advice might besought from medical colleagues and defenceorganisations. The guidelines recommend aperiod of trial leave (paragraph 18) undersection 17 of the mental health act to test outuncertainties about the patient's ability to copein the community and to permit staff tomonitor the patient's progress. While onleave the patient's general practitioner shouldbe informed in anticipation of possibleproblems.24

Finally, the Ritchie report recommends(paragraph 3) that when a mentally disorderedperson charged with an offence is remanded tohospital the consultant psychiatrist shouldconsider whether it is appropriate for thepatient to be detained in hospital under theMental Health Act 1983, "irrespective ofthe charge and of the ultimate disposal of thecase." This includes those cases where thecharge is dropped or the verdict is "notguilty. 16

Assessing risk of suicideThe Health ofthe Nation document on suicide25is a model practical manual which provides aneffective strategy for preventing suicide. Thissection draws extensively on its procedures andrecommendations.

Suicide accounts for at least 1% of all deathsannually, with a male:female ratio of over 2:1.The highest suicide rates occur in people agedover 75, but the past decade has seen analarming increase in the suicide rate amongyoung men.26 The commonest means ofsuicide used by men include asphyxiation withcar exhaust fumes and hanging whereas selfpoisoning with drugs is the preferred methodof committing suicide among women.27

Factors predicting risk of suicide:summary* Declared intent* Preparation, including hoarding of tablets,

settling financial affairs or leaving a note, orboth

* Past history of deliberate self harm, especiallyin the previous six months

* Severe depressive illness, schizophrenia, andsubstance abuse

* Depression in young unemployed men withschizophrenia, with frequent relapses and fearof deterioration

* Pessimism, anhedonia, despair, morbid guilt,insomnia, self neglect, memory impairment,agitation, and panic attacks

* Recent adverse life events and lack ofsupportive relationships or failure to establisha working alliance with a mental healthprofessional (malignant alienation), or both

* First few weeks after discharge from hospitalare particularly risky.

Modified from Linford Rees W, Lipsedge M, Ball C, eds.Textbook ofPsychiatry. Arnold, 1995.

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In addition to age and sex, the socio-demographic and personal factors showing apositive statistical correlation with suicideinclude divorce; loss of job, unemployment, orretirement; social isolation; recent bereave-ment; chronic, painful, or terminal illness; afamily history ofmood disorder, alcoholism, orsuicide; loss of a parent in childhood; andbeing in either social class I or V. In addition,most people who commit suicide have a psy-chiatric disorder, most commonly depression,schizophrenia, and alcohol addiction.28High risk clinical factors for suicide

associated illness include severe insomnia, selfneglect, memory impairment, agitation, andpanic attacks. In patients with schizophreniathe risk of suicide is known to be greater inyoung and unemployed men with a history ofdepression, loss of appetite and weight,recurrent relapses, and a fear of deterioration.29A previous history of selfharm greatly increasesthe risk of subsequent suicide, to 30-foldhigher than that expected during the 10 yearsafter an episode of deliberate selfharm, the firstsix months being the period of greatest risk.Eventual suicide in such patients is signifi-cantly commoner among unemployed menof social class V who misuse alcohol ordrugs and who have a history of psychiatricdisorder.30

In the clinical evaluation of a particularperson who might be at risk of suicide, thestatistical correlates of suicide enumeratedabove have low specificity and sensitivity sothat screening for at risk cases results in highnumbers of both false positives and falsenegatives.30 In one study risk factors forsuicide combined had a sensitivity of 60% anda specificity of 61%.3 Although risk factorsare not especially helpful in the clinicalassessment of short term risk,30 they cancontribute to the overall assessment of risk.Rather than relying too heavily on actuarialrisk factors, the evaluation of short term riskshould be based on assessing the person'sstate of mind, recent adverse life events,relationships and degree of available support,which requires a detailed history ofthe presentillness, an assessment of mental state, and adiagnostic formulation.30 31

In addition to establishing whether theperson has shown evidence of suicidal intent byleaving a note or making a will, the extent ofhis or her pessimism and anhedonia, despair,and morbid guilt should be elicited sincehopelessness and helplessness are knownprecursors of suicidal behaviour.32 Has theperson considered the possible method ofsuicide? What circumstances might increasethe risk? Is there a risk to others? Informationshould also be obtained from previous medicaland psychiatric records, from relatives, andfrom other key informants.The degree of suicidal intent can fluctuate,

and apparent improvement may occur in thepatient on being removed from a stressfulenvironment, with a risk of relapse ondischarge. Furthermore, a gravely suicidalperson may deliberately conceal his or herlethal intentions. Others may appear calm and

even serene to the interviewer after they havemade an undisclosed but firm decision to killthemselves.Some patients who are at risk of suicide may

be cared for in the community. Patients whopresent a more serious risk will have to beadmitted to hospital, either voluntarily orunder the Mental Health Act 1983 in thosewho seem to be at severe and immediate riskof suicide but who refuse admission.

Managing suicidal patientsCOMMUNITY MANAGEMENT

The advantages of community care of suicidalpatients include avoiding the stigma associatedwith admission to a mental hospital and main-taining contact with the patient's usual socialenvironment, thus permitting retention ofpersonal autonomy and the deployment ofcoping skills with the back up of a supportiveand understanding therapeutic relationship.The disadvantages include lack of close super-vision of the patient's safety and compliancewith treatment, absence of refuge from anoxious family ambiance, and, at times,imposition of excessive strain on the family orcarers.Community management is not indicated

when there is a grave risk of suicide or lack ofadequate support, or both, or failure toestablish a good working alliance with thepatient. The risk is significantly increased by ahistory of self destructive impulsive behaviour,current substance misuse, and failure to set upa therapeutic rapport. Valuable informationcan be obtained by a domiciliary visit, whichmight disclose a cache of medication, evidenceof alcohol misuse, or the proximity of a railwayline or other hazardous local factors.Community management requires a care

plan that states the type of support and thenames of key care staff. The plan should bediscussed with and agreed by the patient andthe professionals involved. Patients whopresent a continuing long term risk of suicideshould be included on the supervision register(see below). There should be regularsystematic reviews of suicide risk with dailyreassessment of mental state in the firstinstance. These reviews should be recordedand the management plan modified whennecessary. Hospital admission may become theonly safe option if the patient's conditiondeteriorates. Communication between generalpractitioners, carers, and other agencies mustbe thorough. The patient and carer should begiven a contact number to use in emergenciesas well as a specific appointment for the nextreview. Treatment should be prescribed only inlimited quantities. The selective serotonin re-uptake inhibitor antidepressants are generallyregarded as less toxic if taken in an overdose.33Ideally, storage and dispensing of drugs shouldbe delegated to a responsible carer.Some patients will require long term

community support for persistent butrelatively mild suicide risk. Patients who caneventually be discharged from follow uprequire gradual and planned termination ofcontact rather than an abrupt ending whereas

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patients whose care is to be transferred toanother service should be "handed over" in ameasured fashion to allow their familiarizationwith the new team.

HOSPITAL MANAGEMENT

The period shortly after admission carries ahigh risk of selfharm, and when the suicide riskis particularly high patients are initially nursedin bed, and belongings such as ties, belts, andscissors are removed. The patient shouldremain continuously visible to the staff andshould not be allowed to leave the ward. Thestaff should carefully supervise smoking andthe patient's use of matches and lighters.Patients should be examined as soon aspossible after admission by the ward doctor.The treatment plan and the level of observationneed to be agreed jointly by medical andnursing staff and recorded and communicatedto all ward staff and the patient.The wards where patients at high risk of

suicide are nursed must be physically safe.There should be no access to high windows orstaircases, curtain rails should not be able tobear heavy weights, and exit from the wardmust be controlled. A guaranteed quota of staffis essential to provide intensive levels of super-vision. A keyworker and a deputy should bedesignated to the patient to try to establish aneffective therapeutic rapport, and, in general,the patient should be encouraged to approachstaff when feeling distressed and to discusssuicidal ideas freely.

Staff should be aware of the possibility of a

misleading shortlived improvement due torespite from a stressful home situation, whichwill cause a later recrudescence of suicide riskif unresolved. They should also be able torecognise "malignant alienation" which is a

potentially lethal distancing of the patient fromstaff and from carers caused by challengingbehaviour or repeated relapses, or both.34Another risky clinical situation is the period ofrecovery of drive and energy in a depressedpatient who retains suicidal ideas.Home leave from the ward presents a period

of high risk in recently suicidal inpatients.35Patients should be encouraged to return to theward at any time of the day or night if they feelunable to cope at home. If a patient goes absentwithout leave the nurse in charge and theresident medical officer should be informedimmediately, the hospital and its groundsshould be searched, and both the carers andthe police should be informed. After anabsence without leave or incident of deliberateselfharm within the hospital while on leave, thelevel of observation and the management planshould be reviewed.An appropriate level of supportive

observation is decided after discussion betweenthe medical and nursing staff and may beintensified unilaterally by the nursing staff. Itshould be reviewed at every change of nursingshift and confirmed by the patient's doctor andalso reviewed periodically by the consultant.Intensive supportive observation permits closemonitoring of the patients's behaviour andmental state. There are three levels of

supportive observation: constant, 15 minute,"known place" (box).

The first few weeks after discharge representa period of greatly increased risk of suicide.36The risk can be reduced by careful planning fordischarge in accordance with the care pro-gramme approach'9 by prescribing treatmentin safe amounts, by arranging for an earlyreview, and by ensuring that the patient andcarers know how to obtain help rapidly if thepatient's condition deteriorates.

Successful litigation against hospitals inconnection with self harm and suicide hashighlighted contributory factors for which thehospital and its staff might be regarded asresponsible.37* Unsafe design* Failure to monitor patient* Failure to remove dangerous objects* Failure to use a locked ward* Failure to supervise staff* Failure to obtain past records* Poor communication between staff* Failure to treat psychiatric disorderadequately

* Negligent discharge.In a survey of litigation claims against

hospitals in Australia from 1972 to 1992,in which twenty cases claiming failure toprevent suicidal behaviour were identified,38all but one case involved inpatients, andfailure to supervise was the leading basis of theclaims. Jumping from heights accounted forthirteen of the twenty incidents, seven ofwhich were caused by jumping throughhospital windows. The basis of the claims wasalleged failure to provide a suitable degree ofobservation and supervision, and most of theclaims resulted in settlement in favour of theplaintiffs. The high frequency of jumps hasimplications for the architectural design ofpsychiatric units.

Supportive observationConstant supportive observation is indicated forpatients expressing active suicidal intent or whohave recently carried out a self destructive actwith serious suicidal intent. The designated nurseremains with the patient at all times throughout24 hours.

Fifteen minute supportive observation is suitable fora patient who is not actively suicidal but has morerisk than the average patient. The designatednurse observes the patient every 15 minutes. Thepatient is required to inform the nurse of his orher whereabouts, cannot leave the ward withouta nurse escort, but can go to the lavatoryunaccompanied or talk to visitors for shortperiods. Visitors should tell the staff when theyleave.

"Known place" supportive observation is usedduring recovery from a suicidal crisis. Thedesignated nurse knows exactly where the patientis at any given time. The patient may go tooccupational therapy unaccompanied, but thedepartment is informed when this occurs. Thepatient may also leave the ward for otherpurposes for up to fifteen minutes.

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CARE PROGRAMME APPROACH AND SUPERVISION

REGISTERS

The purpose of the care programme

approach39 is to ensure the support of mentallyill people in the community, therebyminimising the possibility of their losingcontact with services and maximising the effectof any therapeutic intervention. The essentialelements of the programme include systematicassessment of both health and social care

needs, preparing a written care plan agreedbetween professional staff, the patient, andcarers; and allocating a keyworker, who isrequired to keep in close contact with thepatient, to monitor that the programme of careis delivered and to take immediate action if itis not. Implementation of the care programme

approach is ensured by regular review of thepatient's progress. This policy emphasises theimportance of ensuring continuity of care, withspecific guidelines on how to reduce the risk ofpatients "falling through the net" when theymove from one area to another.The NHS Management Executive's

guidance on discharging mentally disorderedpatients'9 includes invaluable advice on carry-

ing out an assessment of risk in potentiallyviolent patients and emphasises the need totake into account patients' past history, theirown self reporting, their behaviour and mentalstate, and any discrepancies between what isreported and what is observed. Effective riskassessment must identify relevant factorsinvolved in previous violent behaviour,including the personal and domestic circum-stances which might lead to a recurrence.

On 1 October 1994 the Department ofHealth introduced supervision registers formentally ill people.40 The criteria for inclusioninclude a significant risk of committing seriousviolence or suicide, or of severe self neglect, as

a result of severe and enduring mental illnessor severe personality disorder. The RoyalCollege of Psychiatrists has voiced concern

that the criteria are too broad, that additionalexpenditure would be involved, that arrange-ments for withdrawal from the register are

ambiguous, and that the register constitutes a

threat to the patient's civil liberties.4' Inaddition, the introduction of the register carriesthe risk of an increase in litigation since failureto include a patient who subsequently commitsa serious violent offence might be interpretedas negligent.42Although the register does not bring with it

specific additional resources, the new systemmight provide a suitable framework forcommunity support of potentially violent or

self destructive patients. It has been suggestedthat the register will damage therapeuticrelationships, but rather than feeling stig-matised, patients whose names are entered on

the register might actually feel more secure andreassured by the knowledge that at times ofcrisis their needs will be met by a rapidresponse by the multidisciplinary team. Thereis a useful emphasis on the prediction ofcircumstances which might lead to increasedrisk, such as ceasing to take treatment,.loss ofa supportive relationship, or loss of accommo-

dation. There is an obligation to conveneurgent multidisciplinary reassessments of apatient's status and an emphasis on teamworkand communication with the patient andbetween professionals and carers. (Staffperforming domiciliary visits to potentiallydangerous patients should be equipped withemergency call systems and trained in calmingand breakaway techniques. Solo visits shouldnot be made to an increasingly unstablepatient.43)

It might be thought that there is an unduereliance on prophylactic antipsychotic treat-ment but there is well documented evidencethat regular neuroleptics greatly reduce the riskof both relapse and violent incidents inmentally disordered offenders."The Buchanan inquiry concluded that place-

ment on the supervision register might havereduced the risk of Michael Buchanan'soffending by making clinicians more "riskaware" and therefore less likely to discharge apotentially dangerous patient after very shortperiods (two to three weeks after admissionunder section 37).18 However, given the lack ofsemisecure or intensively staffed accommo-dation in the community, the inquiry con-cluded that placement on the supervisionregister would not have completely removed allrisk.

Why do things go wrong?The concluding points below summarise thefactors contributing the clinical risk inpsychiatry.(1) Professional arrogance combined with a

reckless tolerance of deviance can lead tofailure by mental health professionals toheed reports by carers and members of thepublic about disturbed behaviour. 16 45

(2) Undue emphasis on the civil liberties ofpsychiatric patients at the expense of toler-ating grave suicidal risk and the danger ofviolent behaviour.

(3) Failure to implement the Mental HealthCode of Practice (paragraph 2.6) recom-mendation that compulsory admission isindicated to prevent deterioration and notjust when the patient is regarded as adanger to self or others.

(4) Belief that compulsory admission under themental health act cannot be implemented"until a patient actually does somethingdangerous." Formerly a widely held viewamong mental health professionals, sincepublication of the Ritchie report they arenow prepared to be somewhat more pro-active. Mental health professionals have toaccept that the practice of psychiatry isessentially a paternalistic activity and thatimposing treatment against a patient's willis justified when they believe that thepatient's life or health would be at risk ifcoercion were not applied and the con-dition were allowed to deteriorate.46

(5) A tendency, especially among approvedsocial workers, to take a "snapshot" crosssectional view of the potentially suicidal orviolent patient's mental state and behaviourand to ignore both previous episodes and

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any recent history of deterioration. Socialworkers routinely take a "longitudinal"view when assessing a case of alleged childabuse but, paradoxically, often insist onminimising the importance of both pastand recent history when making mentalhealth assessments.

(6) Failure to pass on information aboutpotential dangerousness to other pro-fessionals, such as hostel staff,"' for reasonsranging from inertia, inefficiency, oroverwork to a misguided overprotectiveview of the patient at the expense of thesafety of potential victims.

(7) Lack of resources, in terms of staff andinpatient facilities. There is a graveshortage of general psychiatric beds and ofbeds on closed wards. With an increasingawareness of the risk of both suicide andviolence within the community, there is agreater demand for admission but the bedstend to be occupied for longer because ofstaff reluctance to discharge potentiallydangerous or suicidal patients into thecommunity, where hostel accommodationand support services are inadequate. Theshortage of beds places psychiatric staff ina difficult position if they try to follow theDepartment of Health's guidance on thedischarge of mentally disordered people,"'which seeks to ensure that psychiatricpatients are discharged "only when and ifthey are ready to leave hospital" and, "anyrisk to the public or to patients themselvesis minimal and is managed effectively...

I thank Dr John Reed, Professor E Murphy, and 1)r JohnBradley for helpful advice and comments, and Mrs MarciaAndresvs for taping the manuscript.

Tan MW., McDonough XVJ. Risk management in pss chiatrs.P's'hiiat C/in North Ant 1990;13:135-47.

2 Humphreys MS, Johnstone EC, MacMillan JF, Taylor PJ.Dangerous behaviour preceding first admissions forschizophrenia. Br]PRsvcl/iatrv 1992;161:501-5.

3 Lindqvist P, Allebeck P. Schizophrenia and crime. Br 7Psychiatry 1990;157:345-50.

4 Nobel P, Rodger S. Violence by psychiatric inpatients. B 7Psythiao'y 1989;155:384-90.

5 Taylor PJ. Motives for offending among violent andpsychotic men. Brt Ptschiamrr 1985;147:491 -8.

6 Link B, Andrews J, Cullen F. The violent and illegalbehaviour of mental patients reconsidered. AnizertiCanSociOlogical Reci'ezi' 1 992;57:275 92.

7 Krakowski Jaeger J. Volavka J. Violence and psycho-pathology: a longitudinal study. (foniipt PYciiiatrv1988;29:174 8 1.

8 Addad M, Benezech M, Bourgeois M, Yesevage J. Criminalacts among schizophrenics in French mental hospitals.7NXtr'Mvciit Dis 1981;169:289-93.

Coccozza J, Steadman H. Failure of psychiatric predictionsof dangerousness. Ritgers Iau! Reviezcx" 1976;29:1084-1101.

10 Monahan J. Risk assessment of violence among the mentallydisordered: generating useful knowledge. Int 7 I ac'Psvchiiatr 1988;11:249-57.

1 1 Monahan J, Steadman HJ. Toward a rejuvenation of riskassessment research. In: Monahan J, Steadman HJ, eds.Violence and ninetal ditSordert Chicago: University ofChicago Press, 1994.

12 Steering Committee of the Confidential Enquiry intoHomicides and Suicides by Mentallh Ill People. Aptc'iln1iinatll2 report()i hoIinicide. London, 1994.

13 Scott PD. Assessing dangerousness in criminals. Br 7Ptt'thiatr' 1977;131:127-42.

14 Gunn J. Dangerousness. In: GunnJ, Taylor PJ, eds. Fotwt'ticpsvchiiatit. Oxford: Butterworth-Heinemann. 1993:624-45.

15 'Walker Z, Seifert R. Violent incidents in a psychiatricintensive care unit. Br7Psstliiatry 1994;164:820--8.

16 Ritchie JH, Dick D, Lingham R. Report of tde ioiqutirv\ iltt'l/i Care anld treattntnlit of (C/isttop/ie Chont. London:HMSO, 1994.

17 Lidz CXW, Mulvev EP, Gardner WX The accuracy ofpredictions of violence to others. 7A.I.-l1 1993:269:10(07 11.

18 Heginbotham C. Report tlt thi Itideplndelt Pant!l ofhItiqitnste-alnining case (of1liiiael Bucaliana. Lcondon: North X'estLondon NHS Mental Health Trust, 1994,

19 NHS Management Executise. Giodanlt oil tiic i/t't/tatct osnntla/tall/ disordered people and theni coinuning tLite Inl tilttoti0ininoiitv. Leeds: NHSME, 1994. (HSG (94) (27).)

20 Revised C(/t of Ptatratic .X1clttal Health ACt 1993. AUSInt1993.

21 S anson J\V, Holzer CE, Ganju VK, Jono RT. X'iolcnce andpsychiatric disorder in the community: evidence from theepidemiological catchment area surveys. Hp('otnnpootPsvchiat'v 1990;41:761-70.

22 Wv Egdell and others (1988) 2 WLR 689.23 Brahams D. Psychiatrist's dutv of confidentiality. Latnttt

1988;ii: 1503-4.24 Roval College of Psychiatrists. Good niediCa/ pIaLttict anld thi

ti/trcate qfporte'nial/v z'iole/n rvt 'idnerab/cbl' patients dischargedftitni in1patitie ptv/chiat`Ict'ttf'nitn)l1t. London: Royal Collegeof Psychiatrists, 1991. (Council report CR 1 2.

25 .Xorgan HG, Williams R. Suicide prevewmis.- thc challci,,t(onfronttd. London: HMSO, 1994.

26 Hawiton K. Bs their own young hand. B.ll7 1992304:1000.

27 Nordentoft Xl, Breun L, Monk LK, Nordestgaard AG,et al. High mortality by natural and unnatural causes: a tensear follow up study of patients admitted to a poisoningcentre after suicide attempts. BAI7 1993;306:1637 41.

28 King E. Suicide in the mentally ill: an epidemiologicalsample and implications for clinicians. Bt 7 Pttchtiiattt1994;165:658-63.

29 Drake RE, Gates C, Cotton PG, et al. Suicide amongschizophrenics: sho is at risk? I7 .c\'r .Xc/tt Iis 1984;172:613-7.

30 Hawton K. Assessment of suicide risk. Bt 7 Pivtciltatt1987IS0: 145-53.

31 Goldstein RB, Black Tw, Nasarallah A, XWinokur G. Theprediction of suicide. Ardh G.t Ptvct/iatt\v 1991;48:418-22.

32 Beck AT, Resink HLP, Lettieri D, eds. Tit prtedictiol ofsiicidc. Bowie, Maryland: Charles Press, 1974.

33 Anon. Selective serotonin reuptake inhibitors ttordepression? Drig f'fui Bl// 1993;31:57 8.

34 X'atts D, Morgan HG. Malignant alienation. Bt J~itY1tiltlat\t1994;164:11-5.

35 Morgan HG, Priest P. Suicide and other unexpected deathsamong psychiatric patients. BAM7 199 1; 1 8:368 74.

36 Goldcare .XI, Seagrott V, Hawton K. Suicide after dischargefrom psychiatric care. Lanicet 1993;342:283--6.

37 Amchin J, WXettslein R.,4, Roth LH. Suicide, ethiti atid tittI at'. In: Blumenthal SJ, Kupfer DJ, eds. Suicide ovte tihtIlfi tycle. Washington, DC: American Psvchiatric Press,1990:637-63.

38 Cantor CH, McDermott PM. Suicide litigation: anAustralian survey. Aost N Z7 Psvcihiatnr 1994;28:426 3(0.

39 Department of Health Health Circular (90) (23)/LocalAuthorities Social Sernices letter (9() (11). I ondon:DoH, 1990.

40 NHS Management Executive. Ilittdtuctinttt Of suptrtt ittlegisters ]ttt neienta//y ill people frtutut I Aptil /994. Leeds:NHSME, 1994. (HSG (94) (5).)

41 Caldicott F. Supervision registers. The college's response,PIx'ciiiatri B/lletiti 1994;18:385-6.

42 Harrison G, Bartlett P. Supervision registers for mentally illpeople. BM7 1994;309:551-2.

43 Tavlor P. Forensic psychiatry. In: Paykel ES, Jenkins R, eds.Pt'tl'1titlOpt itl ps5ychiatt'y. London: Gaskell, 1994:157 7 3.

44 Wessley SC, Castle D, Douglas AJ, Taylor PJ. The criminalcareers of incident cases of schizophrenia. P'.chiit .11ld1994;24:483-502.

45 National Schizophrenia Fellowship 1995. " he SilentPartners" by Gary Hogman.

46 Lipsedge M. Choices in psvchiatry. In: Dunstan GR,Sinebourne EA, eds. Doctors' decisiltOts: et/iical conflicts ittmedical practiCe. Oxford: Oxford Universitn Press, 1989:145-53.

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