Psychiatric Bulletin (2001) 25: 250-252. doi: 10.1192/pb.25.7.250
© 2001 The Royal College of Psychiatrists
Psychiatric Bulletin (2001) 25: 250-252
© 2001 The Royal College of Psychiatrists
Improving the assessment of risk of violence
a clinical audit of case note documentation
Michael Campbell, Specialist Registrar in Adult psychiatry
Tolworth Hospital, Red Lion Road, Surbiton, Surrey KT6 7QU
Robert Chaplin, Consultant in General Adult Psychiatry
South West London & St George's Mental Health NHS Trust, 61
Glenburnie Road, London SW17 7DJ
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Abstract
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AIMS AND METHODS
To improve the rate of documentation of risk in new referrals to a
community mental health team. A retrospective audit of 46 case notes was
followed by a training session on risk of violence. The following 50 case
notes were studied for changes in risk assessment.
RESULTS
Prior to the study there were very low rates of documentation of risk of
violence. Significant improvements were made in 45% of the items in the
history and mental state although not in the formulation of a risk assessment
statement.
CLINICAL IMPLICATIONS
It is possible to improve the risk of violence documentation with no extra
time, resources or paperwork and with true multi-disciplinary involvement.
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Introduction
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Assessment and management of risk is now considered an essential component
of good psychiatric practice. The National Service Framework for Mental
Health (Department of Health,
1999) states that all mental health service users on the Care
Programme Approach should receive care that optimises engagement, anticipates
or prevents a crisis and reduces risk. The Report of the Confidential
Enquiry into Homicides and Suicides by Mentally Ill People
(Steering Committee of the Confidential
Inquiry into Homicides and Suicides by Mentally Ill People, 1996) noted in cases of homicide that previous convictions were frequently not
documented in the mental health case notes. Vinestock
(1996) wrote that the
information gathering process, the maintenance of good medical records and
good communication form the basis of the management of the risk of violence.
With incomplete or inaccurate information the assessment is likely to be
flawed. The Clunis Report (Ritchie,
1994) recommends increased research and audit into risk of
violence; however we were unable to find any published audit in this area.
Objectives
Our objectives were to:
- assess current ability of team members to record factors relevant to risk
of violence in the history and mental state examination of new referrals
- train all staff in the assessment of risk of violence
- reassess the team's performance in the 3 months immediately following the
training session.
Approved standards
The audit form was based on the Assessment and Clinical Management of
Risk of Harm to Other People (Royal
College of Psychiatrists, 1996). This council report contains
guidance in the form of a list of important risk factors in the history,
mental state and environment (see Table
1). In conclusion, it is suggested that a formulation should be
made based on these factors and others in the history.
In addition, a number of other items were included on the audit form, such
as whether collateral information was available, a history of violent
thoughts, attitude to any violent incidents and a personality assessment,
including nature of fantasies and interests and presence of impulsiveness
(Vinestock, 1996).
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The study
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The study was carried out by a community mental health team (CMHT), which
serves the general adult population of 18-75-year-olds in a multicultural
inner-city area of South-West London. The team has a multi-disciplinary
composition and adopts a flexible approach to the assessment of new referrals.
A form was developed and agreed by team members to act as a guideline for
history taking and mental state examination.
Initially we completed a baseline, retrospective audit of the assessments
of 46 consecutive referrals to the team. The College standard for taking a
history of risk was taught at an hour-long meeting. This was incorporated into
the regular meeting time of the team and was led by M.C. No additional
resources were necessary. All team members, including social workers
(non-trust employees), attended and participated in data collection.
Following the training, a further 50 consecutive assessments were audited
in a similar way. Chi-squared analyses were used to measure significant
differences in the items included on the form. Results have been fed back to
the team and a continuous cycle of audit will be maintained.
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Findings
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The recording of items in the history, mental state examination and risk
assessment statement is presented in Table
1. There was an increase in recording in 17 of the 20 items
relating to the history and mental state, of which nine (45%) reached
statistical significance. Significant improvement occurred in the recording of
forensic history, violent thoughts, violent actions, alcohol and substance
misuse history and self-harm behaviour following the intervention. Relevant
items in the mental state examination were recorded infrequently both at
baseline and follow-up. However, there were improvements in recorded frequency
of all items, in particular violent and homicidal thoughts. The recording of a
risk assessment statement (e.g. low, medium and high) and risk management plan
did not increase following the teaching, remaining at a low level.
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Comment
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The most obvious finding was the neglect of attention to risk of violence
in the initial sample assessed. These scores were considered worryingly low by
the team. However non-urgent, general practitioner referrals are probably at
low risk of harm to others compared to inpatient or CMHT case-load cohorts.
Many of the patients assessed had already been discharged back to primary care
at the time of the audit. However, presumption of a low-risk of violence may
lead to the ‘collusive denial’ described by Bowden
(1997). A percentage of these
patients required ongoing treatment and/or had serious mental illness and may
not have had an adequate risk assessment on their initial appointment. Alcohol
and drug misuse are strongly associated with psychiatric illness and risk of
violence, but were recorded in only 53% and 40% of assessments, respectively.
Omission of this part of the history is probably best explained by the lack of
a systematic approach of the team to assessment.
Our findings at baseline are supported by Sanders et al
(2000), who found that clinical
enquiry regarding recent violent thoughts and behaviour and ongoing violent
thoughts was rarely recorded in the case notes of psychiatric in-patient
admissions. Aggressive ideation regarding damage to property and interpersonal
violence was recorded in 2.6% and 13.2% of cases, respectively.
The audit has, however, demonstrated three important points. First, it is
possible to make significant improvements in the recording of the relevant
aspects of history taking with a minimal intervention and without the need of
additional finance or team time. Second, the improvements were gained at a
cost of no extra paperwork. And finally, the audit was prioritised, designed
and carried out in a true multidisciplinary setting. The main goal of risk
assessment audit, to demonstrate an effect on the actual incidence of violent
incidents, needs to be studied in further research.
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Recommendations
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- Taking a full risk of violence history is necessary to manage risk
appropriately. Risk assessment forms cannot be completed if the relevant
information is not available.
- CMHTs should regularly audit the quality of their notes with regard to
assessment of risk of violence.
- A structured approach to assessment will improve the comprehensiveness of
risk assessment.
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Acknowledgments
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We would like to acknowledge the staff of Tooting/Furzedown CMHT and Anna
Gotte and Maria Iliopoulou of Springfield University Hospital Audit
Department.
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References
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BOWDEN, P. (1997) Risk management: from patient to
client. Psychiatric Bulletin,
21, 36-38.[Free Full Text]
DEPARTMENT OF HEALTH (1999) The National
Service Framework for Mental Health. London: Department of
Health.
RITCHIE, J. (1994) Report of the Inquiry
into the Care and Treatment of Christopher Clunis. London:
HMSO.
ROYAL COLLEGE OF PSYCHIATRISTS (1996)
Assessment and Clinical Management of Risk of Harm to Other
People. Council Report CR53. London: Royal College of
Psychiatrists.
SANDERS, J., MILNE, S., BROWN, P., et al
(2000) Assessment of aggression in psychiatric admissions:
semistructured interview and case note survey. British Medical
Journal, 320,
1112.[Free Full Text]
STEERING COMMITTEE OF THE CONFIDENTIAL INQUIRY INTO HOMICIDES AND
SUICIDES BY MENTALLY ILL PEOPLE (1996) Report of the
Confidential Enquiry into Homicides and Suicides. London: Royal
College of Psychiatrists.
VINESTOCK, M. (1996) Risk assessment: "A word to
the wise?" Advances in Psychiatric Treatment,
2, 3-10.
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Abstract
Introduction
