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Improving Mental Health Improving Mental Health

HUMAN RIGHTS JOINT RISK HUMAN RIGHTS JOINT RISK

ASSESSMENT AND ASSESSMENT AND
MANAGEMENT PLAN MANAGEMENT PLAN
(HR-JRAMP) (HR-JRAMP)

A HUMAN RIGHTS BASED APPROACH A HUMAN RIGHTS BASED APPROACH

 Authors Authors
Dr. Beth Greenhill Dr. Beth Greenhill
Richard Whitehead Richard Whitehead
Dr. Melonie Grannell Dr. Melonie Grannell
Ged Carney Ged Carney
Dr. Jim Williams Dr. Jim Williams
Dr. Alex Cookson Dr. Alex Cookson
Dr. Frank Chapman Dr. Frank Chapman
Emma Ward Emma Ward
Amy Lee Amy Lee

Also available:- Also available:-

1) Keeping Me Safe and Well Risk Assessment 1) Keeping Me Safe and Well Risk Assessment
2) Human Rights Benchmarking Tool 2) Human Rights Benchmarking Tool
3) Speaking Up for Myself Group 3) Speaking Up for Myself Group
4) Standing Up for My Rights Booklet 4) Standing Up for My Rights Booklet
5) Accessible Information Pack 5) Accessible Information Pack

This manual is a Mersey Care NHS Trust publication and should not be reproduced without the This manual is a Mersey Care NHS Trust publication and should not be reproduced without the
authorsʼ permission. The manual can however be printed and used clinically as part of a authorsʼ permission. The manual can however be printed and used clinically as part of a
validation process. If you wish to take part in our validation project please contact the authors validation process. If you wish to take part in our validation project please contact the authors
below. The validation process will contribute to any further revisions to the document. below. The validation process will contribute to any further revisions to the document.

For further information and training opportunities contact:- For further information and training opportunities contact:-

[email protected] [email protected]
[email protected] [email protected]

© <2008> Mersey Care NHS Trust. All rights reserved. This material may be copied for © <2008> Mersey Care NHS Trust. All rights reserved. This material may be copied for
use within NHS organisations only on the understanding that Mersey Care NHS Trust is use within NHS organisations only on the understanding that Mersey Care NHS Trust is
acknowledged as the developer of the material on all copies and that this copyright statement acknowledged as the developer of the material on all copies and that this copyright statement
is retained. is retained.

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Contents Contents

Page Page
Authors’ Preface 4 Authors’ Preface 4

1 A Human Rights Based Approach to Complex Care & Risk Management 6 1 A Human Rights Based Approach to Complex Care & Risk Management 6
1.1 What is a Human Rights Based Approach? 6 1.1 What is a Human Rights Based Approach? 6
1.2 Human Rights Act Summary 7 1.2 Human Rights Act Summary 7
1.3 Human Rights Aims & Principles in Complex Care Pathways 8 1.3 Human Rights Aims & Principles in Complex Care Pathways 8
1.4 Human Rights Process in Complex Care Pathways 10 1.4 Human Rights Process in Complex Care Pathways 10
1.5 Proportionality 11 1.5 Proportionality 11
1.6 Proactive and Reactive Strategies 13 1.6 Proactive and Reactive Strategies 13
1.7 Balanced Decision Making 14 1.7 Balanced Decision Making 14
1.8 Policy Summary 15 1.8 Policy Summary 15

2 Research and Practice 16 2 Research and Practice 16

2.1 Introduction 16 2.1 Introduction 16
2.2 Current Difficulties 16 2.2 Current Difficulties 16
2.3 Clinical Versus Actuarial Judgements 17 2.3 Clinical Versus Actuarial Judgements 17
2.4 What’s Important in Risk Assessment? 18 2.4 What’s Important in Risk Assessment? 18
2.5 The Service Context of Assessment 24 2.5 The Service Context of Assessment 24
2.6 The Importance of Life Events 25 2.6 The Importance of Life Events 25
2.7 Actuarial Characteristics of People with Learning Disabilities who Offend 26 2.7 Actuarial Characteristics of People with Learning Disabilities who Offend 26
2.8 Actuarial / Background Factors Related to Violence 28 2.8 Actuarial / Background Factors Related to Violence 28
2.9 Actuarial / Research Data on Suicide 29 2.9 Actuarial / Research Data on Suicide 29
2.10 Clinical Variables 30 2.10 Clinical Variables 30

3 Procedure 32 3 Procedure 32
3.1 Introduction 32 3.1 Introduction 32
3.2 Joint Risk Assessment 32 3.2 Joint Risk Assessment 32
3.3 Applying to Complete a HR-JRAMP 32 3.3 Applying to Complete a HR-JRAMP 32
3.4 Time Allowed for Completion of Assessment/ Plan 33 3.4 Time Allowed for Completion of Assessment/ Plan 33
3.5 Circulation of Completed Assessment / Plan 33 3.5 Circulation of Completed Assessment / Plan 33
3.6 Roles of Assessors 33 3.6 Roles of Assessors 33

4 Guidance Notes 35 4 Guidance Notes 35

4.0 Introduction 35 4.0 Introduction 35
4.1 About Me 35 4.1 About Me 35
4.2 Who’s Filling this in? (Assessor) 35 4.2 Who’s Filling this in? (Assessor) 35
4.3 Where Did This Information Come From? 35 4.3 Where Did This Information Come From? 35
4.4 Why is the Assessment Being Carried Out Now? 36 4.4 Why is the Assessment Being Carried Out Now? 36
4.5 When Will We Look At My Risk Plan Again? 36 4.5 When Will We Look At My Risk Plan Again? 36
4.6 My Wishes 37 4.6 My Wishes 37
4.7 About My Life (Critical Event History) 37 4.7 About My Life (Critical Event History) 37
4.8 Things Me Or Other People Are Worried About (Risk Factors) 39 4.8 Things Me Or Other People Are Worried About (Risk Factors) 39
4.8.a Historical Factors 39 4.8.a Historical Factors 39
4.8.b Clinical Factors 40 4.8.b Clinical Factors 40
4.8.c Social Factors 42 4.8.c Social Factors 42
4.8.d Actuarial Factors 44 4.8.d Actuarial Factors 44
4.9 What Does All This Mean? (Analysis and Summary) 47 4.9 What Does All This Mean? (Analysis and Summary) 47
4.10 Looking At My Risks, What Options Have I Got? 48 4.10 Looking At My Risks, What Options Have I Got? 48
4.11 Where’s the Best Place for me to Live? 49 4.11 Where’s the Best Place for me to Live? 49
4.12 What Legal Documents Are Important In My Risk Plan? 49 4.12 What Legal Documents Are Important In My Risk Plan? 49
4.13 My Risk Management Plan 50 4.13 My Risk Management Plan 50
4.14 Will The Risk Decision Help Me? (Benefits of Risk Decision To The Service User) 52 4.14 Will The Risk Decision Help Me? (Benefits of Risk Decision To The Service User) 52
4.15 Benchmarking, Monitoring and Review: 53 4.15 Benchmarking, Monitoring and Review: 53
4.16 What Do I Think Of My Plan? 54 4.16 What Do I Think Of My Plan? 54

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4.17 What Do The People Who Care For Me Think Of My Plan? 54 4.17 What Do The People Who Care For Me Think Of My Plan? 54
4.18 What Do My Staff Think Of My Plan 54 4.18 What Do My Staff Think Of My Plan 54
4.19 Who Is Allowed To See My Plan? 54 4.19 Who Is Allowed To See My Plan? 54
4.20 Signatures of Assessors 55 4.20 Signatures of Assessors 55
4.21 Plan Approvers / Recommendations. 55 4.21 Plan Approvers / Recommendations. 55

5 HR-JRAMP Form 56 5 HR-JRAMP Form 56

6 References & Further Reading 70 6 References & Further Reading 70

7 Appendices 78 7 Appendices 78
7.1 Appendix 1 – Keep Me Safe and Well Manual 7.1 Appendix 1 – Keep Me Safe and Well Manual
7.2 Appendix 2 – Human Rights Strategies Flowchart 7.2 Appendix 2 – Human Rights Strategies Flowchart
7.3 Appendix 3 – Human Rights Decision Making Form 7.3 Appendix 3 – Human Rights Decision Making Form

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Authors’ Preface Authors’ Preface

“We are disappointed that, at the start of the 21st century, almost ten years after “We are disappointed that, at the start of the 21st century, almost ten years after
the introduction of the Human Rights Act…the evidence convinces us that we the introduction of the Human Rights Act…the evidence convinces us that we
need to emphasise that adults with learning disabilities have the need to emphasise that adults with learning disabilities have the
same human rights as everyone else” same human rights as everyone else”

(Joint Committee on Human Rights, 2008) (Joint Committee on Human Rights, 2008)

This quotation from ‘A life like any other?’ gives some indication of just how far away the realities of This quotation from ‘A life like any other?’ gives some indication of just how far away the realities of
many services for people with learning disabilities are from lawful, let alone aspirational, practice. many services for people with learning disabilities are from lawful, let alone aspirational, practice.
Making human rights real for people with complex needs and learning disabilities might seem to be Making human rights real for people with complex needs and learning disabilities might seem to be
starting with the ‘hard part’ but is perhaps also about starting where the need for change is greatest starting with the ‘hard part’ but is perhaps also about starting where the need for change is greatest
(Bush, 2007). The human rights paradigm provides an overarching framework, a robust process, and (Bush, 2007). The human rights paradigm provides an overarching framework, a robust process, and
clarifies the concepts needed for positive risk taking. This, it is hoped, will ensure balanced decision clarifies the concepts needed for positive risk taking. This, it is hoped, will ensure balanced decision
making and proportionality regarding human rights, risk assessment and risk management plans. These making and proportionality regarding human rights, risk assessment and risk management plans. These
guidance notes attempt to integrate human rights for people with learning disabilities with the complex guidance notes attempt to integrate human rights for people with learning disabilities with the complex
care framework outlined by the Joint Risk Assessment and Management Plan (J-RAMP; Williams et al. care framework outlined by the Joint Risk Assessment and Management Plan (J-RAMP; Williams et al.
1999 unpublished). 1999 unpublished).

The J-RAMP was first developed in 1999 by Jim Williams, Chris Ferns and Tim Riding. The primary aim The J-RAMP was first developed in 1999 by Jim Williams, Chris Ferns and Tim Riding. The primary aim
of the document was to set out how Social Workers and Clinicians should go about a formal joint of the document was to set out how Social Workers and Clinicians should go about a formal joint
assessment of the risks associated with the relatively small group of adults with a learning disability who assessment of the risks associated with the relatively small group of adults with a learning disability who
present a likely and serious risk of harm to either themselves or others. The J-RAMP was based on present a likely and serious risk of harm to either themselves or others. The J-RAMP was based on
recognised research and good practice in this field (Webster and Eaves, 1994; Pollock et al., 1990; Prin, recognised research and good practice in this field (Webster and Eaves, 1994; Pollock et al., 1990; Prin,
1996; Turner, 1998). In doing this, a numerical quantification of risk was adopted whilst avoiding the 1996; Turner, 1998). In doing this, a numerical quantification of risk was adopted whilst avoiding the
‘figure to trigger’ approach of some assessment schemes. ‘figure to trigger’ approach of some assessment schemes.

The J-RAMP has been used many times over the years and has proved to be a useful tool. However, a The J-RAMP has been used many times over the years and has proved to be a useful tool. However, a
number of difficulties have arisen. One of the major problems identified has been the use of the J- number of difficulties have arisen. One of the major problems identified has been the use of the J-
RAMP in isolation from other person-centred assessments. This has led to staff and agencies providing RAMP in isolation from other person-centred assessments. This has led to staff and agencies providing
direct support to Service Users becoming increasingly preoccupied with risk issues, without adopting a direct support to Service Users becoming increasingly preoccupied with risk issues, without adopting a
balanced, holistic, approach to interventions and support. balanced, holistic, approach to interventions and support.

The Human Rights in Healthcare project seemed to offer a useful paradigm, allowing us to resolve some The Human Rights in Healthcare project seemed to offer a useful paradigm, allowing us to resolve some
of these difficulties. The Human Rights in Healthcare project is a joint initiative between the of these difficulties. The Human Rights in Healthcare project is a joint initiative between the
Department of Health (DH) and the British Institute of Human Rights (BIHR), aiming to encourage NHS Department of Health (DH) and the British Institute of Human Rights (BIHR), aiming to encourage NHS
Trusts to adopt and develop their use of an explicitly ‘Human Rights Based Approach’ in their practice. Trusts to adopt and develop their use of an explicitly ‘Human Rights Based Approach’ in their practice.
Rebuild Clinical Business Unit within Mersey Care NHS Trust was offered the opportunity to participate Rebuild Clinical Business Unit within Mersey Care NHS Trust was offered the opportunity to participate
as one of five pilot sites in this project. One of the areas we chose to focus on was on integrating as one of five pilot sites in this project. One of the areas we chose to focus on was on integrating
human rights with our risk assessment processes and tools. Our previous approach to supporting people human rights with our risk assessment processes and tools. Our previous approach to supporting people
with learning disabilities who have difficult or challenging behaviours aimed to integrate principles of with learning disabilities who have difficult or challenging behaviours aimed to integrate principles of
person-centred care with risk assessment and management frameworks. Within these frameworks person-centred care with risk assessment and management frameworks. Within these frameworks
there was little explicit reference to Service User’s human rights. there was little explicit reference to Service User’s human rights.

In this document we are suggesting a different approach. We hope to shift our focus and understanding In this document we are suggesting a different approach. We hope to shift our focus and understanding
so that the key outcome is an assessment and management framework which balances the human so that the key outcome is an assessment and management framework which balances the human
rights of Service Users, their supporters and their communities. It is through this process of balancing rights of Service Users, their supporters and their communities. It is through this process of balancing
rights that risk too can meaningfully be balanced. rights that risk too can meaningfully be balanced.

Put simply, we feel that we can positively manage and balance risk, if we can support Service Users, Put simply, we feel that we can positively manage and balance risk, if we can support Service Users,
their carers and their communities to access and balance their rights. their carers and their communities to access and balance their rights.

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A reflective practice approach has also been incorporated into the revised Human Rights Joint Risk A reflective practice approach has also been incorporated into the revised Human Rights Joint Risk
Assessment and Management Plan (HR-JRAMP). It has been evident when reading J-RAMPs that a Assessment and Management Plan (HR-JRAMP). It has been evident when reading J-RAMPs that a
person’s professional background or beliefs have influenced the way it has been written. This can have person’s professional background or beliefs have influenced the way it has been written. This can have
quite serious consequences as the use of emotive language and an unbalanced approach can influence quite serious consequences as the use of emotive language and an unbalanced approach can influence
whether a person is considered appropriate for living in the community. whether a person is considered appropriate for living in the community.

The HR-JRAMP document has been comprehensively revised in line with ‘Valuing People Now’ (DH, The HR-JRAMP document has been comprehensively revised in line with ‘Valuing People Now’ (DH,
2009a), current legislation, (Mental Capacity Act, 2005; Mental Health Act, 2007; Deprivation of Liberty 2009a), current legislation, (Mental Capacity Act, 2005; Mental Health Act, 2007; Deprivation of Liberty
Safeguards, 2009) and recent research evidence. Safeguards, 2009) and recent research evidence.

Finally, human rights principles are now explicit in not only the NHS constitution (DH, 2009b) but also in Finally, human rights principles are now explicit in not only the NHS constitution (DH, 2009b) but also in
informing the approach of the Care Quality Commission (Care Quality Commission, 2009). We believe informing the approach of the Care Quality Commission (Care Quality Commission, 2009). We believe
that our emphasis on service user inclusion, which forms such an essential part of a human rights based that our emphasis on service user inclusion, which forms such an essential part of a human rights based
approach to healthcare, also fits well with policy drivers for service user involvement (Department of approach to healthcare, also fits well with policy drivers for service user involvement (Department of
Health 2008, 2008b, 2009b) and the recent White Paper, “Equity and Excellence: Liberating the NHS” Health 2008, 2008b, 2009b) and the recent White Paper, “Equity and Excellence: Liberating the NHS”
(Department of Health, 2010). (Department of Health, 2010).

Authors of HR-JRAMP and Revisions (2008 and 2011) Authors of HR-JRAMP and Revisions (2008 and 2011)
Dr. Beth Greenhill (Clinical Psychologist/Human Rights Lead, Rebuild Clinical Business Unit) Dr. Beth Greenhill (Clinical Psychologist/Human Rights Lead, Rebuild Clinical Business Unit)
Richard Whitehead (Head of Clinical Psychology, Rebuild Clinical Business Unit) Richard Whitehead (Head of Clinical Psychology, Rebuild Clinical Business Unit)
Dr. Melonie Grannell (Clinical Psychologist) Dr. Melonie Grannell (Clinical Psychologist)
Ged Carney (Community Nurse, Rebuild Clinical Business Unit) Ged Carney (Community Nurse, Rebuild Clinical Business Unit)
Dr. Jim Williams (Clinical Director, Doctoral Training Programme in Clinical Psychology, University of Dr. Jim Williams (Clinical Director, Doctoral Training Programme in Clinical Psychology, University of
Liverpool) Liverpool)
Dr. Alex Cookson (Clinical Psychologist, Rebuild Clinical Business Unit) Dr. Alex Cookson (Clinical Psychologist, Rebuild Clinical Business Unit)
Dr. Frank Chapman (Clinical Psychologist, Rebuild Clinical Business Unit) Dr. Frank Chapman (Clinical Psychologist, Rebuild Clinical Business Unit)
Emma Ward (Assistant Clinical Psychologist, Rebuild Clinical Business Unit) Emma Ward (Assistant Clinical Psychologist, Rebuild Clinical Business Unit)
Amy Lee (Assistant Clinical Psychologist, Rebuild Clinical Business Unit) Amy Lee (Assistant Clinical Psychologist, Rebuild Clinical Business Unit)

Authors of J-RAMP (1999) Authors of J-RAMP (1999)

Jim Williams (Clinical Psychologist, Learning Disability Directorate) Jim Williams (Clinical Psychologist, Learning Disability Directorate)
Chris Ferns (Learning Disability Social Work Team Manager, Social Services) Chris Ferns (Learning Disability Social Work Team Manager, Social Services)
Tim Riding (Specialist Nurse Consultant, Learning Disability Directorate) Tim Riding (Specialist Nurse Consultant, Learning Disability Directorate)

Numerous people have been involved with the revision of the text so a big ‘thank you’ to: Lucy Numerous people have been involved with the revision of the text so a big ‘thank you’ to: Lucy
Matthews and Hannah Clayton from the British Institute of Human Rights, Lindsey Dyer (Director, Matthews and Hannah Clayton from the British Institute of Human Rights, Lindsey Dyer (Director,
Service Users and Carers, Mersey Care NHS Trust), Kulvinder Kaur, Michelle Montrose (Liverpool PCT), Service Users and Carers, Mersey Care NHS Trust), Kulvinder Kaur, Michelle Montrose (Liverpool PCT),
Dr. Janet Shelmerdine, Dr. Julie Blakely, Bill Hiley, ‘The Liverpool Team’ and “People First, Liverpool”. Dr. Janet Shelmerdine, Dr. Julie Blakely, Bill Hiley, ‘The Liverpool Team’ and “People First, Liverpool”.

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1 A Human Rights Based Approach to Complex Care & Risk Management 1 A Human Rights Based Approach to Complex Care & Risk Management

“He who forgets his history is destined to repeat it” “He who forgets his history is destined to repeat it”
(George Santayana) (George Santayana)

On a plaque in block four of the Auschwitz barracks, George Santayana’s words act as a powerful On a plaque in block four of the Auschwitz barracks, George Santayana’s words act as a powerful
reminder that memory of our social, cultural and personal journeys is vital to our ability to progress and reminder that memory of our social, cultural and personal journeys is vital to our ability to progress and
transcend our history; for Service Users with complex needs, understanding a person’s journey is the transcend our history; for Service Users with complex needs, understanding a person’s journey is the
key to potential development and growth. The Joint Risk Assessment and Management Plan (HR- key to potential development and growth. The Joint Risk Assessment and Management Plan (HR-
JRAMP) attempts to understand the risky behaviours of People with a Learning Disability in the context JRAMP) attempts to understand the risky behaviours of People with a Learning Disability in the context
of their personal history. of their personal history.

The desire to effect change through understanding our histories, but on an international scale, also The desire to effect change through understanding our histories, but on an international scale, also
precipitated the first attempts to enshrine in international law rights for all. The United Nations precipitated the first attempts to enshrine in international law rights for all. The United Nations
Convention on Human Rights (‘the UN Convention’) formed part of the international community’s Convention on Human Rights (‘the UN Convention’) formed part of the international community’s
response to the horror of the Holocaust. The rights listed in the UN Convention were adopted in 1950 by response to the horror of the Holocaust. The rights listed in the UN Convention were adopted in 1950 by
the Council of Europe and have been brought into UK law by the Human Rights Act (1998). the Council of Europe and have been brought into UK law by the Human Rights Act (1998).

Services for people with learning disabilities have long been concerned with the underlying values Services for people with learning disabilities have long been concerned with the underlying values
central to our practice (O’Brien, 1987; Wolfensberger, 1972). The core human rights principles central to our practice (O’Brien, 1987; Wolfensberger, 1972). The core human rights principles
underpinning the Human Rights Act, those of Fairness, Respect, Equality, Dignity and Autonomy underpinning the Human Rights Act, those of Fairness, Respect, Equality, Dignity and Autonomy
(FREDA) give these values a powerful contemporary expression, meaningful in the day-to-day lives of (FREDA) give these values a powerful contemporary expression, meaningful in the day-to-day lives of
the people we serve, and in our own lives. the people we serve, and in our own lives.

This introductory section presents an overview of a ‘human rights based approach’ (HRBA) to complex This introductory section presents an overview of a ‘human rights based approach’ (HRBA) to complex
care. It explains how the FREDA human rights principles apply to risk assessment and management care. It explains how the FREDA human rights principles apply to risk assessment and management
planning. It also explains how human rights processes apply in ensuring that our risk management planning. It also explains how human rights processes apply in ensuring that our risk management
practice is lawful, balances the interests of all those involved in a package of care and is proportionate in practice is lawful, balances the interests of all those involved in a package of care and is proportionate in
terms of the risk management strategies we advise. terms of the risk management strategies we advise.

1.1 What is a Human Rights Based Approach (HRBA)? 1.1 What is a Human Rights Based Approach (HRBA)?

Key to making human rights real in risk management is a ‘human rights based approach’ built on the Key to making human rights real in risk management is a ‘human rights based approach’ built on the
following: following:

• Putting human rights & human rights principles at the heart of policy and planning. • Putting human rights & human rights principles at the heart of policy and planning.
• Empowering staff and Service Users with the knowledge, skills and the organisational • Empowering staff and Service Users with the knowledge, skills and the organisational
leadership and commitment to achieve human rights based approaches. leadership and commitment to achieve human rights based approaches.
• Enabling meaningful involvement & participation of all key people. • Enabling meaningful involvement & participation of all key people.
• Ensuring clear accountability. • Ensuring clear accountability.
• Non-discrimination & attention to vulnerable groups. • Non-discrimination & attention to vulnerable groups.

(Human Rights in Health Care, DH & BIHR, 2007) (Human Rights in Health Care, DH & BIHR, 2007)

In essence, employing a HRBA approach promotes service user involvement (DH 2008a; 2008b; 2009b), In essence, employing a HRBA approach promotes service user involvement (DH 2008a; 2008b; 2009b),
encourages personal responsibility and upholds respects for the rights of others; whilst accounting for encourages personal responsibility and upholds respects for the rights of others; whilst accounting for
issues of equality and diversity. issues of equality and diversity.

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1.2 Human Rights Act Summary 1.2 Human Rights Act Summary

The Human Rights Act (1998) incorporated into UK law most of the rights detailed in the European The Human Rights Act (1998) incorporated into UK law most of the rights detailed in the European
Convention on Human Rights. The European Convention is the main source of our legal human rights Convention on Human Rights. The European Convention is the main source of our legal human rights
protection in the UK. Although its focus is on civil and political rights, because the rights it contains are protection in the UK. Although its focus is on civil and political rights, because the rights it contains are
defined broadly, it has strong significance within the context of health services. defined broadly, it has strong significance within the context of health services.

The Human Rights Act imposes a direct legal obligation on NHS Trusts to ensure that we respect The Human Rights Act imposes a direct legal obligation on NHS Trusts to ensure that we respect
European Convention rights in all we do. The articles of the Human Rights Act are described below. European Convention rights in all we do. The articles of the Human Rights Act are described below.

The rights contained in the Human Rights Act are: The rights contained in the Human Rights Act are:

• The right to life • The right to life

• The right not to be tortured or treated in an inhuman or degrading way • The right not to be tortured or treated in an inhuman or degrading way
• The right to be free from slavery or forced labour • The right to be free from slavery or forced labour
• The right to liberty • The right to liberty
• The right to a fair trial • The right to a fair trial
• The right to no punishment without law • The right to no punishment without law
• The right to respect for private and family life, home and correspondence • The right to respect for private and family life, home and correspondence
• The right to freedom of thought, conscience and religion • The right to freedom of thought, conscience and religion
• The right to freedom of expression • The right to freedom of expression
• The right to freedom of assembly and association • The right to freedom of assembly and association
• The right to marry and found a family • The right to marry and found a family
• The right not to be discriminated against in relation to any of the rights contained in the • The right not to be discriminated against in relation to any of the rights contained in the
European Convention. European Convention.
• The right to peaceful enjoyment of possessions • The right to peaceful enjoyment of possessions
• The right to education • The right to education
• The right to free elections • The right to free elections

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1.3 Human Rights Aims & Principles in Complex Care Pathways 1.3 Human Rights Aims & Principles in Complex Care Pathways

As public authorities, NHS and Health Trusts and Social Services have a ‘positive obligation’ to take As public authorities, NHS and Health Trusts and Social Services have a ‘positive obligation’ to take
proactive steps to protect human rights if we are aware, or should be aware that someone is at risk. We proactive steps to protect human rights if we are aware, or should be aware that someone is at risk. We
have a responsibility to assess and manage all risks arising from and associated with the services we have a responsibility to assess and manage all risks arising from and associated with the services we
provide. We are also responsible for doing this in a way that ensures Service User’s human rights are provide. We are also responsible for doing this in a way that ensures Service User’s human rights are
upheld. upheld.

Overall, Mersey Care NHS Trust and Liverpool Social Services aim to: Overall, Mersey Care NHS Trust and Liverpool Social Services aim to:

o Use a human rights based approach to risk assessment and management. o Use a human rights based approach to risk assessment and management.

o Involve the person as much as possible in the process of planning their own care and o Involve the person as much as possible in the process of planning their own care and
management of their own risk (DH 2008a; 2008b; 2009b). management of their own risk (DH 2008a; 2008b; 2009b).

o Apply a holistic, person centred approach to assessment in which the individual’s rights to non- o Apply a holistic, person centred approach to assessment in which the individual’s rights to non-
discrimination on the basis of their religion or spirituality, their race or culture, their gender, sexual discrimination on the basis of their religion or spirituality, their race or culture, their gender, sexual
preference, disability or mental health are considered. preference, disability or mental health are considered.

o Assist in finding a suitable placement for the individual. Its aim would be to achieve a supported o Assist in finding a suitable placement for the individual. Its aim would be to achieve a supported
living placement within the city (Mansell, 2007). Where possible, the placement will be in a living placement within the city (Mansell, 2007). Where possible, the placement will be in a
community that recognises and promotes the individual’s cultural, religious and other diversity community that recognises and promotes the individual’s cultural, religious and other diversity
needs, allowing them the potential to make a positive contribution to that community. needs, allowing them the potential to make a positive contribution to that community.

o Promote access and quality in generic health and social care services and contribute to the o Promote access and quality in generic health and social care services and contribute to the
planning and development of comprehensive services. planning and development of comprehensive services.

o Provide sufficient skilled support to enable, wherever possible, individuals with a disability to remain o Provide sufficient skilled support to enable, wherever possible, individuals with a disability to remain
within their community, benefit from being a member of and make a positive contribution to within their community, benefit from being a member of and make a positive contribution to
their community (Mansell, 2007). their community (Mansell, 2007).

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The way in which we assess and manage rights and risk should be consistent with the overall aims of The way in which we assess and manage rights and risk should be consistent with the overall aims of
the Human Rights Act and should be based on the FREDA principles. The table below shows some the Human Rights Act and should be based on the FREDA principles. The table below shows some
examples of how the FREDA principles may be relevant to risk management. The table identifies which examples of how the FREDA principles may be relevant to risk management. The table identifies which
of the FREDA principles are most relevant to each particular risk management example, but note that of the FREDA principles are most relevant to each particular risk management example, but note that
often more than one of the principles will be relevant to a particular situation or example. often more than one of the principles will be relevant to a particular situation or example.

Human Rights Risk Management Example Human Rights Risk Management Example
Principle Principle

Risk decisions always involve balancing health and safety issues, for the service Risk decisions always involve balancing health and safety issues, for the service
Fairness user and others (including the general public) with Service User’s quality of life, Fairness user and others (including the general public) with Service User’s quality of life,
personal growth, rights and choice. personal growth, rights and choice.
Risk assessments and judgements should be founded on the application of explicit Risk assessments and judgements should be founded on the application of explicit
criteria and form part of an overall assessment process. criteria and form part of an overall assessment process.
Service Users and carers should be able to access information held about them Service Users and carers should be able to access information held about them
regarding risk and know in advance on what basis information may be shared with regarding risk and know in advance on what basis information may be shared with
others. others.

Decisions which flow from risk assessments should be communicated effectively Decisions which flow from risk assessments should be communicated effectively
Respect with relevant individuals. Respect with relevant individuals.

Any risk assessment should take into account and respond to a person’s age, race, Any risk assessment should take into account and respond to a person’s age, race,
Equality religion, spirituality, culture, gender, sexual orientation, disability and Equality religion, spirituality, culture, gender, sexual orientation, disability and
communication needs. communication needs.
Adults who lack capacity in law should, wherever possible, be protected from Adults who lack capacity in law should, wherever possible, be protected from
Dignity significant harm. Dignity significant harm.
Service Users and carers should have the opportunity to live as safely and free Service Users and carers should have the opportunity to live as safely and free
from harm as possible. from harm as possible.
Interventions implemented following risk assessments should be the least Interventions implemented following risk assessments should be the least
restrictive possible in the circumstances. restrictive possible in the circumstances.
Protection of Children is paramount. Protection of Children is paramount.
Autonomy Risk is an important aspect of learning; it is also an unavoidable part of life. It is Autonomy Risk is an important aspect of learning; it is also an unavoidable part of life. It is
not possible or desirable to remove all aspects of risk from the experience of not possible or desirable to remove all aspects of risk from the experience of
Service Users. Service Users.
Encouragement and information should be given to maximise the freedom of Encouragement and information should be given to maximise the freedom of
choice of users and carers and to encourage independence (considering their choice of users and carers and to encourage independence (considering their
capacity in law, age and understanding). capacity in law, age and understanding).
Service Users and carers should be supported to judge the potential benefits as Service Users and carers should be supported to judge the potential benefits as
well as the potential harms of any situation well as the potential harms of any situation
Services aim not only too reduce the risk of harm, but to manage and promote Services aim not only too reduce the risk of harm, but to manage and promote
risk-taking in a planned, controlled way. risk-taking in a planned, controlled way.

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1.4 Human Rights Processes in Complex Care 1.4 Human Rights Processes in Complex Care

Different Types of Human Rights Different Types of Human Rights

Human rights can be most simply classified as absolute rights and non-absolute rights. These are Human rights can be most simply classified as absolute rights and non-absolute rights. These are
described more fully below. The right to liberty (Article 5) is described separately. described more fully below. The right to liberty (Article 5) is described separately.

• Absolute rights • Absolute rights

These rights can never be interfered with, in any way by NHS Trusts, Social Services or any other public These rights can never be interfered with, in any way by NHS Trusts, Social Services or any other public
authorities. They are: authorities. They are:
o The right to life o The right to life
o the right not to be tortured or treated in an inhuman or degrading way o the right not to be tortured or treated in an inhuman or degrading way
o The right to be free from slavery o The right to be free from slavery

• Non-absolute rights • Non-absolute rights

Most rights in the HRA are not absolute but have some degree of qualification. They can be interfered Most rights in the HRA are not absolute but have some degree of qualification. They can be interfered
with by NHS Trusts and Social services if the decisions we make are: with by NHS Trusts and Social services if the decisions we make are:
o lawful –completed with reference to the appropriate legal frameworks. o lawful –completed with reference to the appropriate legal frameworks.
o Have a legitimate aim – “to protect the rights of others or for the wider good” o Have a legitimate aim – “to protect the rights of others or for the wider good”
o proportionate – “appropriate and not excessive in the circumstances” or “not using a o proportionate – “appropriate and not excessive in the circumstances” or “not using a
sledgehammer to crack a nut” sledgehammer to crack a nut”
o balanced – take into account the rights of the Service User, their staff and the rights o balanced – take into account the rights of the Service User, their staff and the rights
and general interests (e.g. national security and economic well-being) of the wider and general interests (e.g. national security and economic well-being) of the wider
community of which both are a part. community of which both are a part.

An example of a non-absolute right is the right to respect for private and family life, home and An example of a non-absolute right is the right to respect for private and family life, home and
correspondence. correspondence.

The Right to Liberty (Article 5) The Right to Liberty (Article 5)

Article 5 can be ‘limited in specific and finite circumstances’ which are described within the HRA. For Article 5 can be ‘limited in specific and finite circumstances’ which are described within the HRA. For
example, the right to liberty may be restricted to allow the legal detention of someone with mental example, the right to liberty may be restricted to allow the legal detention of someone with mental
health problems. health problems.

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1.5 Proportionality 1.5 Proportionality

Proportionality is fundamental to assessing risk. In essence, a proportionate strategy is one that is Proportionality is fundamental to assessing risk. In essence, a proportionate strategy is one that is
‘appropriate and not excessive in the circumstances’ (DH, 2007). In practice, proportionality ‘appropriate and not excessive in the circumstances’ (DH, 2007). In practice, proportionality
ensures that the infringement of a person’s human rights is kept to a minimum. It is probable that as ensures that the infringement of a person’s human rights is kept to a minimum. It is probable that as
the level of perceived risk increases, so too would the reasonable restrictiveness of any strategy the level of perceived risk increases, so too would the reasonable restrictiveness of any strategy
employed (see below). However, the principle of proportionality should ensure that this is always the employed (see below). However, the principle of proportionality should ensure that this is always the
least restrictive strategy. least restrictive strategy.

Restrictiveness of strategy employed

Restrictiveness of strategy employed

Level of perceived Level of perceived
risk risk

When considering if a strategy is proportionate the assessor should ask: When considering if a strategy is proportionate the assessor should ask:

• What will be left of the person’s rights if the strategy is employed? • What will be left of the person’s rights if the strategy is employed?

• Is there an alternative strategy that would be less drastic? • Is there an alternative strategy that would be less drastic?

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Proportionality: Case Example Proportionality: Case Example

Calvin is a young man with Cornelia de Lange Syndrome. Calvin began to display self-injurious Calvin is a young man with Cornelia de Lange Syndrome. Calvin began to display self-injurious
behaviours including pulling his own hair out, and attempting to bite his hands. These incidents behaviours including pulling his own hair out, and attempting to bite his hands. These incidents
occurred roughly once a week and could last for an entire morning or afternoon. The occurred roughly once a week and could last for an entire morning or afternoon. The
management team at Calvin’s day centre decided to introduce straight arm restrictive devices management team at Calvin’s day centre decided to introduce straight arm restrictive devices
(splints) to avoid Calvin seriously hurting himself. Over a five year period, the time Calvin spent (splints) to avoid Calvin seriously hurting himself. Over a five year period, the time Calvin spent
wearing the splints increased until he spent most days in them. This risked violating Calvin’s wearing the splints increased until he spent most days in them. This risked violating Calvin’s
right not to be treated in an inhuman or degrading way. In particular, the period of intervention right not to be treated in an inhuman or degrading way. In particular, the period of intervention
(i.e. the amount of time Calvin spent wearing the splints) was not proportionate to the self- (i.e. the amount of time Calvin spent wearing the splints) was not proportionate to the self-
injurious behaviours displayed (they occurred at most for one morning or afternoon per week). injurious behaviours displayed (they occurred at most for one morning or afternoon per week).

The intervention was reviewed, using a human rights based approach, to see if it was The intervention was reviewed, using a human rights based approach, to see if it was
proportionate to the risk. As a result, staff systematically faded down the amount of time Calvin proportionate to the risk. As a result, staff systematically faded down the amount of time Calvin
wore the splints. The splints are now only used when Calvin’s self-injurious behaviour poses wore the splints. The splints are now only used when Calvin’s self-injurious behaviour poses
significant risk to his own well-being. significant risk to his own well-being.

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1.6 Proactive and Reactive Strategies 1.6 Proactive and Reactive Strategies

The principle of proportionality means that, in risk management, an emphasis on proactive rather than The principle of proportionality means that, in risk management, an emphasis on proactive rather than
reactive strategies is more likely to be consistent with a human rights based approach. reactive strategies is more likely to be consistent with a human rights based approach.

Proactive Strategies aim to reduce the occurrence of risk/challenging behaviours or prevent Proactive Strategies aim to reduce the occurrence of risk/challenging behaviours or prevent
them from occurring in the first place. them from occurring in the first place.

They might include: They might include:

• Sex education and sexual health awareness to support a person who takes sexual risks. • Sex education and sexual health awareness to support a person who takes sexual risks.
• Increasing social activities identified as relevant to the person to reduce boredom and • Increasing social activities identified as relevant to the person to reduce boredom and
therefore reduce the risks of fire-setting. therefore reduce the risks of fire-setting.
• Working through a desensitisation programme with a person for their needle-phobia. • Working through a desensitisation programme with a person for their needle-phobia.
• Providing someone with psychological therapy to help them understand why they are angry • Providing someone with psychological therapy to help them understand why they are angry
and upset after one of their parents has died. and upset after one of their parents has died.

Reactive strategies are an immediate or emergency response to the risk/challenging Reactive strategies are an immediate or emergency response to the risk/challenging
behaviour which aim to minimise its severity behaviour which aim to minimise its severity

They might include: They might include:

• Physical restraint to stop a distressed person assaulting their staff • Physical restraint to stop a distressed person assaulting their staff
• Mechanical restraint to prevent a person from serious self harm • Mechanical restraint to prevent a person from serious self harm
• Pro Ra Nate (PRN) Medication to help a person calm down when they are angry • Pro Ra Nate (PRN) Medication to help a person calm down when they are angry

A human rights based approach will mean carefully analysing the person’s history and the context in A human rights based approach will mean carefully analysing the person’s history and the context in
which their difficult behaviours occur to try and identify the cause of the difficulty. Functional analysis of which their difficult behaviours occur to try and identify the cause of the difficulty. Functional analysis of
the person’s behaviour and a comprehensive life history or ‘critical event history’ will be essential to the person’s behaviour and a comprehensive life history or ‘critical event history’ will be essential to
identifying ‘causes’. Once the cause has been identified the least restrictive option will often be to identifying ‘causes’. Once the cause has been identified the least restrictive option will often be to
develop proactive strategies to address the cause of the person’s behaviour. develop proactive strategies to address the cause of the person’s behaviour.

It may take time for proactive strategies (e.g. psychological therapies) to have an impact on the It may take time for proactive strategies (e.g. psychological therapies) to have an impact on the
person’s behaviour. It may also take time for clinicians to understand the meaning of and person’s behaviour. It may also take time for clinicians to understand the meaning of and
communication in the person’s behaviour. In this context, where reactive strategies are not being communication in the person’s behaviour. In this context, where reactive strategies are not being
exclusively relied upon but have been developed as a short term measure or in conjunction with exclusively relied upon but have been developed as a short term measure or in conjunction with
proactive strategies, they are more likely to be human rights compliant. proactive strategies, they are more likely to be human rights compliant.

Reactive strategies should always; Reactive strategies should always;

• Be reviewed at regular specified intervals • Be reviewed at regular specified intervals
• Be the least restrictive possible intervention • Be the least restrictive possible intervention
• Use approved & accredited techniques • Use approved & accredited techniques
• Follow best practice and professional guidelines • Follow best practice and professional guidelines
• Be explained to the person in an accessible format where possible. • Be explained to the person in an accessible format where possible.

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 Proactive & Reactive Strategies: Case Example Proactive & Reactive Strategies: Case Example

Joe is a young man with autism. Joe was reported by care staff to be trying to hit and bite them. Joe is a young man with autism. Joe was reported by care staff to be trying to hit and bite them.
This usually happened in the mornings. Staff were trying to manage Joe’s aggression reactively by This usually happened in the mornings. Staff were trying to manage Joe’s aggression reactively by
using physical intervention techniques for extended periods of time. This risked violating Joe’s right using physical intervention techniques for extended periods of time. This risked violating Joe’s right
not to be treated in an inhuman or degrading way. not to be treated in an inhuman or degrading way.

After looking at when and why incidents occurred, staff realised Joe would become aggressive After looking at when and why incidents occurred, staff realised Joe would become aggressive
when they were trying to assist him to get washed. After speaking to Joe’s mum, staff realised that when they were trying to assist him to get washed. After speaking to Joe’s mum, staff realised that
to wash him as a child Joe’s Mum had developed a highly structured shower routine which he was to wash him as a child Joe’s Mum had developed a highly structured shower routine which he was
used to following every day. They proactively adopted this routine and the physical aggression they used to following every day. They proactively adopted this routine and the physical aggression they
were experiencing from Joe reduced dramatically. were experiencing from Joe reduced dramatically.

1.7 Balanced Decision Making 1.7 Balanced Decision Making

The principle of proportionality leads to an additional concept of risk assessment – ‘balanced decision The principle of proportionality leads to an additional concept of risk assessment – ‘balanced decision
making.’ There are two important dimensions across which rights need to be balanced: making.’ There are two important dimensions across which rights need to be balanced:

The assessor should balance the potentially competing rights associated with: The assessor should balance the potentially competing rights associated with:

• the risk posed (for the person or other people) • the risk posed (for the person or other people)

• and the strategy employed (for the person or the other people) • and the strategy employed (for the person or the other people)

In practice, this may mean that you are trying to balance the Service User’s different rights. You may be In practice, this may mean that you are trying to balance the Service User’s different rights. You may be
trying to balance the rights involved in the person’s risky behaviour against the rights involved in any trying to balance the rights involved in the person’s risky behaviour against the rights involved in any
management strategy proposed. The following example illustrates this point. management strategy proposed. The following example illustrates this point.

Balancing the Rights in the Risk & the Rights in the Strategy: Case Example Balancing the Rights in the Risk & the Rights in the Strategy: Case Example

Melissa is a Service User with a learning disability who seriously self harms and leaves her package Melissa is a Service User with a learning disability who seriously self harms and leaves her package
of care without support. When she leaves her carers, Melissa engages in unprotected sex with of care without support. When she leaves her carers, Melissa engages in unprotected sex with
strangers. She has tried to take her own life on previous occasions when alone in the community. strangers. She has tried to take her own life on previous occasions when alone in the community.
Melissa is on a section of the Mental Health Act. Melissa is on a section of the Mental Health Act.

Staff have placed restrictors on a Melissa’s window to prevent her from leaving her package of Staff have placed restrictors on a Melissa’s window to prevent her from leaving her package of
care. This interferes with Melissa’s right to liberty, a limited right, to protect her absolute right to care. This interferes with Melissa’s right to liberty, a limited right, to protect her absolute right to
life which would be compromised by not employing a strategy. In this instance staff, are attempting life which would be compromised by not employing a strategy. In this instance staff, are attempting
to balance Melissa’s right to life against her right to liberty. As Melissa is under a section of Mental to balance Melissa’s right to life against her right to liberty. As Melissa is under a section of Mental
Health Act her right to liberty can legally be restricted. Health Act her right to liberty can legally be restricted.

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You may also be involved in trying to balance the Service User’s rights against those of other people in You may also be involved in trying to balance the Service User’s rights against those of other people in
their life, as illustrated below. their life, as illustrated below.

Balancing the Service User’s Rights against those of Others: Case Example Balancing the Service User’s Rights against those of Others: Case Example

Lorna is 25 and lives in a shared house for people with learning disabilities. George also lives in the Lorna is 25 and lives in a shared house for people with learning disabilities. George also lives in the
house, is of the same age, and has become attracted to Lorna. George has begun to express his house, is of the same age, and has become attracted to Lorna. George has begun to express his
feelings to Lorna and on occasion has tried to kiss her when they are alone. George has also tried to feelings to Lorna and on occasion has tried to kiss her when they are alone. George has also tried to
enter Lorna’s bedroom and when asked by the staff team has explained that he ‘just wants to watch TV enter Lorna’s bedroom and when asked by the staff team has explained that he ‘just wants to watch TV
with her’. Staff are concerned about these events, but are reluctant to intervene as they do not want to with her’. Staff are concerned about these events, but are reluctant to intervene as they do not want to
breach George’s right to a private life. However, staff are aware that Laura’s anxiety over George’s breach George’s right to a private life. However, staff are aware that Laura’s anxiety over George’s
behaviour and that this raises her right to a private life and their duty to protect this. behaviour and that this raises her right to a private life and their duty to protect this.

Staff realised a balanced decision needed to be made, and any intervention would need to balance the Staff realised a balanced decision needed to be made, and any intervention would need to balance the
rights of George and Laura. rights of George and Laura.

1.8 Policy Summary 1.8 Policy Summary

This joint policy statement briefly summarises the most relevant elements of Mersey Care NHS Trust and This joint policy statement briefly summarises the most relevant elements of Mersey Care NHS Trust and
Social Services’ policies regarding the assessment and management of risk and human rights. It forms Social Services’ policies regarding the assessment and management of risk and human rights. It forms
the framework within which Mersey Care and Social Services staff enable people to live lives which the framework within which Mersey Care and Social Services staff enable people to live lives which
respect their rights and choices, balancing these with the rights of their supporters and the communities respect their rights and choices, balancing these with the rights of their supporters and the communities
to which they belong, through the process of meaningfully assessing and managing risk. The policy to which they belong, through the process of meaningfully assessing and managing risk. The policy
describes the standard to which this should be done. describes the standard to which this should be done.

Each agency has to discharge its duty of care towards their Service Users to an appropriate standard. Each agency has to discharge its duty of care towards their Service Users to an appropriate standard.
This entails being able to demonstrate that as staff we have acted and made decisions in a manner This entails being able to demonstrate that as staff we have acted and made decisions in a manner
which is comparable to that of another competent body of responsible co-professionals, acting in the which is comparable to that of another competent body of responsible co-professionals, acting in the
same circumstances. same circumstances.

In exercising professional judgement all staff will act within the law and in accordance with the policies In exercising professional judgement all staff will act within the law and in accordance with the policies
and procedures of Liverpool Social Services Directorate, Mersey Care NHS Trust and Liverpool Health and procedures of Liverpool Social Services Directorate, Mersey Care NHS Trust and Liverpool Health
Authority. Authority.

Staff can expect to be supported in action which they have taken provided they have adhered to their Staff can expect to be supported in action which they have taken provided they have adhered to their
agency’s policies and procedures in regard to the assessment and management of risk and agency’s policies and procedures in regard to the assessment and management of risk and
demonstrated an acceptable standard of care in the discharge of their responsibilities. At times this will demonstrated an acceptable standard of care in the discharge of their responsibilities. At times this will
mean supporting a Service User to receive services or to remain in a situation in which there are mean supporting a Service User to receive services or to remain in a situation in which there are
significant risks. Decisions regarding risk situations should only be made following a full evaluation of all significant risks. Decisions regarding risk situations should only be made following a full evaluation of all
the relevant information in accordance with the guidance herein. The decision taken will be on the basis the relevant information in accordance with the guidance herein. The decision taken will be on the basis
of the informed consent of the Service User (or their representative), subject to their legal capacity, age of the informed consent of the Service User (or their representative), subject to their legal capacity, age
and understanding. and understanding.

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2 Research and Practice 2 Research and Practice

2.1 Introduction 2.1 Introduction

This section examines the current state of research into risk assessment and its links to current practice. This section examines the current state of research into risk assessment and its links to current practice.
The material presented is part of an analysis of literature that has informed our work. The material presented is part of an analysis of literature that has informed our work.

2.2 Current Difficulties 2.2 Current Difficulties

One of the main difficulties in this area is that much of the research related to risk assessment has been One of the main difficulties in this area is that much of the research related to risk assessment has been
carried out with violent or other criminal offenders and people with mental health problems. These, carried out with violent or other criminal offenders and people with mental health problems. These,
findings cannot automatically be transposed to the field of learning disability. findings cannot automatically be transposed to the field of learning disability.

Johnson (2002) review identified that there was no research evidence to support the assumption that Johnson (2002) review identified that there was no research evidence to support the assumption that
existing learning disability assessment and management frameworks provide adequate information existing learning disability assessment and management frameworks provide adequate information
when determining future re-offending and devising risk management plans. He also stated that when determining future re-offending and devising risk management plans. He also stated that
adaptations to theoretical models in non-learning disabled populations have been applied but not adaptations to theoretical models in non-learning disabled populations have been applied but not
validated for those with learning disabilities. It was highlighted that the published evidence for existing validated for those with learning disabilities. It was highlighted that the published evidence for existing
clinical practice in forensic risk assessment of offenders with learning disabilities is small (Johnson, clinical practice in forensic risk assessment of offenders with learning disabilities is small (Johnson,
2002). Three serious deficits in the field of risk assessment have been identified. 2002). Three serious deficits in the field of risk assessment have been identified.

o Firstly, research and practice were unconnected. Webster and Eaves (1995) stated that research o Firstly, research and practice were unconnected. Webster and Eaves (1995) stated that research
on the prediction of violence needed to be integrated into clinical assessment. Rice et. al. (1991) on the prediction of violence needed to be integrated into clinical assessment. Rice et. al. (1991)
reported how only a small sample of clinician’s were using standardised assessment tools. The reported how only a small sample of clinician’s were using standardised assessment tools. The
reasons for this were multiple, including that many instruments were designed for research reasons for this were multiple, including that many instruments were designed for research
rather than clinical work, required expensive training, did not inform clinical decision-making, rather than clinical work, required expensive training, did not inform clinical decision-making,
were time-consuming to administer, and could be used as part of routine clinical practice. were time-consuming to administer, and could be used as part of routine clinical practice.

o Secondly, assessment validation research was almost exclusively concerned with psychiatric o Secondly, assessment validation research was almost exclusively concerned with psychiatric
offenders or patients, and not with those with learning disabilities. Mossman (1994) added that offenders or patients, and not with those with learning disabilities. Mossman (1994) added that
there was evidence that clinical judgement was a poor predictor of future offending, with no there was evidence that clinical judgement was a poor predictor of future offending, with no
obvious advantages over actuarial methods or assessments by non-clinical care staff. obvious advantages over actuarial methods or assessments by non-clinical care staff.

o Thirdly, the accuracy of any systematic method of risk assessment for those with learning o Thirdly, the accuracy of any systematic method of risk assessment for those with learning
disabilities, whether short or long term, in inpatient or community settings, or for particular disabilities, whether short or long term, in inpatient or community settings, or for particular
categories of prisoners or Service Users, had not yet been established. categories of prisoners or Service Users, had not yet been established.

Reporting of Risk Reporting of Risk

Each stage of risk assessment is influenced by each individual’s interpretation of events, their Each stage of risk assessment is influenced by each individual’s interpretation of events, their
perspectives on the individual involved, and the role they occupy in relation to services. Identical perspectives on the individual involved, and the role they occupy in relation to services. Identical
incidents may be interpreted differently by different professionals and by those with varying degrees of incidents may be interpreted differently by different professionals and by those with varying degrees of
knowledge, experience and skills. It has also been suggested that people who work with those with a knowledge, experience and skills. It has also been suggested that people who work with those with a
learning disability have a different body of knowledge and experience compared to those who work with learning disability have a different body of knowledge and experience compared to those who work with
offenders or offenders with mental health difficulties (Johnson, 2002). Studies by Kiernan and Alborz offenders or offenders with mental health difficulties (Johnson, 2002). Studies by Kiernan and Alborz
(1991), Lyall et. al. (1995) and Clare and Murphy (1998) identified that where there is contact between (1991), Lyall et. al. (1995) and Clare and Murphy (1998) identified that where there is contact between
an alleged offender and learning disability services, offending behaviour is underreported, even for an alleged offender and learning disability services, offending behaviour is underreported, even for
offences as serious as rape. Staff attitudes towards offending, and therefore its prevalence may vary offences as serious as rape. Staff attitudes towards offending, and therefore its prevalence may vary
according to service setting (Wilson et. al., 1996). according to service setting (Wilson et. al., 1996).

Assessment of risk must be informed by evidence relating to the prevalence and nature of the risks Assessment of risk must be informed by evidence relating to the prevalence and nature of the risks
being considered. This is particularly difficult when the person has a learning disability (Turner, 2000). being considered. This is particularly difficult when the person has a learning disability (Turner, 2000).
Maden (1996) stated that the process of risk assessment and management was that of data collection, Maden (1996) stated that the process of risk assessment and management was that of data collection,
recording, interpretation, communication and implementation of a risk reduction plan. This is not always recording, interpretation, communication and implementation of a risk reduction plan. This is not always
carried out. carried out.

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Prediction of Risk Prediction of Risk

Turner (1996) identifies that it is extremely difficult to predict the future violent acts of individuals with Turner (1996) identifies that it is extremely difficult to predict the future violent acts of individuals with
mental health difficulties. Despite our inability to make these predictions well, such predictions are made mental health difficulties. Despite our inability to make these predictions well, such predictions are made
routinely and, regardless of the discouraging evidence. Further, a variety of professionals in the justice routinely and, regardless of the discouraging evidence. Further, a variety of professionals in the justice
and mental health systems are required to make them. In 2000, Turner reviewed the learning disability and mental health systems are required to make them. In 2000, Turner reviewed the learning disability
literature and suggested that much of the evidence relating to the prevalence and pattern of offending literature and suggested that much of the evidence relating to the prevalence and pattern of offending
by individuals with a learning disability is thwarted with methodological weaknesses. Turner concluded by individuals with a learning disability is thwarted with methodological weaknesses. Turner concluded
that assessors should be aware that “the knowledge base for risk assessment is at best partial and at that assessors should be aware that “the knowledge base for risk assessment is at best partial and at
worst misleading [which] should underpin the process of assessment, management and review” (Turner, worst misleading [which] should underpin the process of assessment, management and review” (Turner,
2000). 2000).

Therefore processes in which judgements about risk can be made more effectively and efficiently remain Therefore processes in which judgements about risk can be made more effectively and efficiently remain
necessary. Department of Health (DH) guidance (1994) on the assessment of offenders with mental necessary. Department of Health (DH) guidance (1994) on the assessment of offenders with mental
health difficulties suggests that assessment should be based on: health difficulties suggests that assessment should be based on:

• evidence and clinical opinion on the past history of the patient; • evidence and clinical opinion on the past history of the patient;
• self-reporting of the patient at interview; • self-reporting of the patient at interview;
• observation of her or his behaviour and mental state; • observation of her or his behaviour and mental state;
• discrepancies between reports and observation; • discrepancies between reports and observation;
and statistics derived from studies of related cases and prediction indicators derived from research.. and statistics derived from studies of related cases and prediction indicators derived from research..

2.3 Clinical Versus Actuarial Judgements 2.3 Clinical Versus Actuarial Judgements

Following deinstitutionalisation there has been a general perception that more people are at a greater Following deinstitutionalisation there has been a general perception that more people are at a greater
risk of offending (Turner, 2000). This has increased forensic interest into developing clinical and risk of offending (Turner, 2000). This has increased forensic interest into developing clinical and
actuarial data for this population. actuarial data for this population.

Turner (2000) noted assessment tools often combine actuarial and clinical data; increasingly they also Turner (2000) noted assessment tools often combine actuarial and clinical data; increasingly they also
include the dynamic nature of risk, situational and accidental triggers. The clinical approach considers include the dynamic nature of risk, situational and accidental triggers. The clinical approach considers
the individuals medical condition, symptoms and treatment. Whilst the actuarial approach, compares the individuals medical condition, symptoms and treatment. Whilst the actuarial approach, compares
individuals statistically with characteristics of groups with a known negative outcome. The actuarial individuals statistically with characteristics of groups with a known negative outcome. The actuarial
approach is rooted in probability theory borrowed from the field of insurance risk assessment. It has approach is rooted in probability theory borrowed from the field of insurance risk assessment. It has
recently been applied in the field of social welfare. Actuarial predictors developed from prison or recently been applied in the field of social welfare. Actuarial predictors developed from prison or
psychiatric population studies may also be invalid for learning disabled populations. It is important to psychiatric population studies may also be invalid for learning disabled populations. It is important to
note that of the research available, little or no indication is given regarding participant’s gender, note that of the research available, little or no indication is given regarding participant’s gender,
sexuality, race or cultural backgrounds. sexuality, race or cultural backgrounds.

The lack of actuarial data for the learning disabled population has allowed for the predominance of The lack of actuarial data for the learning disabled population has allowed for the predominance of
clinical models of assessment to become the norm, although, as Johnson (2002) documented, few have clinical models of assessment to become the norm, although, as Johnson (2002) documented, few have
been described in the public domain. The clinical approach is a process in which decisions are reliant on been described in the public domain. The clinical approach is a process in which decisions are reliant on
the subjective state and experience of the clinician/professional, each stage is subject to their bias, the subjective state and experience of the clinician/professional, each stage is subject to their bias,
which may confound the interpretation of each incident (Johnson, 2002). Clinical judgement has which may confound the interpretation of each incident (Johnson, 2002). Clinical judgement has
previously been shown to be extremely poor in relation to risk prediction (Lindsay & Beail, 2004. McNiel previously been shown to be extremely poor in relation to risk prediction (Lindsay & Beail, 2004. McNiel
et. al.. (2000) highlighted that when there was agreement between professionals regarding the et. al.. (2000) highlighted that when there was agreement between professionals regarding the
prediction of risk, the accuracy of that prediction was significantly increased. prediction of risk, the accuracy of that prediction was significantly increased.

Clinical assessment in forensic psychiatry attempts to answer the legal, public and administrators` Clinical assessment in forensic psychiatry attempts to answer the legal, public and administrators`
question “Will s/he do it again?” (Prins, 1990). Pollock and Webster (1990) argued that it was impossible question “Will s/he do it again?” (Prins, 1990). Pollock and Webster (1990) argued that it was impossible
to give a definitive answer since it is based on the assumption that dangerousness is a stable and to give a definitive answer since it is based on the assumption that dangerousness is a stable and
consistent quality existing within the individual. Litwack (1993) noted it is preferable to ask what are the consistent quality existing within the individual. Litwack (1993) noted it is preferable to ask what are the
psychological, social and biological factors influencing behaviour, and thus the implications for future psychological, social and biological factors influencing behaviour, and thus the implications for future
behaviour and for change. They note that different actuarial factors are relevant for different types of behaviour and for change. They note that different actuarial factors are relevant for different types of
risk of outcome behaviours. They say that situational factors (e.g. heavy drinking or non compliance risk of outcome behaviours. They say that situational factors (e.g. heavy drinking or non compliance
with medication) need to be recognised as potential modifiers of risk, and be incorporated into with medication) need to be recognised as potential modifiers of risk, and be incorporated into
assessment reports. Such factors may be wholly unpredictable, while others (e.g. family stress) may be assessment reports. Such factors may be wholly unpredictable, while others (e.g. family stress) may be
open to intervention. open to intervention.

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In general researchers agree that importance should be ascribed to actuarial considerations. It has been In general researchers agree that importance should be ascribed to actuarial considerations. It has been
argued that the prediction of risk should consist of two parts (Webster and Eaves, 1995; Litwack et. al. argued that the prediction of risk should consist of two parts (Webster and Eaves, 1995; Litwack et. al.
1993; Johnson, 2002); 1993; Johnson, 2002);

o An actuarial approach in which pertinent information is extracted from historical records, o An actuarial approach in which pertinent information is extracted from historical records,
however clinicians should remain aware of the biases within these however clinicians should remain aware of the biases within these

o A clinical component which would, in some cases, allow for variation from the statistically- o A clinical component which would, in some cases, allow for variation from the statistically-
derived probabilities. Risk assessment should combine actuarial and clinical approaches in a derived probabilities. Risk assessment should combine actuarial and clinical approaches in a
structured approach to clinical judgement (Lindsay & Beail, 2004). structured approach to clinical judgement (Lindsay & Beail, 2004).

2.4 What’s Important in Risk Assessment? 2.4 What’s Important in Risk Assessment?

Involving the Person in the Process Involving the Person in the Process

Risk assessment should not be a process which is ‘done to’ a person. Rather, professionals should strive Risk assessment should not be a process which is ‘done to’ a person. Rather, professionals should strive
to ensure that the process adopts a collaborative (i.e. a non-didactic) approach; collaborative in the to ensure that the process adopts a collaborative (i.e. a non-didactic) approach; collaborative in the
sense that the professionals work, whenever possible, in collaboration with the individual with whom the sense that the professionals work, whenever possible, in collaboration with the individual with whom the
assessment is concerned. In other words, where possible, any perceived risk is in fact ‘openly and assessment is concerned. In other words, where possible, any perceived risk is in fact ‘openly and
explicitly acknowledged and managed’ (Alaszewski and Alaszewski, 2005; Langan and Lindow, 2004). explicitly acknowledged and managed’ (Alaszewski and Alaszewski, 2005; Langan and Lindow, 2004).
Furthermore, where possible, risk assessment should be framed within a person-centred model of Furthermore, where possible, risk assessment should be framed within a person-centred model of
practice, incorporating the underlying human rights principles of Fairness, Respect, Equality, Dignity, practice, incorporating the underlying human rights principles of Fairness, Respect, Equality, Dignity,
and Autonomy (FREDA). and Autonomy (FREDA).

In achieving this aim, organisational support systems need to adopt a person-centred approach to risk In achieving this aim, organisational support systems need to adopt a person-centred approach to risk
assessment which emphasises an individual’s gender, sexuality, race, and cultural backgrounds and assessment which emphasises an individual’s gender, sexuality, race, and cultural backgrounds and
attends to health inequalities. Moreover, psychological, social and biological factors also require attends to health inequalities. Moreover, psychological, social and biological factors also require
consideration and implementation into any risk assessment programme. Indeed, judgements of risk consideration and implementation into any risk assessment programme. Indeed, judgements of risk
‘need to be about values, and [in person-centred risk assessment] primacy should be given to the ‘need to be about values, and [in person-centred risk assessment] primacy should be given to the
person at the centre of the planning system’ (Alaszewski and Alaszewski, 2005). person at the centre of the planning system’ (Alaszewski and Alaszewski, 2005).

Consequently, the principal objective of a Human Rights-based approach for risk assessment is to Consequently, the principal objective of a Human Rights-based approach for risk assessment is to
enable decisions to be collaboratively arrived upon at each stage, where the individual is as thoroughly enable decisions to be collaboratively arrived upon at each stage, where the individual is as thoroughly
immersed and involved in the decision tree as possible. To enable facilitation of this process, where immersed and involved in the decision tree as possible. To enable facilitation of this process, where
possible teams should consider aspects such as ethics, and employ ethical decision-making team possible teams should consider aspects such as ethics, and employ ethical decision-making team
meetings regularly. Such bodies should embrace the process of decision-making and examine how the meetings regularly. Such bodies should embrace the process of decision-making and examine how the
quality of decision-making can be improved upon. quality of decision-making can be improved upon.

Guidance on how to make information easier for the individual for whom the risk assessment concerns Guidance on how to make information easier for the individual for whom the risk assessment concerns
needs to be employed throughout the process, such as up-to-date literature on accessible information needs to be employed throughout the process, such as up-to-date literature on accessible information
(see Rogers and Namaganda, 2005; Ward and Townsley, 2005). Moreover, such accessible information (see Rogers and Namaganda, 2005; Ward and Townsley, 2005). Moreover, such accessible information
needs to be accessible not only at the level of ‘easy-info.’, but also be produced with issues of diversity needs to be accessible not only at the level of ‘easy-info.’, but also be produced with issues of diversity
in mind. in mind.

To this end, in keeping with the recommendations regarding collaborative approaches, organisational To this end, in keeping with the recommendations regarding collaborative approaches, organisational
systems should endeavour to produce (accessible) step-by-step guides to each (Human Rights-driven) systems should endeavour to produce (accessible) step-by-step guides to each (Human Rights-driven)
risk assessment for the person the assessment concerns. This could be achieved, for example, by risk assessment for the person the assessment concerns. This could be achieved, for example, by
producing a ‘Your Guide to Your Risk Assessment – What We Will Do’ document. Such a guide would producing a ‘Your Guide to Your Risk Assessment – What We Will Do’ document. Such a guide would
explain what the person can expect at each stage of the process, and how they can contribute in explain what the person can expect at each stage of the process, and how they can contribute in
partnership with the stakeholders, in order to produce as person-centred an assessment as is possible. partnership with the stakeholders, in order to produce as person-centred an assessment as is possible.

As an example of this inclusive approach, the manual for the collaborative risk assessment developed As an example of this inclusive approach, the manual for the collaborative risk assessment developed
within Mersey Care NHS Trust, the ‘Keeping Me Safe and Well Assessment’ (Lee, Kaur, Cookson and within Mersey Care NHS Trust, the ‘Keeping Me Safe and Well Assessment’ (Lee, Kaur, Cookson and
Greenhill, 2008) is included in Appendix one. Greenhill, 2008) is included in Appendix one.

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People with Learning Disabilities are believed to have low levels of awareness of their own human rights People with Learning Disabilities are believed to have low levels of awareness of their own human rights
(JCHR Report, 2007). As part of the process of assessment clinicians should ensure that Service Users (JCHR Report, 2007). As part of the process of assessment clinicians should ensure that Service Users
have accessible information about their human rights. A number of ‘easy read’ human rights guides are have accessible information about their human rights. A number of ‘easy read’ human rights guides are
included in the references (Standing Up for My Human Rights Group, 2011; summarised in DH, 2010b) included in the references (Standing Up for My Human Rights Group, 2011; summarised in DH, 2010b)
and further resources section of this document. A group approach working with people with a learning and further resources section of this document. A group approach working with people with a learning
disability to develop an understanding of human rights has also been shown to be useful (Roberts, disability to develop an understanding of human rights has also been shown to be useful (Roberts,
Greenhill, Talbot and Cuzak, 2011). Greenhill, Talbot and Cuzak, 2011).

Reflective Practice Reflective Practice

Reflectively informed processes of risk assessment in organisations can enable organisations to avoid Reflectively informed processes of risk assessment in organisations can enable organisations to avoid
becoming iatrogenic systems; where a person’s problems are exacerbated within the system by the becoming iatrogenic systems; where a person’s problems are exacerbated within the system by the
system itself. In not being reflective, we build a system that feeds into and confirms the identity of the system itself. In not being reflective, we build a system that feeds into and confirms the identity of the
person who challenges as a person who ultimately is powerless, unworthy of a voice, and dangerous. person who challenges as a person who ultimately is powerless, unworthy of a voice, and dangerous.
Clearly, such an outcome is unlikely to be a moral, fair or just reflection of that individual. Clearly, such an outcome is unlikely to be a moral, fair or just reflection of that individual.

To support reflective thinking, systems can be ‘broken down’ and considered at different levels. For To support reflective thinking, systems can be ‘broken down’ and considered at different levels. For
example, staff characteristics should be reflected upon at multiple stages when compiling a complex example, staff characteristics should be reflected upon at multiple stages when compiling a complex
case care pathway. Clinicians completing the care pathway should be reflective of the position and case care pathway. Clinicians completing the care pathway should be reflective of the position and
stance they take when collating the information, whilst direct support workers should be reflective of stance they take when collating the information, whilst direct support workers should be reflective of
their position and their feelings when completing incident forms, particularly with regards to, for their position and their feelings when completing incident forms, particularly with regards to, for
example, discrimination (or risk of discriminatory practices). At every point in the process there should example, discrimination (or risk of discriminatory practices). At every point in the process there should
be a space for reflection, in which people ask themselves: be a space for reflection, in which people ask themselves:

1. How could I have done things differently? 1. How could I have done things differently?
2. Have I acted in a fair and just manner (incorporating the FREDA principles outlined 2. Have I acted in a fair and just manner (incorporating the FREDA principles outlined
above)? above)?
and and
3. Is this a true reflection of the person being written about? 3. Is this a true reflection of the person being written about?

Clinicians can model helpful relationships by working with teams of support workers in a non- Clinicians can model helpful relationships by working with teams of support workers in a non-
judgemental, non-blaming manner. Systemic models of reflective practice are important here, both for judgemental, non-blaming manner. Systemic models of reflective practice are important here, both for
the members of the team to adopt, but, in addition, also for the clinicians working and supporting those the members of the team to adopt, but, in addition, also for the clinicians working and supporting those
teams. Indeed, it is vital that clinicians monitor their own working practice throughout the process, to teams. Indeed, it is vital that clinicians monitor their own working practice throughout the process, to
ensure that they deliver a service to the team concerned that is in no way judgemental, nor in any way ensure that they deliver a service to the team concerned that is in no way judgemental, nor in any way
blaming. blaming.

At the organisational level, Learning Disability services continue to strive to meet the needs of those At the organisational level, Learning Disability services continue to strive to meet the needs of those
whose behaviour presents challenges to those services themselves. Indeed, recent reports at national whose behaviour presents challenges to those services themselves. Indeed, recent reports at national
level (see Mansell, 2007) suggest that those services for people who display ‘challenging behaviours’ are level (see Mansell, 2007) suggest that those services for people who display ‘challenging behaviours’ are
often most at risk of breaking down Placement breakdowns present further financial costs to services; often most at risk of breaking down Placement breakdowns present further financial costs to services;
when service provision breaks down at the local level, then expensive out-of-area placements are when service provision breaks down at the local level, then expensive out-of-area placements are
commissioned. Such an outcome not only places financial burden on NHS providers, but, more commissioned. Such an outcome not only places financial burden on NHS providers, but, more
importantly, can be seen to violate the person’s human rights. Service users may become excluded from importantly, can be seen to violate the person’s human rights. Service users may become excluded from
mainstream community services, are at risk of experiencing reduced contact with their family and mainstream community services, are at risk of experiencing reduced contact with their family and
friendship networks, and serving to exacerbate behaviours which are already seen as ‘challenging’ (see friendship networks, and serving to exacerbate behaviours which are already seen as ‘challenging’ (see
also Bush, 2007; Bailey, Ridley and Greenhill, 2010). also Bush, 2007; Bailey, Ridley and Greenhill, 2010).

In line with ‘Valuing People’ (2001) and ‘Valuing People Now’ (2009a), the Mansell Reports (DH, 1993; In line with ‘Valuing People’ (2001) and ‘Valuing People Now’ (2009a), the Mansell Reports (DH, 1993;
DH, 2007) outline ways in which people with Learning Disabilities can continue to have their rights, DH, 2007) outline ways in which people with Learning Disabilities can continue to have their rights,
independence, inclusion and choices recognised by the services at local level to avoid such outcomes. independence, inclusion and choices recognised by the services at local level to avoid such outcomes.
Consequently, in aiming to implement such recommendations, the creation of ethical decision making Consequently, in aiming to implement such recommendations, the creation of ethical decision making
teams should be employed, with organisational support systems mapped-out and provided-for to ensure teams should be employed, with organisational support systems mapped-out and provided-for to ensure
such models are adhered to. Again, such models should be based on recommendations made by Mansell such models are adhered to. Again, such models should be based on recommendations made by Mansell
(2007) for both the commissioning and implementation of such services. (2007) for both the commissioning and implementation of such services.

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Mediator Analysis Mediator Analysis

The principle of non-discrimination is key within a human rights based approach; subtle prejudices can The principle of non-discrimination is key within a human rights based approach; subtle prejudices can
have serious consequences and it is vital that staff are aware of how their own biases may, however have serious consequences and it is vital that staff are aware of how their own biases may, however
unwittingly, lay the basis for discrimination. unwittingly, lay the basis for discrimination.

When analysing documents written by another person, the perspective of the writer must be considered. When analysing documents written by another person, the perspective of the writer must be considered.
Understanding the staff member’s context may help us to understand meaning they may have attributed Understanding the staff member’s context may help us to understand meaning they may have attributed
to any given situation. For example, an experienced staff member may trivialise an incident that an to any given situation. For example, an experienced staff member may trivialise an incident that an
inexperienced staff member may have deemed serious, or the staff member and the individual may inexperienced staff member may have deemed serious, or the staff member and the individual may
clash on an interpersonal level, and therefore the incident may be documented in a way that reflects clash on an interpersonal level, and therefore the incident may be documented in a way that reflects
this. The knowledge, meanings and language different people use, effect their observations and this. The knowledge, meanings and language different people use, effect their observations and
narratives of events. Consequently, how these events are interpreted and documented will affect narratives of events. Consequently, how these events are interpreted and documented will affect
intervention, and moreover affect any decisions that will concern the person’s reputation and future intervention, and moreover affect any decisions that will concern the person’s reputation and future
choices. choices.

How staff respond to episodes of challenging behaviour is dependent on their beliefs and the strategies How staff respond to episodes of challenging behaviour is dependent on their beliefs and the strategies
they employ when attempting to assign understanding to such behaviour. For example, a study by Grey, they employ when attempting to assign understanding to such behaviour. For example, a study by Grey,
McClean and Barnes-Holme (2002) identified the potential for staff responses to intensify the situation. McClean and Barnes-Holme (2002) identified the potential for staff responses to intensify the situation.
These authors highlighted how the power and knowledge of professionals served them in their role. For These authors highlighted how the power and knowledge of professionals served them in their role. For
example, staff may implement chemical or behavioural strategies to change an individual’s behaviour, example, staff may implement chemical or behavioural strategies to change an individual’s behaviour,
yet in some cases this may be done in the absence of a thorough understanding as to the reasons for yet in some cases this may be done in the absence of a thorough understanding as to the reasons for
such behaviours. such behaviours.

How staff teams respond to behaviours, and the support strategies that they subsequently employ to How staff teams respond to behaviours, and the support strategies that they subsequently employ to
remediate those challenges, may act as barriers for those in their care, because those Service Users remediate those challenges, may act as barriers for those in their care, because those Service Users
might not be accepted by the wider society, which in turn will likely limit these persons’ opportunities to might not be accepted by the wider society, which in turn will likely limit these persons’ opportunities to
integrate into the society (Lavigna and Willis, 1995). Moreover, studies such as Jones and Stenfert- integrate into the society (Lavigna and Willis, 1995). Moreover, studies such as Jones and Stenfert-
Kroese (2006) have also highlighted Service Users views on ‘controlling’ techniques such as restraint Kroese (2006) have also highlighted Service Users views on ‘controlling’ techniques such as restraint
procedures, and how such procedures can violate personal space (Topping-Morris, 1995), can threaten procedures, and how such procedures can violate personal space (Topping-Morris, 1995), can threaten
injury to both Service Users and staff (Hill and Spreat, 1987), and can result in devalued images of the injury to both Service Users and staff (Hill and Spreat, 1987), and can result in devalued images of the
Service User (Middlewick,2000). Furthermore, research has also found that in some instances Service Service User (Middlewick,2000). Furthermore, research has also found that in some instances Service
Users have questioned whether restraint techniques do indeed achieve the ‘desired’ effect (e.g. to ‘calm’ Users have questioned whether restraint techniques do indeed achieve the ‘desired’ effect (e.g. to ‘calm’
a person down), and moreover whether staff actually enjoy performing restraint (Jones and Stenfert- a person down), and moreover whether staff actually enjoy performing restraint (Jones and Stenfert-
Kroese, 2006). Consequently, in a human rights-driven approach, it is essential to consider whether such Kroese, 2006). Consequently, in a human rights-driven approach, it is essential to consider whether such
restriction techniques have a legitimate aim, are lawful, necessary, and proportionate. restriction techniques have a legitimate aim, are lawful, necessary, and proportionate.

LaVigna and Willis (1995) suggested that staff team’s support strategies need to be evaluated not only LaVigna and Willis (1995) suggested that staff team’s support strategies need to be evaluated not only
in terms of the durability and generalization of their effects, also with regards to their social, clinical and in terms of the durability and generalization of their effects, also with regards to their social, clinical and
educational validity, whilst being mindful of any ‘side-effects’ produced. In short, LaVigna and Willis educational validity, whilst being mindful of any ‘side-effects’ produced. In short, LaVigna and Willis
(1995) suggest that the focus of such interventions should not simply be the elimination of target (1995) suggest that the focus of such interventions should not simply be the elimination of target
events, but more importantly should strive to ‘contribute to the overall quality of the person’s life’. To events, but more importantly should strive to ‘contribute to the overall quality of the person’s life’. To
achieve such a goal, therefore, and consequently to support individuals to have increased access, achieve such a goal, therefore, and consequently to support individuals to have increased access,
opportunity, competency, choice, control, and to develop nurturing and mutually gratifying relationships, opportunity, competency, choice, control, and to develop nurturing and mutually gratifying relationships,
multidisciplinary (and multi-agency) teams need to work in constantly collaborative ways with each multidisciplinary (and multi-agency) teams need to work in constantly collaborative ways with each
other. other.

LaVigna and Willis (1995) argue that achieving such a ‘complex array of…outcomes’ means it is often LaVigna and Willis (1995) argue that achieving such a ‘complex array of…outcomes’ means it is often
not possible to adopt any one sole strategy, and that desired outcomes often require ‘multi-element not possible to adopt any one sole strategy, and that desired outcomes often require ‘multi-element
support plans…whose components…address the full range of outcome requirements.’ These authors, support plans…whose components…address the full range of outcome requirements.’ These authors,
therefore, have provided a model, “Breaking the Barrier”, which was set out in an attempt to overcome therefore, have provided a model, “Breaking the Barrier”, which was set out in an attempt to overcome
these obstacles. Their model places heavy emphasis on multidisciplinary teamwork when attempting to these obstacles. Their model places heavy emphasis on multidisciplinary teamwork when attempting to
overcome any barriers to social and community integration, and identify mediator analyses as crucial to overcome any barriers to social and community integration, and identify mediator analyses as crucial to
any success in achieving these aims. Such a model, where possible they argue, should involve a any success in achieving these aims. Such a model, where possible they argue, should involve a
collaborative, pro-active approach to individual care planning, incorporating both proactive strategies collaborative, pro-active approach to individual care planning, incorporating both proactive strategies
(e.g. ecological changes; positive programming; focussed support) alongside agreed, legitimate, lawful, (e.g. ecological changes; positive programming; focussed support) alongside agreed, legitimate, lawful,
proportionate reactive strategies. Furthermore, LaVigna and Willis (1995) stress the importance of proportionate reactive strategies. Furthermore, LaVigna and Willis (1995) stress the importance of

20 20
teamwork in producing desired outcomes for any support plan, in that all team members should teamwork in producing desired outcomes for any support plan, in that all team members should
implement plans collaboratively with the Service User, in as full and consistent a manner as possible. implement plans collaboratively with the Service User, in as full and consistent a manner as possible.

Staff Characteristics Staff Characteristics

Roy (2000) described the key attributes of a good care coordinator; these are also applicable to Roy (2000) described the key attributes of a good care coordinator; these are also applicable to
clinicians completing a comprehensive risk plan. Attributes include; clinicians completing a comprehensive risk plan. Attributes include;

o A good understanding of the mental health needs of individuals with learning disabilities o A good understanding of the mental health needs of individuals with learning disabilities

o Knowledge of the Service User and his/her family o Knowledge of the Service User and his/her family

o Have an awareness of the individual’s race, gender, social and cultural context, etc. o Have an awareness of the individual’s race, gender, social and cultural context, etc.

o Knowledge of and communication with all agencies and teams who have a role in the o Knowledge of and communication with all agencies and teams who have a role in the
individual’s life individual’s life

Additionally, recent guidelines from the Department of Health (DH, 2007) with regards to best practice Additionally, recent guidelines from the Department of Health (DH, 2007) with regards to best practice
in risk management suggest the following essentials for staff when working with Service Users and in risk management suggest the following essentials for staff when working with Service Users and
carers: carers:

1. That all staff involved in risk management must be capable of demonstrating sensitivity and 1. That all staff involved in risk management must be capable of demonstrating sensitivity and
competence in relation to diversity in race, faith, age, gender, disability and sexual orientation, competence in relation to diversity in race, faith, age, gender, disability and sexual orientation,
and and

2. That risk management must always be based on awareness of the capacity for the Service 2. That risk management must always be based on awareness of the capacity for the Service
User’s risk level to change over time, and a recognition that each Service User requires a User’s risk level to change over time, and a recognition that each Service User requires a
consistent and individualised approach. consistent and individualised approach.

Factors in Risk Assessment Factors in Risk Assessment

Department of Health guidance (Department of Health, HSG\94\27, 1994) on the discharge of offenders Department of Health guidance (Department of Health, HSG\94\27, 1994) on the discharge of offenders
suggests the following issues and sources were important in risk assessment: suggests the following issues and sources were important in risk assessment:

o Past history of the person. o Past history of the person.

o Self-reporting of the person at interview. o Self-reporting of the person at interview.

o Observation of the behaviour and mental state of the person. o Observation of the behaviour and mental state of the person.

o Discrepancies between what is reported and what is observed. o Discrepancies between what is reported and what is observed.

o Statistics derived from studies of related cases. o Statistics derived from studies of related cases.

o Prediction indicators derived from research pertinent to those with learning disabilities. o Prediction indicators derived from research pertinent to those with learning disabilities.

Risk assessment with people with learning disability has much the same purpose and content, as Clare Risk assessment with people with learning disability has much the same purpose and content, as Clare
(1993) highlighted that the aim of assessment was to clarify the factors contributing to the aetiology (1993) highlighted that the aim of assessment was to clarify the factors contributing to the aetiology
and maintenance of the individual’s offending. All of the above issues and attributes are important when and maintenance of the individual’s offending. All of the above issues and attributes are important when
completing a comprehensive risk assessment. completing a comprehensive risk assessment.

Recent guidelines developed by the Department of Health (2007; see above) have suggested that: Recent guidelines developed by the Department of Health (2007; see above) have suggested that:

• Best practice involves making decisions based on knowledge of the research evidence, • Best practice involves making decisions based on knowledge of the research evidence,
knowledge of the individual Service User and their social context, knowledge of the Service knowledge of the individual Service User and their social context, knowledge of the Service
User’s own experience, and clinical judgment. User’s own experience, and clinical judgment.

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 Moreover, the guidelines state that such practice incorporates the following key fundamental Moreover, the guidelines state that such practice incorporates the following key fundamental
requirements; requirements;

• That positive risk management as part of a carefully constructed plan is a required competence • That positive risk management as part of a carefully constructed plan is a required competence
for all mental health practitioners. for all mental health practitioners.

• That risk management should be conducted in a spirit of collaboration and based on a • That risk management should be conducted in a spirit of collaboration and based on a
relationship between the Service User and their carers that is as trusting as possible. relationship between the Service User and their carers that is as trusting as possible.

• That risk management must be built on a recognition of the Service User’s strengths, and • That risk management must be built on a recognition of the Service User’s strengths, and

• That risk management requires an organisational strategy as well as efforts by the individual • That risk management requires an organisational strategy as well as efforts by the individual
practitioner. practitioner.

The guidelines go on to suggest the following basic ideas in risk management: The guidelines go on to suggest the following basic ideas in risk management:

• Risk management involves developing flexible strategies aimed at preventing any negative event • Risk management involves developing flexible strategies aimed at preventing any negative event
from occurring or, if this is not possible, minimising the harm caused. from occurring or, if this is not possible, minimising the harm caused.

• Risk management should take into account that risk can be both general and specific, and that • Risk management should take into account that risk can be both general and specific, and that
good management can reduce and prevent harm. good management can reduce and prevent harm.

• Knowledge and understanding of legislation (e.g. mental health legislation) is an important • Knowledge and understanding of legislation (e.g. mental health legislation) is an important
component of risk management. component of risk management.

• The risk management plan should include a summary of all risks identified, formulations of the • The risk management plan should include a summary of all risks identified, formulations of the
situations in which identified risks may occur, and actions to be taken by practitioners and the situations in which identified risks may occur, and actions to be taken by practitioners and the
Service User in response to crisis. Service User in response to crisis.

Finally, the guidelines offer the following points as examples of best practice in managing risk: Finally, the guidelines offer the following points as examples of best practice in managing risk:

• That where suitable tools are available, risk management should be based on assessment using • That where suitable tools are available, risk management should be based on assessment using
the structured clinical judgment approach, and the structured clinical judgment approach, and

• That risk assessment is integral to deciding on the most appropriate level of risk management • That risk assessment is integral to deciding on the most appropriate level of risk management
and the right kind of intervention for a Service User. and the right kind of intervention for a Service User.

Webster and Eaves (1995) identified that the circumstances in which an assessment occurred should Webster and Eaves (1995) identified that the circumstances in which an assessment occurred should
also be considered. They argue that although most authorities agree that assessing dangerousness and also be considered. They argue that although most authorities agree that assessing dangerousness and
risk of violence is a difficult task, they have not attended to the basic task of ensuring that conditions for risk of violence is a difficult task, they have not attended to the basic task of ensuring that conditions for
evaluation are made as near ideal as possible. This includes ensuring that assessors have sufficient time evaluation are made as near ideal as possible. This includes ensuring that assessors have sufficient time
and resources to complete the assessment. and resources to complete the assessment.

Risk assessments must be thorough and systematic. Assessors should acquaint themselves fully with Risk assessments must be thorough and systematic. Assessors should acquaint themselves fully with
the relevant aspects of a file before rendering opinion. Predictions about risk should be in specific terms the relevant aspects of a file before rendering opinion. Predictions about risk should be in specific terms
for specific periods. They should not be framed in terms of yes/no, but in terms of the probability of for specific periods. They should not be framed in terms of yes/no, but in terms of the probability of
certain behaviours in certain circumstances. certain behaviours in certain circumstances.

Webster and Eaves (1995) break down the process of risk assessment into three phases: Webster and Eaves (1995) break down the process of risk assessment into three phases:

o Phase 1 o Phase 1
This is concerned with the orderly and detailed review and cross-checking of historical and This is concerned with the orderly and detailed review and cross-checking of historical and
statistical variables. We would add that systemic issues and context are cross referenced with statistical variables. We would add that systemic issues and context are cross referenced with
the appropriate documents and clinicians. the appropriate documents and clinicians.

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 o Phase 2 o Phase 2
This is taken up with a consideration of present clinical issues, including estimating how This is taken up with a consideration of present clinical issues, including estimating how
particular kinds of symptomatology might be related to potential for violent conduct. particular kinds of symptomatology might be related to potential for violent conduct.

o Phase 3 o Phase 3
This centres on forecasting how the individual might respond, given the existence of a This centres on forecasting how the individual might respond, given the existence of a
comprehensive plan, and suitable physical, social, and vocational support. This part of the comprehensive plan, and suitable physical, social, and vocational support. This part of the
evaluation is influenced not so much by files or characteristics of the individual, but on the evaluation is influenced not so much by files or characteristics of the individual, but on the
orchestration of social support systems. orchestration of social support systems.

Recently, the Department of Health (DH, 2007) have recommended the following requirements for both Recently, the Department of Health (DH, 2007) have recommended the following requirements for both
individual and team working practice when considering risk assessment and management: individual and team working practice when considering risk assessment and management:

• Risk management plans should be developed by multidisciplinary and multiagency teams • Risk management plans should be developed by multidisciplinary and multiagency teams
operating in an open, democratic and transparent culture that embraces reflective practice. operating in an open, democratic and transparent culture that embraces reflective practice.
• That all staff involved in risk management should receive relevant training, which should be • That all staff involved in risk management should receive relevant training, which should be
updated at least every three years, and updated at least every three years, and
• That a risk management plan is only as good as the time and effort put into communicating its • That a risk management plan is only as good as the time and effort put into communicating its
findings to others. findings to others.

Positive Risk Management Positive Risk Management

Moreover, the 2007 guidelines emphasise Positive Risk Management, which is defined as: Moreover, the 2007 guidelines emphasise Positive Risk Management, which is defined as:

“being aware that risk can never be completely eliminated, and aware that “being aware that risk can never be completely eliminated, and aware that
management plans inevitably have to include decisions that carry some risk” management plans inevitably have to include decisions that carry some risk”

and that: and that:

“This should be explicit in the decision-making process, and should be “This should be explicit in the decision-making process, and should be
discussed openly with the Service User” discussed openly with the Service User”

Positive risk management therefore includes: Positive risk management therefore includes:
• Working with the Service User to identify what is likely to work; • Working with the Service User to identify what is likely to work;

• Paying attention to the views of carers and others around the service • Paying attention to the views of carers and others around the service
user when deciding a plan of action; user when deciding a plan of action;

• Weighing up the potential benefits and harms of choosing one action • Weighing up the potential benefits and harms of choosing one action
over another; over another;

• being willing to take a decision that involves an element of risk because • being willing to take a decision that involves an element of risk because
the potential positive benefits outweigh the risk; the potential positive benefits outweigh the risk;

• being clear to all involved about the potential benefits and the potential • being clear to all involved about the potential benefits and the potential
risks; risks;

• developing plans and actions that support the positive potentials and • developing plans and actions that support the positive potentials and
priorities stated by the Service User, and minimise the risks to the service priorities stated by the Service User, and minimise the risks to the service
user or others; user or others;

• ensuring that the Service User, carer and others who might be affected • ensuring that the Service User, carer and others who might be affected
are fully informed of the decision, the reasons for it and the associated plans; are fully informed of the decision, the reasons for it and the associated plans;

and and

23 23
 • using available resources and support to achieve a balance between a • using available resources and support to achieve a balance between a
focus on achieving the desired outcomes and minimising the potential harmful outcome. focus on achieving the desired outcomes and minimising the potential harmful outcome.

2.5 The Service Context of Assessment 2.5 The Service Context of Assessment

Assessing a person with a learning disability may present unique difficulties. Clare (1993) lists these Assessing a person with a learning disability may present unique difficulties. Clare (1993) lists these
potential problems as: potential problems as:

o Poor memory. o Poor memory.

o Acquiescence and suggestibility. o Acquiescence and suggestibility.
o Reading problems. o Reading problems.
o Poor understanding of complex language and concepts. o Poor understanding of complex language and concepts.
o Responding inappropriately to questions due to poor understanding. o Responding inappropriately to questions due to poor understanding.

Such problems may be minimised by use of open, general questions, and back-up checks using audio Such problems may be minimised by use of open, general questions, and back-up checks using audio
tapes. Standard measures may be adaptable to pictorial form, and response scales simplified. tapes. Standard measures may be adaptable to pictorial form, and response scales simplified.
Responses to fictionalised vignettes are another method. Service Users may need training in order to Responses to fictionalised vignettes are another method. Service Users may need training in order to
understand the significance of such cues, particularly when used with physiological measures. The understand the significance of such cues, particularly when used with physiological measures. The
effect of medication may also mask responses and make assessment more difficult. effect of medication may also mask responses and make assessment more difficult.

Clare and Murphy (1993) also point out that consent is required unless the patient is under a Mental Clare and Murphy (1993) also point out that consent is required unless the patient is under a Mental
Health Act (2007) detention order. However the Mental Capacity Act (2005) provides a statutory Health Act (2007) detention order. However the Mental Capacity Act (2005) provides a statutory
framework to empower and protect vulnerable people who are not able to make their own decisions. It framework to empower and protect vulnerable people who are not able to make their own decisions. It
makes it clear who can take decisions, in which situations, and how they should go about this. The makes it clear who can take decisions, in which situations, and how they should go about this. The
Mental Capacity Act is underpinned by the following five key principles; Mental Capacity Act is underpinned by the following five key principles;

o A presumption of capacity - every adult has the right to make his or her own decisions and o A presumption of capacity - every adult has the right to make his or her own decisions and
must be assumed to have capacity to do so unless it is proved otherwise; must be assumed to have capacity to do so unless it is proved otherwise;

o The right for individuals to be supported to make their own decisions - people must be o The right for individuals to be supported to make their own decisions - people must be
given all appropriate help before anyone concludes that they cannot make their own decisions; given all appropriate help before anyone concludes that they cannot make their own decisions;

o That individuals must retain the right to make what might be seen as eccentric or o That individuals must retain the right to make what might be seen as eccentric or
unwise decisions; unwise decisions;

o Best interests – anything done for or on behalf of people without capacity must be in their o Best interests – anything done for or on behalf of people without capacity must be in their
best interests; and best interests; and

o Least restrictive intervention – anything done for or on behalf of people without capacity should o Least restrictive intervention – anything done for or on behalf of people without capacity should
be the least restrictive of their basic rights and freedoms be the least restrictive of their basic rights and freedoms

Issues may arise with regards to confidentiality. However through the development of the Mental Issues may arise with regards to confidentiality. However through the development of the Mental
Capacity Act it is now possible to identify a framework for minimising risk and service response if re- Capacity Act it is now possible to identify a framework for minimising risk and service response if re-
offending occurs is possible. Clare and Murphy (1993) go on to list the preliminary requirements of offending occurs is possible. Clare and Murphy (1993) go on to list the preliminary requirements of
assessment; assessment;

o Clarify agency roles. o Clarify agency roles.

o Clarify the nature of the behaviour and action planned or taken as a result. o Clarify the nature of the behaviour and action planned or taken as a result.
o Collation of evidence. o Collation of evidence.
o Confidentiality issues discussed. o Confidentiality issues discussed.
o Non-threatening but safe interview setting. o Non-threatening but safe interview setting.
o Safeguards regarding repetition during interview. o Safeguards regarding repetition during interview.
o Named contact in each agency established. o Named contact in each agency established.
o Case manager identified. o Case manager identified.
o Key worker’s involvement. o Key worker’s involvement.
o Progress meetings arranged. o Progress meetings arranged.

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Clare and Murphy (1993) state that while mainstream forensic assessment is cognitive-behavioural, Clare and Murphy (1993) state that while mainstream forensic assessment is cognitive-behavioural,
there is a lack of evidence for the efficacy of this approach for people with learning disabilities. there is a lack of evidence for the efficacy of this approach for people with learning disabilities.
Therefore, broad based assessment is needed, using self-report, reports from others, behavioural Therefore, broad based assessment is needed, using self-report, reports from others, behavioural
observations, and archival material. Given the predominance of mild disabilities among offenders, self- observations, and archival material. Given the predominance of mild disabilities among offenders, self-
report should be possible, but may require additional resources (e.g. pictorial aids). Self-report report should be possible, but may require additional resources (e.g. pictorial aids). Self-report
measures developed in mainstream forensic work are generally unsuitable because they demand measures developed in mainstream forensic work are generally unsuitable because they demand
reading skills and/or use concepts, rating scales etc., which are inaccessible. reading skills and/or use concepts, rating scales etc., which are inaccessible.

2.6 The Importance of Life Events 2.6 The Importance of Life Events

The importance of understanding the meaning of aspects of behaviour, or their function, particularly The importance of understanding the meaning of aspects of behaviour, or their function, particularly
with regards to behaviours which ultimately become labelled ‘challenging’, is well documented within the with regards to behaviours which ultimately become labelled ‘challenging’, is well documented within the
literature pertaining to individuals with Learning Disabilities (see Emerson, 2001). Moreover, literature pertaining to individuals with Learning Disabilities (see Emerson, 2001). Moreover,
understanding these behaviours as means of communication has also often been addressed within the understanding these behaviours as means of communication has also often been addressed within the
literature (Emerson and Bromley, 1995). As previously discussed, such behaviours have often evolved literature (Emerson and Bromley, 1995). As previously discussed, such behaviours have often evolved
over many years, and those who display such behaviours have lives often bereft of meaningful over many years, and those who display such behaviours have lives often bereft of meaningful
relationships, power, a sense of safety and well-being, or value and worth, relevant skills and relationships, power, a sense of safety and well-being, or value and worth, relevant skills and
knowledge, and things to look forward to. Minimising or ignoring such needs in human services settings, knowledge, and things to look forward to. Minimising or ignoring such needs in human services settings,
therefore, can result in persons becoming depressed, isolated, helpless, insecure, and sometimes therefore, can result in persons becoming depressed, isolated, helpless, insecure, and sometimes
persistent ‘rule’-breakers (Pitonyak, 2001). persistent ‘rule’-breakers (Pitonyak, 2001).

It is important therefore to view evolved behaviours within this context, as such an approach can foster It is important therefore to view evolved behaviours within this context, as such an approach can foster
and encourage the development of sound relationships with these persons, and encourage team and encourage the development of sound relationships with these persons, and encourage team
members to concentrate more fully on working with the person, as opposed to focussing solely on those members to concentrate more fully on working with the person, as opposed to focussing solely on those
behaviours considered problematic. Moreover, authors have suggested that such behaviours derive behaviours considered problematic. Moreover, authors have suggested that such behaviours derive
initially from the persons’ attempts to problem-solve or sort a problem out; in other words their best initially from the persons’ attempts to problem-solve or sort a problem out; in other words their best
attempt at finding a solution to a problem (Pitonyak, 2001). Over time, therefore, such an initial attempt attempt at finding a solution to a problem (Pitonyak, 2001). Over time, therefore, such an initial attempt
at solution ultimately evolves and becomes labelled a ‘challenging’ behaviour. at solution ultimately evolves and becomes labelled a ‘challenging’ behaviour.

By employing such a model to our practice, the importance of a person’s life events inevitably become By employing such a model to our practice, the importance of a person’s life events inevitably become
more salient to all aspects when assessing for any level of risk. Researchers generally agree on the more salient to all aspects when assessing for any level of risk. Researchers generally agree on the
importance of studying a person’s records thoroughly and constructing an accurate history. Monahan importance of studying a person’s records thoroughly and constructing an accurate history. Monahan
(1981) reminds us that; (1981) reminds us that;

“If there is one finding that overshadows all others in the area of prediction, it “If there is one finding that overshadows all others in the area of prediction, it
is that the probability of future crime increases with each prior criminal act” is that the probability of future crime increases with each prior criminal act”

As with offenders who have mental health difficulties, there is a consensus in the literature that previous As with offenders who have mental health difficulties, there is a consensus in the literature that previous
offending is a powerful predictor of future offending with people who have a learning disability. Payne offending is a powerful predictor of future offending with people who have a learning disability. Payne
et. al. (1974) found that offenders with a conviction prior to the offence that led to the current hospital et. al. (1974) found that offenders with a conviction prior to the offence that led to the current hospital
order were twice as likely to be convicted again during the 2 years after discharge than those with no order were twice as likely to be convicted again during the 2 years after discharge than those with no
such previous offence. Those with six or more previous convictions were four times more likely to be such previous offence. Those with six or more previous convictions were four times more likely to be
re-convicted than those with no previous offence. In support of this, Day (1993) found that the risk of re-convicted than those with no previous offence. In support of this, Day (1993) found that the risk of
recidivism within the learning disabled population is highest during the year immediately following recidivism within the learning disabled population is highest during the year immediately following
discharge. Gibbens and Robertson (1983) carried out a multiple-regression analysis of the factors discharge. Gibbens and Robertson (1983) carried out a multiple-regression analysis of the factors
predisposing to subsequent offences in their cohort and found that for all categories the best single predisposing to subsequent offences in their cohort and found that for all categories the best single
predictor of reconviction was the number of previous court appearances; however it is not clear whether predictor of reconviction was the number of previous court appearances; however it is not clear whether
age, gender, sexuality, race, etc was controlled for. Both Payne et. al.. and Gibbens and Robertson age, gender, sexuality, race, etc was controlled for. Both Payne et. al.. and Gibbens and Robertson
identified that learning disabled and offenders with psychopathic symptoms were more likely to be re- identified that learning disabled and offenders with psychopathic symptoms were more likely to be re-
convicted than individuals with mental health difficulties. convicted than individuals with mental health difficulties.

Day (1990) suggests the following pattern. Firstly, while one offence is not necessarily predictive of Day (1990) suggests the following pattern. Firstly, while one offence is not necessarily predictive of
future offending behaviour, a history of previous convictions is strongly predictive of future failure. future offending behaviour, a history of previous convictions is strongly predictive of future failure.
Secondly, that the chance of re-offending and reconviction among those under hospital orders is high, Secondly, that the chance of re-offending and reconviction among those under hospital orders is high,
and increases in proportion to length of follow-up. Thirdly, very few re-offenders commit serious and increases in proportion to length of follow-up. Thirdly, very few re-offenders commit serious
offences. Fourthly, that longer institutional care is associated with lower re-offending rates, perhaps offences. Fourthly, that longer institutional care is associated with lower re-offending rates, perhaps

25 25
showing that prolonged socialisation is effective, although it may be that there is an age effect showing that prolonged socialisation is effective, although it may be that there is an age effect
operating. operating.

2.7 Actuarial Characteristics of People with Learning Disabilities who Offend 2.7 Actuarial Characteristics of People with Learning Disabilities who Offend

Logan (2007), in “Implementing best practice in managing risk in England” highlights that no risk Logan (2007), in “Implementing best practice in managing risk in England” highlights that no risk
assessment should be based solely on actuarial assessment. Rather any such assessment should assessment should be based solely on actuarial assessment. Rather any such assessment should
combine both clinical and actuarial assessment, and we would add, should be underpinned by a human combine both clinical and actuarial assessment, and we would add, should be underpinned by a human
rights based approach. Thus when undertaking an analysis of the actuarial characteristics the person’s rights based approach. Thus when undertaking an analysis of the actuarial characteristics the person’s
human rights should be considered at all times. human rights should be considered at all times.

Whilst there has been much work in the area of offenders in general, and those with mental health Whilst there has been much work in the area of offenders in general, and those with mental health
difficulties in particular, there is not a great deal in the area of learning disability. This is partly because difficulties in particular, there is not a great deal in the area of learning disability. This is partly because
learning disability tends to be administratively defined and biased to those with moderate to profound learning disability tends to be administratively defined and biased to those with moderate to profound
disabilities. The propensity to offending behaviour however is more likely to be higher among those disabilities. The propensity to offending behaviour however is more likely to be higher among those
with mild or borderline disabilities. with mild or borderline disabilities.

Clare and Murphy (1998) have highlighted that the term offender is often used in relation to people Clare and Murphy (1998) have highlighted that the term offender is often used in relation to people
diagnosed with a learning disability, specifically when considering challenging behaviour, which could diagnosed with a learning disability, specifically when considering challenging behaviour, which could
constitute a criminal act. In English law, a behaviour or an act and its consequences (the ‘actus reus’) is constitute a criminal act. In English law, a behaviour or an act and its consequences (the ‘actus reus’) is
not considered to be criminal act unless combined with ‘guilty state of mind’ (‘mens rea’). ‘Mens rea’ not considered to be criminal act unless combined with ‘guilty state of mind’ (‘mens rea’). ‘Mens rea’
refers to the mental element of the offence and comprises of four classes: intention; knowledge; refers to the mental element of the offence and comprises of four classes: intention; knowledge;
recklessness; negligence, along with the presence or absence of foresight. Holland et.al. (2002) recklessness; negligence, along with the presence or absence of foresight. Holland et.al. (2002)
acknowledge that this area is blurred in terms of what constitutes a challenging behaviour and what is acknowledge that this area is blurred in terms of what constitutes a challenging behaviour and what is
an offence. an offence.

Evidence about challenging behaviour (Emerson et. al.. 2001) identified that; Evidence about challenging behaviour (Emerson et. al.. 2001) identified that;

o Challenging behaviours were demonstrated by between 10-15% of individuals with a learning o Challenging behaviours were demonstrated by between 10-15% of individuals with a learning
disability who were in contact with educational, health and/or social services. disability who were in contact with educational, health and/or social services.

o The most common forms of challenging behaviours were described as “other” (recorded by 9- o The most common forms of challenging behaviours were described as “other” (recorded by 9-
12% of all people questioned), aggression (7%), destructive behaviour (4-5%) and self- 12% of all people questioned), aggression (7%), destructive behaviour (4-5%) and self-
injurious behaviour (4%). injurious behaviour (4%).

o The majority of people identified as having challenging behaviour demonstrated two or more of o The majority of people identified as having challenging behaviour demonstrated two or more of
the above behaviours. the above behaviours.

o Approximately two thirds of those identified were male o Approximately two thirds of those identified were male

o Almost two thirds of those identified were adolescents or young adults o Almost two thirds of those identified were adolescents or young adults

o Approximately half of those identified as illustrating more demanding challenging behaviours o Approximately half of those identified as illustrating more demanding challenging behaviours
lived with their families lived with their families

o Those who demonstrated more demanding challenging behaviour tended to need more o Those who demonstrated more demanding challenging behaviour tended to need more
assistance in self care and have restricted expressive and receptive communication. assistance in self care and have restricted expressive and receptive communication.

Quinsey (2004) has highlighted the now considerable research into the actuarial assessment of long- Quinsey (2004) has highlighted the now considerable research into the actuarial assessment of long-
term risk in offending populations. However, little of this research has been used to explore offenders term risk in offending populations. However, little of this research has been used to explore offenders
who have a learning disability. In recent years, research has begun to explore both the characteristics who have a learning disability. In recent years, research has begun to explore both the characteristics
and prevalence of offenders with a learning disability. and prevalence of offenders with a learning disability.

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Individual Characteristics Individual Characteristics
Holland et.al.’s (2002) review suggests that there are two distinct groups of people with learning Holland et.al.’s (2002) review suggests that there are two distinct groups of people with learning
disability who offend; the first is described as a broad group of people who are intellectually and socially disability who offend; the first is described as a broad group of people who are intellectually and socially
disadvantaged who may not be known or included in learning disability services. This group is disadvantaged who may not be known or included in learning disability services. This group is
characterised by; a higher ratio of males to females, mental illness and substance misuse and history of characterised by; a higher ratio of males to females, mental illness and substance misuse and history of
risk taking, impulsivity and social exclusion. The second group is usually known to services and risk taking, impulsivity and social exclusion. The second group is usually known to services and
comprises of people who exhibit challenging behaviour, which may be perceived as offending. The comprises of people who exhibit challenging behaviour, which may be perceived as offending. The
following characteristics have been identified (Simpson & Hogg, 2001, Holland et.al., 2002) that indicate following characteristics have been identified (Simpson & Hogg, 2001, Holland et.al., 2002) that indicate
if an individual is at greater risk of offending, many of which overlap the evidence provided by Emerson if an individual is at greater risk of offending, many of which overlap the evidence provided by Emerson
et.al. (2001) for those displaying challenging behaviours. et.al. (2001) for those displaying challenging behaviours.

Simpson and Hogg (2001) and Holland et. al. (2002) reviewed the evidence for people with learning Simpson and Hogg (2001) and Holland et. al. (2002) reviewed the evidence for people with learning
disabilities who offended. They identified the following characteristics that indicated if an individual was disabilities who offended. They identified the following characteristics that indicated if an individual was
at a greater risk of offending, many of which overlap the evidence provided by Emerson et. al. (2001) at a greater risk of offending, many of which overlap the evidence provided by Emerson et. al. (2001)
for those who display challenging behaviours. for those who display challenging behaviours.

o Men o Men
o Younger age groups o Younger age groups
o Less severe learning disability o Less severe learning disability
o Mental health difficulties o Mental health difficulties
o Previous offending o Previous offending
o Behavioural problems since childhood o Behavioural problems since childhood
o Psychosocial disadvantage o Psychosocial disadvantage
o Lower social class o Lower social class
o Unemployment o Unemployment

Demetral (1994) concluded that the degree of social isolation perceived by the offender was highly Demetral (1994) concluded that the degree of social isolation perceived by the offender was highly
correlated with the probability of offending and re-offending. He reported that 87% of sex offenders correlated with the probability of offending and re-offending. He reported that 87% of sex offenders
with had a learning disability, who had been referred to an outpatient treatment program run by a non- with had a learning disability, who had been referred to an outpatient treatment program run by a non-
profit organisation were not in any day care or employment programme. Adding that 84% of these profit organisation were not in any day care or employment programme. Adding that 84% of these
individuals had been physically abused and 66% sexually abused in the past. individuals had been physically abused and 66% sexually abused in the past.

In West and Farrington’s (1977) longitudinal study of boys growing up in South London, both low In West and Farrington’s (1977) longitudinal study of boys growing up in South London, both low
intelligence and educational failure were predictive of offending. It is not surprising that offender intelligence and educational failure were predictive of offending. It is not surprising that offender
populations tend to score lower on intelligence tests than the general population. Whilst there may be populations tend to score lower on intelligence tests than the general population. Whilst there may be
important educational needs in many offenders, significant learning disability (that which needs special important educational needs in many offenders, significant learning disability (that which needs special
services) is much less common. services) is much less common.

Studies based in courts and hospitals have shown that learning disabilities have a specific association Studies based in courts and hospitals have shown that learning disabilities have a specific association
with sexual offending. Possible explanations include lack of sexual knowledge, deficiencies in social with sexual offending. Possible explanations include lack of sexual knowledge, deficiencies in social
skills, and general disinhibition associated with some individuals with a learning disability. Rejection, skills, and general disinhibition associated with some individuals with a learning disability. Rejection,
and the denial of ordinary sexual outlets, may also play a part. It is important to disentangle these and the denial of ordinary sexual outlets, may also play a part. It is important to disentangle these
factors when attempting treatment and risk management. factors when attempting treatment and risk management.

Arson has also been association with learning disability. This offence may be seen as a form of violence Arson has also been association with learning disability. This offence may be seen as a form of violence
or criminal damage which is adopted by those who are otherwise powerless, in that a small action can or criminal damage which is adopted by those who are otherwise powerless, in that a small action can
cause enormous damage. Arson is also more common in female offenders, probably for similar reasons. cause enormous damage. Arson is also more common in female offenders, probably for similar reasons.

Most offending by those with learning disabilities is theft, as is the case with offenders from the general Most offending by those with learning disabilities is theft, as is the case with offenders from the general
population. Most are best considered as examples of the petty and frequent offender and due to their population. Most are best considered as examples of the petty and frequent offender and due to their
learning disabilities these individuals may be caught more easily. Management is often concerned with learning disabilities these individuals may be caught more easily. Management is often concerned with
circumstantial factors, including accommodation, substance misuse and protection from exploitation. circumstantial factors, including accommodation, substance misuse and protection from exploitation.
The latter is a particular problem within prison, and is a powerful argument for diversion. The latter is a particular problem within prison, and is a powerful argument for diversion.

Problems of definition and with the limitations of statistical evidence mean that it is difficult to predict Problems of definition and with the limitations of statistical evidence mean that it is difficult to predict
which behaviours individuals with learning disabilities are at risk of taking. Riding et. al. (2005) identified which behaviours individuals with learning disabilities are at risk of taking. Riding et. al. (2005) identified
that studies over the past 20 years suggested that sexual misconduct may be more common (however that studies over the past 20 years suggested that sexual misconduct may be more common (however

27 27
less serious), alcohol and drug related problems less common and physical violence offences are less less serious), alcohol and drug related problems less common and physical violence offences are less
common, at least among men, compared with the general population. The most common offences are common, at least among men, compared with the general population. The most common offences are
petty theft, burglary and vandalism. Some studies suggest that arson is over-represented among males petty theft, burglary and vandalism. Some studies suggest that arson is over-represented among males
with learning disabilities. However the use of different definitions of offending and learning disability in with learning disabilities. However the use of different definitions of offending and learning disability in
many studies has made interpretation difficult. Simpson and Hogg (2001) concluded that there was no many studies has made interpretation difficult. Simpson and Hogg (2001) concluded that there was no
convincing evidence to suggest that individuals with learning disabilities were more likely to commit any convincing evidence to suggest that individuals with learning disabilities were more likely to commit any
particular offence than anyone else. particular offence than anyone else.

Historical factors are of particular importance as several studies have identified that previous behaviour Historical factors are of particular importance as several studies have identified that previous behaviour
is a good indicator of future behaviour rates (Riding, Swann & Swann, 2005). Different offences have is a good indicator of future behaviour rates (Riding, Swann & Swann, 2005). Different offences have
different recidivism rates. Holland et. al. (2002) suggested that there may be some similarities in different recidivism rates. Holland et. al. (2002) suggested that there may be some similarities in
predictors of offending amongst those with learning disabilities and those with mental health difficulties. predictors of offending amongst those with learning disabilities and those with mental health difficulties.
They went on to add that the level and nature of offending amongst women has largely been neglected, They went on to add that the level and nature of offending amongst women has largely been neglected,
but there is some evidence that service and legal responses to offending may be different for women but there is some evidence that service and legal responses to offending may be different for women
than for men, i.e. the ‘gender lens’. than for men, i.e. the ‘gender lens’.

The evidence base relating to female offenders with a learning disability is sparse (Kendall 2004). Much The evidence base relating to female offenders with a learning disability is sparse (Kendall 2004). Much
of the research (Lindsay et. al., 2004; Holland, Clare & Mukhopadhyay, 2002) that has been carried out of the research (Lindsay et. al., 2004; Holland, Clare & Mukhopadhyay, 2002) that has been carried out
focuses specifically on the characteristics of female offenders in comparison to their male counterparts. focuses specifically on the characteristics of female offenders in comparison to their male counterparts.
Authors such as Lindsay et. al. (2004) recognise the paucity of research and have attempted to provide Authors such as Lindsay et. al. (2004) recognise the paucity of research and have attempted to provide
a “reasonable picture” (Lindsay et. al., 2004) of women with learning disabilities who offend. a “reasonable picture” (Lindsay et. al., 2004) of women with learning disabilities who offend.

Within their study, Lindsay et. al. (2004) identified that the female offenders within their study showed Within their study, Lindsay et. al. (2004) identified that the female offenders within their study showed
similar characteristics to their male counterparts. However, they noted higher levels of sexual abuse, similar characteristics to their male counterparts. However, they noted higher levels of sexual abuse,
higher levels of mental illness and lower levels of re-offending. More specifically Lindsay et. al. (2004) higher levels of mental illness and lower levels of re-offending. More specifically Lindsay et. al. (2004)
noted that mental illness appeared to be an intervening variable in the female’s offending behaviour, noted that mental illness appeared to be an intervening variable in the female’s offending behaviour,
and posit that such behaviour should reduce if the mental illness is placed at the focus of intervention. and posit that such behaviour should reduce if the mental illness is placed at the focus of intervention.
These findings have been replicated by Hayes (2007). These findings have been replicated by Hayes (2007).

One explanation for the increased rates of psychiatric disorder may relate to the tendency to pathologise One explanation for the increased rates of psychiatric disorder may relate to the tendency to pathologise
the experiences of female offenders in general since they have violated both the law and challenged the experiences of female offenders in general since they have violated both the law and challenged
what is culturally expected of them as a female (Kendall, 2004). Hence females who have offended are what is culturally expected of them as a female (Kendall, 2004). Hence females who have offended are
perceived as ‘doubly deviant’. perceived as ‘doubly deviant’.

Crawford has highlighted that women with learning disabilities in secure services are considered to be Crawford has highlighted that women with learning disabilities in secure services are considered to be
an “especially challenging group’ (Crawford, 2002) when compared to non disabled women in secure an “especially challenging group’ (Crawford, 2002) when compared to non disabled women in secure
services. Kendall (2004), has stated that female offenders with a learning disability are perceived to be services. Kendall (2004), has stated that female offenders with a learning disability are perceived to be
‘triply deviant’ by virtue of the diagnosis of learning disability. ‘triply deviant’ by virtue of the diagnosis of learning disability.

Holland et.al. (2002) also highlighted that whilst those from different ethnic minorities may be over Holland et.al. (2002) also highlighted that whilst those from different ethnic minorities may be over
represented among defendants and prisoners with learning disabilities in studies from other countries; represented among defendants and prisoners with learning disabilities in studies from other countries;
there is little evidence for this issue in the UK. there is little evidence for this issue in the UK.

2.8 Actuarial / Background Factors Related to Violence 2.8 Actuarial / Background Factors Related to Violence

Webster and Eaves (1995) identify from research a number of factors relating to the background of Webster and Eaves (1995) identify from research a number of factors relating to the background of
violent offenders in general. Many of these overlap with the research summarised by Clare and Murphy. violent offenders in general. Many of these overlap with the research summarised by Clare and Murphy.
Webster and Eaves also identify what may be ‘protective characteristics’ and go into more detail about Webster and Eaves also identify what may be ‘protective characteristics’ and go into more detail about
how background factors may operate to increase or decrease risk. Some of the factors they examine how background factors may operate to increase or decrease risk. Some of the factors they examine
are: are:

Relationship Stability Relationship Stability

It is generally found that social support works to protect against violent crime. Marriage, civil It is generally found that social support works to protect against violent crime. Marriage, civil
partnership or stability in some form of close relationship in particular seems to serve as a “protective partnership or stability in some form of close relationship in particular seems to serve as a “protective
factor”. It is worth considering how these factors may affect a person with a learning disability: factor”. It is worth considering how these factors may affect a person with a learning disability:

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Employment Stability Employment Stability
General statistics on criminal recidivism show a link between income level and conduct on parole. General statistics on criminal recidivism show a link between income level and conduct on parole.

Alcohol or Drug Abuse Alcohol or Drug Abuse

Clinicians have little difficulty recognising, on the basis of experience, the link between alcohol and drug Clinicians have little difficulty recognising, on the basis of experience, the link between alcohol and drug
abuse and violent conduct. Swanson (1994) has recently reported that, in his large-scale, multi-sided abuse and violent conduct. Swanson (1994) has recently reported that, in his large-scale, multi-sided
Epidemiological Catchment Area (ECA) project, having a substance abuse diagnosed yielded much Epidemiological Catchment Area (ECA) project, having a substance abuse diagnosed yielded much
stronger associations with violence than did having a mental disorder stronger associations with violence than did having a mental disorder

Mental Health Difficulties Mental Health Difficulties

It can be expected that, relative to the general population, individuals experiencing psychosis, or at least It can be expected that, relative to the general population, individuals experiencing psychosis, or at least
certain symptoms of it in particular stages, would have raised potential for violence certain symptoms of it in particular stages, would have raised potential for violence

Early Childhood Experiences (at Home and School) Early Childhood Experiences (at Home and School)
This variable includes consideration of both academic ability and accomplishments as well as classroom This variable includes consideration of both academic ability and accomplishments as well as classroom
conduct and general adjustment to school. Assessors will be interested in progress through the grades, conduct and general adjustment to school. Assessors will be interested in progress through the grades,
marks obtained, reasons for leaving school, truancy and the like. These authors found that being marks obtained, reasons for leaving school, truancy and the like. These authors found that being
separated from parents before age 16 also yielded a significant correlation with later violent outcome. separated from parents before age 16 also yielded a significant correlation with later violent outcome.

2.9 Actuarial / Research Data on Suicide 2.9 Actuarial / Research Data on Suicide

There have been a large number of studies on the background characteristics of those who commit There have been a large number of studies on the background characteristics of those who commit
suicide. These have resulted in a well defined list of factors associated with a higher risk of suicide. suicide. These have resulted in a well defined list of factors associated with a higher risk of suicide.
Strathdee (1998) summarises this data as follows. Strathdee (1998) summarises this data as follows.

The suicide rate in men is twice that among women, and in both sexes the rate rises with age. In The suicide rate in men is twice that among women, and in both sexes the rate rises with age. In
recent years, suicide rates among men have risen in the U.K., especially young men. From this, some recent years, suicide rates among men have risen in the U.K., especially young men. From this, some
researchers have concluded that as there has been no increase in mental health difficulties, (the most researchers have concluded that as there has been no increase in mental health difficulties, (the most
common aetiology for suicide), it follows that unemployment is a significant factor. common aetiology for suicide), it follows that unemployment is a significant factor.

Depression is the most common mental health difficulty associated with suicide (Strathdee, 1998). The Depression is the most common mental health difficulty associated with suicide (Strathdee, 1998). The
Health of the Nation handbook delineates the order of risk for the three other groups which carry high Health of the Nation handbook delineates the order of risk for the three other groups which carry high
mortality rates; mortality rates;

o affective disorder 15% o affective disorder 15%

o “personality disorder” 15% o “personality disorder” 15%
o alcohol dependent 15% o alcohol dependent 15%
o psychosis 10% o psychosis 10%

Previous deliberate self-harm or suicidal behaviour is a consistent predictor of future attempts. Previous deliberate self-harm or suicidal behaviour is a consistent predictor of future attempts.
Research shows a suicide rate of 1% per annum following suicide attempts. After 10 years, 11% of 484 Research shows a suicide rate of 1% per annum following suicide attempts. After 10 years, 11% of 484
attempted suicides in one study had died by suicide, the period of risk being highest immediately after attempted suicides in one study had died by suicide, the period of risk being highest immediately after
the first attempt. Most people who take their own lives have had contact with their doctor within weeks the first attempt. Most people who take their own lives have had contact with their doctor within weeks
or even days of their death. In a study of 47 suicides, 16 failed suicides and 24 attempted suicides of or even days of their death. In a study of 47 suicides, 16 failed suicides and 24 attempted suicides of
people who jumped from a high bridge over 15 years, Cantor et.al., (1989) found that one-third of all people who jumped from a high bridge over 15 years, Cantor et.al., (1989) found that one-third of all
incidents occurred while the individuals were in-patients and another one-third as outpatients. Another incidents occurred while the individuals were in-patients and another one-third as outpatients. Another
study likewise found that 91% of deaths by overdose and 71% of suicides by other means had been study likewise found that 91% of deaths by overdose and 71% of suicides by other means had been
under the care of a doctor in the previous 6 months. Patients who discharge themselves against under the care of a doctor in the previous 6 months. Patients who discharge themselves against
medical advice are also at particular risk. medical advice are also at particular risk.

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2.10 Clinical Variables 2.10 Clinical Variables

In the Historical Clinical Risk-20 Scheme (HCR-20), Webster and Eaves identify a number of clinical In the Historical Clinical Risk-20 Scheme (HCR-20), Webster and Eaves identify a number of clinical
variables that have an effect on risk. These are: variables that have an effect on risk. These are:

Insight Insight

This is defined as reasonable understanding and evaluation of one’s own mental processes, reactions, This is defined as reasonable understanding and evaluation of one’s own mental processes, reactions,
abilities; and self knowledge. There should be ample scope in an assessment to determine the extent to abilities; and self knowledge. There should be ample scope in an assessment to determine the extent to
which the individual perceives himself or herself to be dangerous, angry, or out-of-control. which the individual perceives himself or herself to be dangerous, angry, or out-of-control.

It may be useful to think of insight in terms of levels. The individual afflicted with serious psychotic It may be useful to think of insight in terms of levels. The individual afflicted with serious psychotic
symptoms may follow direction and accept medication largely because of respect or liking for the symptoms may follow direction and accept medication largely because of respect or liking for the
clinician. But there may be little self-understanding or self-appreciation of his or her condition. At clinician. But there may be little self-understanding or self-appreciation of his or her condition. At
another level, there may be recognition of some problems but this “insight” may be accompanied by a another level, there may be recognition of some problems but this “insight” may be accompanied by a
belief that the problems do not apply fully to him or her. The individual may conform to a treatment belief that the problems do not apply fully to him or her. The individual may conform to a treatment
program more to escape notice than to achieve recovery. At yet another level, the individual may program more to escape notice than to achieve recovery. At yet another level, the individual may
recognise that he or she has a serious mental disorder and, for example, it is the voices which are giving recognise that he or she has a serious mental disorder and, for example, it is the voices which are giving
instructions. But the same person may feel that the delusions are to be taken seriously and be unable instructions. But the same person may feel that the delusions are to be taken seriously and be unable
to provide distance from this material. Moving to a yet higher level, the person may recognise quite well to provide distance from this material. Moving to a yet higher level, the person may recognise quite well
the fact that she or he has an illness and that it gives rise to false sensations and perceptions. the fact that she or he has an illness and that it gives rise to false sensations and perceptions.

Within a human rights approach it would be positive to identify processes that enable insight to be Within a human rights approach it would be positive to identify processes that enable insight to be
achieved. An example of this is the “Understanding Voices and Disturbing Beliefs” guide produced by achieved. An example of this is the “Understanding Voices and Disturbing Beliefs” guide produced by
Newcastle, North Tyneside and Northumberland Mental Health Trust. This shows how people can Newcastle, North Tyneside and Northumberland Mental Health Trust. This shows how people can
identify and develop positive responses to hearing voices. Materials specifically aimed at People with a identify and develop positive responses to hearing voices. Materials specifically aimed at People with a
Learning Disability have been produced by Mersey Care NHS trust to enable people understand aspects Learning Disability have been produced by Mersey Care NHS trust to enable people understand aspects
of mental health and taking medication ‘Getting Better: Keeping your Mind Healthy’ and ‘Getting Better; of mental health and taking medication ‘Getting Better: Keeping your Mind Healthy’ and ‘Getting Better;
Taking My Medicines’, (Whitehead & Toker-Lester, 2002). It would also be appropriate to identify any Taking My Medicines’, (Whitehead & Toker-Lester, 2002). It would also be appropriate to identify any
service barriers to achieving insight. For example, are there educational materials produced in a number service barriers to achieving insight. For example, are there educational materials produced in a number
of languages or are there easy read versions of the materials? Throughout this process the clinician can of languages or are there easy read versions of the materials? Throughout this process the clinician can
work alongside the person to identify the level of insight and also look at the external barriers to work alongside the person to identify the level of insight and also look at the external barriers to
achieving insight. achieving insight.

Attitude Attitude

This is defined as an enduring, learned predisposition to behave in a consistent way toward a given This is defined as an enduring, learned predisposition to behave in a consistent way toward a given
class of objects; a persistent mental and / or neural state of readiness to react to a certain object or class of objects; a persistent mental and / or neural state of readiness to react to a certain object or
class of objects, not as they are but as they are conceived to be. Attitude is one of many terms that class of objects, not as they are but as they are conceived to be. Attitude is one of many terms that
refer to an aspect of personality inferred to account for persistent and consistent behaviour toward a refer to an aspect of personality inferred to account for persistent and consistent behaviour toward a
family of related situations or objects (English & English, 1958). family of related situations or objects (English & English, 1958).

It is very important in the assessment to determine the extent to which the individual’s pervasive It is very important in the assessment to determine the extent to which the individual’s pervasive
attitudes are pro or anti-social. There needs to be some exploration of the person’s current attitudes attitudes are pro or anti-social. There needs to be some exploration of the person’s current attitudes
towards other people and to agencies and institutions. Attitude toward the law and other authority is towards other people and to agencies and institutions. Attitude toward the law and other authority is
obviously important. As well, it is useful to gain some general index of the person’s overall state of obviously important. As well, it is useful to gain some general index of the person’s overall state of
optimism or pessimism about his or her future. optimism or pessimism about his or her future.

The clinician should be attentive to the Service User’s attitude toward their own risk behaviour. Some The clinician should be attentive to the Service User’s attitude toward their own risk behaviour. Some
individuals will be genuinely sorrowful and regretful about their behaviour, others may minimise and individuals will be genuinely sorrowful and regretful about their behaviour, others may minimise and
deny. The assessor must be at pains to discern remorselessness, callousness, lack of empathy and the deny. The assessor must be at pains to discern remorselessness, callousness, lack of empathy and the
extent to which these apply to the Service User’s current experience. extent to which these apply to the Service User’s current experience.

From a human rights perspective it is important that the source of a person’s attitude is explored. This From a human rights perspective it is important that the source of a person’s attitude is explored. This
can be done by speaking with the person about their life history and what kind of experiences have lead can be done by speaking with the person about their life history and what kind of experiences have lead
to the person’s current attitude towards other people and organisations. It is important to ascertain how to the person’s current attitude towards other people and organisations. It is important to ascertain how

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the person perceives other agencies and institutions. It may also include their perception of the person perceives other agencies and institutions. It may also include their perception of
professionals and what the professional’s role is likely to be. professionals and what the professional’s role is likely to be.

For People with a Learning Disability there has been an historical perception of abuse and mistreatment For People with a Learning Disability there has been an historical perception of abuse and mistreatment
by professionals and institutions .This perception may make it difficult for the person to engage in the by professionals and institutions .This perception may make it difficult for the person to engage in the
risk assessment process and may require addressing whilst formulating the risk assessment plan. risk assessment process and may require addressing whilst formulating the risk assessment plan.
Particular attention is required to enable a partnership rather than paternal approach to risk Particular attention is required to enable a partnership rather than paternal approach to risk
management. management.

Symptoms Symptoms

A symptom is any event or appearance that occurs with something else and indicates its existence or A symptom is any event or appearance that occurs with something else and indicates its existence or
occurrence. This includes something that indicates presence of a pathological condition. It is well to occurrence. This includes something that indicates presence of a pathological condition. It is well to
guard against allowing symptoms to claim a disproportionate influence in some assessments. Factors guard against allowing symptoms to claim a disproportionate influence in some assessments. Factors
other than existing frank symptoms may be much more crucial in determining risk. other than existing frank symptoms may be much more crucial in determining risk.

Stability Stability

Stability is a characteristic of a person not given to swings in mood or marked changes in emotional Stability is a characteristic of a person not given to swings in mood or marked changes in emotional
attitude. It is surely the case that the actions of emotionally stable persons are more easier to predict attitude. It is surely the case that the actions of emotionally stable persons are more easier to predict
than those of unstable people. than those of unstable people.

Treatability Treatability

Treatment is any measure to ameliorate an undesirable condition; an endeavour to help a person attain Treatment is any measure to ameliorate an undesirable condition; an endeavour to help a person attain
better health or better adjustment by whatever means. It is of great interest to the assessor whether better health or better adjustment by whatever means. It is of great interest to the assessor whether
an individual has responded to past and present attempts at remediation or treatment. Some an individual has responded to past and present attempts at remediation or treatment. Some
knowledge is also needed about the amount of effort the person has applied to therapy, education or knowledge is also needed about the amount of effort the person has applied to therapy, education or
vocational advance. vocational advance.

There would also be a requirement to establish the suitability of a previous treatment plan for a person There would also be a requirement to establish the suitability of a previous treatment plan for a person
i.e. was the Sex Offenders Treatment Programme (Murphy, Powells, Guznan & Hays, 2007) adapted i.e. was the Sex Offenders Treatment Programme (Murphy, Powells, Guznan & Hays, 2007) adapted
specifically for people with a learning disability? There may be further knowledge to be gained from specifically for people with a learning disability? There may be further knowledge to be gained from
identifying environments in which the person engaged with treatment plans. It would be positive to identifying environments in which the person engaged with treatment plans. It would be positive to
identify with which approaches the person feels supported therapeutically, educationally or vocationally. identify with which approaches the person feels supported therapeutically, educationally or vocationally.
Overall, when considering treatability assessors should consider how receptive both the person and their Overall, when considering treatability assessors should consider how receptive both the person and their
environment are to treatment, in equal measure. environment are to treatment, in equal measure.

Although an area fraught with difficulties and debate (Moreland, Hendy & Brown, 2008) It is no longer Although an area fraught with difficulties and debate (Moreland, Hendy & Brown, 2008) It is no longer
the case that a diagnosis of ‘personality disorder’ should automatically exclude People with a Learning the case that a diagnosis of ‘personality disorder’ should automatically exclude People with a Learning
Disability from treatment or services (NIHME, 2003; NICE, 2008). Disability from treatment or services (NIHME, 2003; NICE, 2008).

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3 Procedure 3 Procedure

3.1 Introduction 3.1 Introduction

Each local area is likely to have different mechanisms for deciding funding arrangements for individuals Each local area is likely to have different mechanisms for deciding funding arrangements for individuals
with complex needs. In the following section we will describe the current mechanism in place in with complex needs. In the following section we will describe the current mechanism in place in
Merseyside, The Joint Operational Management Group (JOMG). This group of senior Social Workers, Merseyside, The Joint Operational Management Group (JOMG). This group of senior Social Workers,
Team Managers, Clinicians, and Commissioners meet monthly in Liverpool to discuss the packages of Team Managers, Clinicians, and Commissioners meet monthly in Liverpool to discuss the packages of
care and funding for the most complex clients. This forum decides whether a HR-JRAMP should be care and funding for the most complex clients. This forum decides whether a HR-JRAMP should be
completed. completed.

3.2 Joint Risk Assessment 3.2 Joint Risk Assessment

Risk assessments should always be carried out in the context of a general Community Care Assessment Risk assessments should always be carried out in the context of a general Community Care Assessment
by Social Services or of the Care Programme Approach (CPA) by the Learning Disability Directorate. by Social Services or of the Care Programme Approach (CPA) by the Learning Disability Directorate.

The criteria for a Human Rights joint risk assessment are that: The criteria for a Human Rights joint risk assessment are that:

o The Service User fulfils the criteria at CPA or its equivalent for Community Care/Social Work o The Service User fulfils the criteria at CPA or its equivalent for Community Care/Social Work
and and
o Presents a significant (i.e. likely and serious) risk of harm to either themselves or others. o Presents a significant (i.e. likely and serious) risk of harm to either themselves or others.
and and
o The Social Worker’s and CPA Line Manager, MDT and the JOMG agree that a HR -JRAMP is o The Social Worker’s and CPA Line Manager, MDT and the JOMG agree that a HR -JRAMP is
necessary in the circumstances. necessary in the circumstances.

The meaning of significant risk in this context may include; The meaning of significant risk in this context may include;
o Suicide. o Suicide.
o Self-harm. o Self-harm.
o Abuse. o Abuse.
o Violence to others. o Violence to others.
o Criminal offending. o Criminal offending.
o Neglect. o Neglect.

It is important to note that for most Service Users the assessment of risk can be done in collaboration It is important to note that for most Service Users the assessment of risk can be done in collaboration
with other professionals as part of the normal assessment process without the need to implement the with other professionals as part of the normal assessment process without the need to implement the
full joint procedure. The benefits derived from a full joint assessment should be weighed against the full joint procedure. The benefits derived from a full joint assessment should be weighed against the
staff resources used in the process and whether or not this is justified by the risks involved. staff resources used in the process and whether or not this is justified by the risks involved.

A typical joint assessment might be conducted on a person who; A typical joint assessment might be conducted on a person who;

o Is detained, or at risk of being detained, in a medium secure unit. o Is detained, or at risk of being detained, in a medium secure unit.
o Has committed offences for which a court may make a disposal under section (37) of the Mental o Has committed offences for which a court may make a disposal under section (37) of the Mental
Health Act (2007) or the Criminal Procedure (Insanity and Unfitness to Plead) Act 1991. Health Act (2007) or the Criminal Procedure (Insanity and Unfitness to Plead) Act 1991.
o Is subject to a Home Office Restriction Order. o Is subject to a Home Office Restriction Order.

3.3 Applying to Complete a HR-JRAMP. 3.3 Applying to Complete a HR-JRAMP.

Joint risk assessments can be proposed either by a Service User’s Social Worker, Joint risk assessments can be proposed either by a Service User’s Social Worker,
Care co-ordinator, Clinical Lead or Commissioner. In the first instance, such proposals must be Care co-ordinator, Clinical Lead or Commissioner. In the first instance, such proposals must be
discussed with the respective line manager in order to determine; discussed with the respective line manager in order to determine;

o Whether or not the person fulfils the criteria for a joint assessment, o Whether or not the person fulfils the criteria for a joint assessment,
and and
o Whether, taking into account all the relevant circumstances, a joint assessment is necessary, o Whether, taking into account all the relevant circumstances, a joint assessment is necessary,
and and
o Whether the proposed lead and co-assessor have the capacity within their caseload to carry out o Whether the proposed lead and co-assessor have the capacity within their caseload to carry out
the assessment. the assessment.

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Any other person, including an agency providing direct support, who thinks that a joint risk assessment Any other person, including an agency providing direct support, who thinks that a joint risk assessment
is necessary, should firstly discuss this with either the person’s Social Worker or CPA Co-ordinator or is necessary, should firstly discuss this with either the person’s Social Worker or CPA Co-ordinator or
Clinical lead. Ultimately the decision whether to proceed needs to be determined following discussions Clinical lead. Ultimately the decision whether to proceed needs to be determined following discussions
between the multidisciplinary team, including Social workers, and a Clinical lead. An overview should be between the multidisciplinary team, including Social workers, and a Clinical lead. An overview should be
written for presentation to the JOMG highlighting the reasons for The HR-JRAMP. written for presentation to the JOMG highlighting the reasons for The HR-JRAMP.

The JOMG should then discuss the proposal at the next available opportunity. It is essential a member The JOMG should then discuss the proposal at the next available opportunity. It is essential a member
of the Commissioning team is at this meeting. The Care co-ordinator and clinical lead will present the of the Commissioning team is at this meeting. The Care co-ordinator and clinical lead will present the
information to the JOMG. The JOMG will state whether the proposed joint risk assessment should information to the JOMG. The JOMG will state whether the proposed joint risk assessment should
proceed, and confirm the names of the lead and co-assessors. proceed, and confirm the names of the lead and co-assessors.
. .
If the application to proceed with a joint risk assessment is refused the JOMG should briefly outline the If the application to proceed with a joint risk assessment is refused the JOMG should briefly outline the
reasons for this. reasons for this.

3.4 Time Allowed for Completion of Assessment/Plan 3.4 Time Allowed for Completion of Assessment/Plan

This procedure is not intended to be used in short term crises or emergency situations. A joint risk This procedure is not intended to be used in short term crises or emergency situations. A joint risk
assessment should normally be completed between three to six months following the lead assessor assessment should normally be completed between three to six months following the lead assessor
being notified of the approval. The JOMG will schedule a discussion of the completed form at their being notified of the approval. The JOMG will schedule a discussion of the completed form at their
regular meeting 4 months after the meeting at which the application was approved to assess progress. regular meeting 4 months after the meeting at which the application was approved to assess progress.

3.5 Circulation of Completed Assessment/Plan 3.5 Circulation of Completed Assessment/Plan

Once approved, copies of the completed risk assessment and management plan should be held; Once approved, copies of the completed risk assessment and management plan should be held;
o With the commissioners. o With the commissioners.
o within the service user’s social work file. o within the service user’s social work file.
o within the CPA file. o within the CPA file.
o within the Consultant Psychiatrist’s file. o within the Consultant Psychiatrist’s file.

Copies of the risk assessment and/or the management plan may also be circulated to others as Copies of the risk assessment and/or the management plan may also be circulated to others as
appropriate. This should only be done within the normal bounds of confidentiality and access to records appropriate. This should only be done within the normal bounds of confidentiality and access to records
(see Guidance-Section 4.19). Such circulation might include the; (see Guidance-Section 4.19). Such circulation might include the;
o Service User. o Service User.
o Service provider agency. o Service provider agency.
o Family and / or carers. o Family and / or carers.

3.6 Roles of Assessors 3.6 Roles of Assessors

It is important that the assessment is completed by two clinicians, in co-ordination with other It is important that the assessment is completed by two clinicians, in co-ordination with other
professionals, prominent team members, family members and Service User to the maximum of their professionals, prominent team members, family members and Service User to the maximum of their
ability to participate. The clinicians completing the assessment should work closely together and use ability to participate. The clinicians completing the assessment should work closely together and use
their different skills to produce the best possible assessment and management plan. Any problems in their different skills to produce the best possible assessment and management plan. Any problems in
this regard should be reported to the JOMG. Parts of the assessment can be delegated to other this regard should be reported to the JOMG. Parts of the assessment can be delegated to other
members of the team for completion e.g. a critical events history can be completed by a Trainee Clinical members of the team for completion e.g. a critical events history can be completed by a Trainee Clinical
Psychologist or Assistant Psychologist. It is important that the quality of this information is monitored Psychologist or Assistant Psychologist. It is important that the quality of this information is monitored
closely by the lead or co-assessor. closely by the lead or co-assessor.

The Lead assessor (Care co-ordinator) is responsible for: The Lead assessor (Care co-ordinator) is responsible for:
o Co-ordinating and ensuring the overall completion of the risk assessment and management plan o Co-ordinating and ensuring the overall completion of the risk assessment and management plan
in accordance with this policy and procedure. in accordance with this policy and procedure.
o Delegating particular tasks to the co-assessor and other relevant professionals. o Delegating particular tasks to the co-assessor and other relevant professionals.
o Dissemination of the approved risk assessment / plan to all the relevant professionals, user and o Dissemination of the approved risk assessment / plan to all the relevant professionals, user and
carers. carers.
o Revisions of the plan in the light of subsequent reviews. o Revisions of the plan in the light of subsequent reviews.
o Notifying the JOMG if they think the persons risk level status has changed. o Notifying the JOMG if they think the persons risk level status has changed.

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The Co-assessor (Clinical Lead) is responsible for: The Co-assessor (Clinical Lead) is responsible for:
o Supporting the lead assessor in fulfilling their responsibilities. o Supporting the lead assessor in fulfilling their responsibilities.
o Carrying out such tasks as the lead assessor reasonably delegates to them in accordance with o Carrying out such tasks as the lead assessor reasonably delegates to them in accordance with
this policy and procedure. this policy and procedure.

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4 Guidance Notes 4 Guidance Notes

Introduction Introduction

This section contains detailed guidance on the process of completing a risk assessment and constructing This section contains detailed guidance on the process of completing a risk assessment and constructing
a risk management plan. It also defines out how this should be recorded, to ensure a thorough and a risk management plan. It also defines out how this should be recorded, to ensure a thorough and
rigorous analysis of risk and a robust plan for its management is completed. rigorous analysis of risk and a robust plan for its management is completed.

For each item below there is a corresponding section in the recording form. The form however is only a For each item below there is a corresponding section in the recording form. The form however is only a
skeleton document. It has been laid out for the convenience of recording the assessment prior to skeleton document. It has been laid out for the convenience of recording the assessment prior to
completion. Assessors should not be constrained by the space available or think they are required to fill completion. Assessors should not be constrained by the space available or think they are required to fill
it. There should not be any blank spaces in the final assessment document. Assessments and plans it. There should not be any blank spaces in the final assessment document. Assessments and plans
should be written in good, understandable, plain English, or in the language of the Service User and should be written in good, understandable, plain English, or in the language of the Service User and
relevant staff. All documentation should be available in an accessible format, e.g. easy read, without relevant staff. All documentation should be available in an accessible format, e.g. easy read, without
using jargon. using jargon.

4.1 About Me 4.1 About Me

Please state the Service User’s full name, date of birth (in date/month/year format) and current location. Please state the Service User’s full name, date of birth (in date/month/year format) and current location.
Please also state the Service User’s demographic information. Please also state the Service User’s demographic information.

4.2 ‘Who Is Filling This In?’ (Assessors) 4.2 ‘Who Is Filling This In?’ (Assessors)

Details of the lead and co-assessor should be provided here, as should details of all staff who have Details of the lead and co-assessor should be provided here, as should details of all staff who have
contributed to each section of the plan (where available). The demographic characteristics of staff (i.e. contributed to each section of the plan (where available). The demographic characteristics of staff (i.e.
gender, ethnicity etc.) that documented critical incidents and completed interviews should be included. gender, ethnicity etc.) that documented critical incidents and completed interviews should be included.
This is to encourage reflective practice through staff acknowledging their own position and possible This is to encourage reflective practice through staff acknowledging their own position and possible
biases relative to the Service User. biases relative to the Service User.

The Service User should be always be included as a co-assessor, and involved as actively as possible. The Service User should be always be included as a co-assessor, and involved as actively as possible.
This may be through their ‘Essential Lifestyle Plan’ (ELP), ‘Staying Well Plan’ or ‘Advanced Statement’. This may be through their ‘Essential Lifestyle Plan’ (ELP), ‘Staying Well Plan’ or ‘Advanced Statement’.

If a service user is unable to participate fully, you should consider involving a Service User consultant, If a service user is unable to participate fully, you should consider involving a Service User consultant,
familiar with a human rights based approach. familiar with a human rights based approach.

4.3 Where Did This Information Come From? 4.3 Where Did This Information Come From?

In collecting information for a risk assessment it is vital to consult all possible sources of information In collecting information for a risk assessment it is vital to consult all possible sources of information
that may be useful. Where possible, sources should be cross-referenced to provide corroboration of that may be useful. Where possible, sources should be cross-referenced to provide corroboration of
particular critical events. Assessors should also comment on the reliability and comprehensiveness of the particular critical events. Assessors should also comment on the reliability and comprehensiveness of the
information they have obtained, and state where caution needs to be exercised in its interpretation. information they have obtained, and state where caution needs to be exercised in its interpretation.

A qualitative analysis must be completed; comparing critical incidents over the years, medication use, A qualitative analysis must be completed; comparing critical incidents over the years, medication use,
staff turn-over, the number of times the person has moved from place to place, etc. staff turn-over, the number of times the person has moved from place to place, etc.

When interviewing service users, a more accessible format of the HR-JRAMP should be applied, this may When interviewing service users, a more accessible format of the HR-JRAMP should be applied, this may
be in the form of easy read or may need to be adjusted for those who have sensory impairments. be in the form of easy read or may need to be adjusted for those who have sensory impairments.

The following, although not an exhaustive list, may provide a useful checklist of sources of information: The following, although not an exhaustive list, may provide a useful checklist of sources of information:

o Interviewing the service user o Interviewing the service user

o Parents / Relatives. o Parents / Relatives.
o Partners/spouse o Partners/spouse
o Carers / Friends. o Carers / Friends.
o Previous / current care staff. o Previous / current care staff.
o Incident report records of care placements. o Incident report records of care placements.
o The multi-disciplinary team responsible for the person. o The multi-disciplinary team responsible for the person.

35 35
 o Psychiatric reports. o Psychiatric reports.
o Educational services. o Educational services.
o Social Worker / Social Work File. o Social Worker / Social Work File.
o Named Health Worker / Health services file. o Named Health Worker / Health services file.
o Probation services. o Probation services.
o Police services. o Police services.
o Court reports and depositions. o Court reports and depositions.

Having collated all relevant information you should then record the sources you have consulted in the Having collated all relevant information you should then record the sources you have consulted in the
space provided. Please note the date that applies to each particular source (e.g. social work file 1973 to space provided. Please note the date that applies to each particular source (e.g. social work file 1973 to
1998). Where appropriate, list any person’s name, role and relationship to the Service User. The type of 1998). Where appropriate, list any person’s name, role and relationship to the Service User. The type of
environment the individual was living in or experiencing at the time should also be clearly documented; environment the individual was living in or experiencing at the time should also be clearly documented;
for example, was a punitive regime in operation at that time. How the individual reacts to certain events for example, was a punitive regime in operation at that time. How the individual reacts to certain events
should also be considered. The individual’s past history should be considered to then take into account should also be considered. The individual’s past history should be considered to then take into account
any protective strategies or behaviours they have developed over time, for example, if the individual had any protective strategies or behaviours they have developed over time, for example, if the individual had
been abused, they may feel safe when they self-injure. Any protective strategies should be documented, been abused, they may feel safe when they self-injure. Any protective strategies should be documented,
stating what they are and when they are used. If there are any significant omissions (i.e. potentially stating what they are and when they are used. If there are any significant omissions (i.e. potentially
useful sources that you could not consult) you should clearly state the reasons for this. useful sources that you could not consult) you should clearly state the reasons for this.

4.4 Why is The Assessment Being Carried Out Now? 4.4 Why is The Assessment Being Carried Out Now?
Before carrying out the assessment you should have a clear idea about why it is being done. Usually, Before carrying out the assessment you should have a clear idea about why it is being done. Usually,
this will be because the ‘Keeping me Safe and Well Screen’ (risk screen) has identified three or more this will be because the ‘Keeping me Safe and Well Screen’ (risk screen) has identified three or more
areas of risk scoring over ‘9’ or identified as a ‘red’ area by the staff and Service User. The need This areas of risk scoring over ‘9’ or identified as a ‘red’ area by the staff and Service User. The need This
should already have been stated, in part at least, on the submission to the JOMG requesting approval should already have been stated, in part at least, on the submission to the JOMG requesting approval
for the HR-JRAMP to be undertaken. In thinking about ‘why now’, you should ask: for the HR-JRAMP to be undertaken. In thinking about ‘why now’, you should ask:

o Does the person know and understand that a risk assessment is being completed? o Does the person know and understand that a risk assessment is being completed?
o Is there a specific decision to be made, or are you using the assessment to review current risks o Is there a specific decision to be made, or are you using the assessment to review current risks
/ management plan? / management plan?
o Have circumstances changed, or are they about to change? o Have circumstances changed, or are they about to change?
o Has there been a recent incident? o Has there been a recent incident?
o Has anything happened to raise concerns about the degree of risk presented by this person? Or o Has anything happened to raise concerns about the degree of risk presented by this person? Or
concerns about the person’s degree of vulnerability? concerns about the person’s degree of vulnerability?
o What are the consequences of inaction? o What are the consequences of inaction?
o Should the decision be described as a ‘risk’ or a ‘dilemma’? (A dilemma is a situation in which o Should the decision be described as a ‘risk’ or a ‘dilemma’? (A dilemma is a situation in which
the available options could be considered to present similar risks of harm). the available options could be considered to present similar risks of harm).
o How does this risk assessment relate to other health or social services assessments or plans that o How does this risk assessment relate to other health or social services assessments or plans that
are being or have been undertaken? (e.g. Essential Lifestyle Plan or CPA Assessment). are being or have been undertaken? (e.g. Essential Lifestyle Plan or CPA Assessment).

The risk assessment should be a part of the holistic approach to the person and not a separate element. The risk assessment should be a part of the holistic approach to the person and not a separate element.

4.5 When Will We Look At My Risk Plan Again? (Period Covered By Risk Assessment) 4.5 When Will We Look At My Risk Plan Again? (Period Covered By Risk Assessment)
In this section assessors should state the future time period for which the risk assessment and In this section assessors should state the future time period for which the risk assessment and
management plan will apply. Risk assessments should always be carried out with a specific time period management plan will apply. Risk assessments should always be carried out with a specific time period
in mind. We recommend that all assessments are reviewed every 6 months as this reflects a better in mind. We recommend that all assessments are reviewed every 6 months as this reflects a better
approach to the person, where this is not possible, a review should occur within a twelve month period. approach to the person, where this is not possible, a review should occur within a twelve month period.
Research indicates that predicting behaviour over short periods is much more accurate than over long Research indicates that predicting behaviour over short periods is much more accurate than over long
periods (Logan, 2007). periods (Logan, 2007).

A person’s HR-JRAMP is an evolving document and in line with best practice and human right principles A person’s HR-JRAMP is an evolving document and in line with best practice and human right principles
(particularly Article 6, the right to a fair trial) should be reviewed on a minimum six monthly basis. (particularly Article 6, the right to a fair trial) should be reviewed on a minimum six monthly basis.

It is therefore important to consider and record considerations relating to the time period e.g.: It is therefore important to consider and record considerations relating to the time period e.g.:
o What period of time will elapse before the risk is reviewed? o What period of time will elapse before the risk is reviewed?
o What mechanisms are in place for intervening earlier if things go wrong? (e.g. applying the o What mechanisms are in place for intervening earlier if things go wrong? (e.g. applying the
Essential Lifestyle Plan or Care Programme Approach). Essential Lifestyle Plan or Care Programme Approach).

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 o What are the practical implications of having a shorter risk period? o What are the practical implications of having a shorter risk period?
o How will you know if the decision has been ‘successful’? (E.g. by measuring outcomes such as o How will you know if the decision has been ‘successful’? (E.g. by measuring outcomes such as
staff turn over, number of critical incidents, types of intervention applied, i.e. medication use, staff turn over, number of critical incidents, types of intervention applied, i.e. medication use,
control and restraint.) control and restraint.)
o For how long will the risk last (i.e. for how long afterwards is the team responsible for the o For how long will the risk last (i.e. for how long afterwards is the team responsible for the
consequences)? consequences)?
o Is the Service User able and supported to ask for a review? o Is the Service User able and supported to ask for a review?

4.6 My Wishes 4.6 My Wishes

Service User involvement and participation is a key strand of a human rights based approach. This Service User involvement and participation is a key strand of a human rights based approach. This
section is about looking at how the service user perceives the risks they present, or are presented to section is about looking at how the service user perceives the risks they present, or are presented to
them, in the context of how they would like to live their lives. The knowledge and experience of those them, in the context of how they would like to live their lives. The knowledge and experience of those
with learning disabilities has largely been ignored, this assessment aims to involve service users at with learning disabilities has largely been ignored, this assessment aims to involve service users at
multiple levels to gain their insight into incidents and environments. multiple levels to gain their insight into incidents and environments.

Useful information about this may already be contained in; Useful information about this may already be contained in;

• the Keeping Me Safe and Well screen • the Keeping Me Safe and Well screen

• the person’s essential lifestyle plan or other person centred plan. By incorporating the risk • the person’s essential lifestyle plan or other person centred plan. By incorporating the risk
assessment into the essential lifestyle plan the individual can be involved in the risk assessment assessment into the essential lifestyle plan the individual can be involved in the risk assessment
plan, allowing them the opportunity to describe how they perceive the risk they present or their plan, allowing them the opportunity to describe how they perceive the risk they present or their
perspective on the risks that others present to them. perspective on the risks that others present to them.

The assessors should describe how the service user perceives the risks they pose or are subject to. If The assessors should describe how the service user perceives the risks they pose or are subject to. If
there are communication difficulties in assessing this, they should be clearly described, together with the there are communication difficulties in assessing this, they should be clearly described, together with the
efforts made to overcome them, for example the risk plan should be completed in any appropriate efforts made to overcome them, for example the risk plan should be completed in any appropriate
accessible format, e.g. another language, easy read, large print, Braille, recorded onto a CD or DVD. In accessible format, e.g. another language, easy read, large print, Braille, recorded onto a CD or DVD. In
most cases the lead or co-assessors should determine the service user’s perceptions by means of face- most cases the lead or co-assessors should determine the service user’s perceptions by means of face-
to-face contact. If this is not possible and the observations and opinions of the Service User’s wishes to-face contact. If this is not possible and the observations and opinions of the Service User’s wishes
have been sought from other sources (such as the current service providers) this should be made clear. have been sought from other sources (such as the current service providers) this should be made clear.
If this information is collated from other sources their relationship to that person should be clearly If this information is collated from other sources their relationship to that person should be clearly
documented, as should the assessor’s demographics, how the information was collated and in what documented, as should the assessor’s demographics, how the information was collated and in what
environment. environment.

4.7 ‘About My Life’ - Critical Event History 4.7 ‘About My Life’ - Critical Event History

This should be a chronological list of all events that have happened in service user’s life that may be This should be a chronological list of all events that have happened in service user’s life that may be
relevant to the assessment of risk. It should be laid out in the pre-defined format explained below. The relevant to the assessment of risk. It should be laid out in the pre-defined format explained below. The
critical event history should take into account the service user’s culture, beliefs, protective factors, early critical event history should take into account the service user’s culture, beliefs, protective factors, early
childhood experiences etc. in context to the behaviours illustrated. The demographics of the staff who childhood experiences etc. in context to the behaviours illustrated. The demographics of the staff who
documented the incidents should be reflected upon; documented the incidents should be reflected upon;

o All significant dangerous and potentially dangerous events that have occurred. The opportunities o All significant dangerous and potentially dangerous events that have occurred. The opportunities
in the environment, staff involvement and characteristics and the behaviours the service user in the environment, staff involvement and characteristics and the behaviours the service user
engaged in should all be clearly documented. engaged in should all be clearly documented.
o Significant changes in living arrangements. o Significant changes in living arrangements.
o Significant changes in care support. o Significant changes in care support.
o Involvement with the criminal justice system. This should include the reasons for involvement o Involvement with the criminal justice system. This should include the reasons for involvement
and the ways in which they were treated. and the ways in which they were treated.
o Periods of detention under the Mental Health Act. Once again reasons for their detainment and o Periods of detention under the Mental Health Act. Once again reasons for their detainment and
where they were detained should be clearly documented. where they were detained should be clearly documented.
o Occurrence of significant physical or mental health problems. o Occurrence of significant physical or mental health problems.
o Changes in schooling. o Changes in schooling.
o Changes in family / carer circumstances (e.g. birth, marriage, death). o Changes in family / carer circumstances (e.g. birth, marriage, death).
o Employment / unemployment. o Employment / unemployment.

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 o Disclosures/allegations o Disclosures/allegations

It is particularly important to accurately date and record the first of a history of dangerous or criminal It is particularly important to accurately date and record the first of a history of dangerous or criminal
events. E.g. If there has been a history of violence against people it is important to accurately date (to events. E.g. If there has been a history of violence against people it is important to accurately date (to
the year at least) when the first incident happened. Assessors should cross check these dates with the year at least) when the first incident happened. Assessors should cross check these dates with
carers or professionals who can corroborate them. If the risk assessment is completed with essential carers or professionals who can corroborate them. If the risk assessment is completed with essential
lifestyle plans and as a part of the Care Programme Approach, this process should be relatively straight lifestyle plans and as a part of the Care Programme Approach, this process should be relatively straight
forward. forward.

Assessors should seek to explore particular settings, and times in the service user’s life when dangerous, Assessors should seek to explore particular settings, and times in the service user’s life when dangerous,
or potentially dangerous events occurred. In the process of the assessment these will need to be or potentially dangerous events occurred. In the process of the assessment these will need to be
compared with times when such events did not happen. compared with times when such events did not happen.

Questions you may wish to consider when deciding on the relevance of particular incidents include; Questions you may wish to consider when deciding on the relevance of particular incidents include;

o What happened before the behaviour? o What happened before the behaviour?
o What exactly did it look like? o What exactly did it look like?
o What happened afterwards? o What happened afterwards?
o What interventions were implemented? o What interventions were implemented?
o What factors are associated with the non-occurrence of the behaviour? o What factors are associated with the non-occurrence of the behaviour?
o Staff characteristics, their reflections upon the incident o Staff characteristics, their reflections upon the incident
o Environmental characteristics o Environmental characteristics
o What was the service user’s perspective and what are their reflections of the incident? o What was the service user’s perspective and what are their reflections of the incident?
o Were any human rights issues involved? o Were any human rights issues involved?

The Critical Event History is meant to be a brief, easily readable chronological list. It should be recorded The Critical Event History is meant to be a brief, easily readable chronological list. It should be recorded
in the pre-defined format on the form, i.e.: in the pre-defined format on the form, i.e.:

o Date o Date
The date should be written in the format of Day/Month/Year, e.g. 25/6/98. Oldest events should be The date should be written in the format of Day/Month/Year, e.g. 25/6/98. Oldest events should be
placed first. placed first.

o Event o Event
The event should be described as briefly and accurately as possible. Descriptions should be as factual The event should be described as briefly and accurately as possible. Descriptions should be as factual
as possible and avoid terms which are vague or ambiguous e.g.: “Violently attacked support worker who as possible and avoid terms which are vague or ambiguous e.g.: “Violently attacked support worker who
needed some minor hospital treatment” could mean many things whereas: “Stabbed male support needed some minor hospital treatment” could mean many things whereas: “Stabbed male support
worker in arm with fork necessitating two stitches” is a more accurate factual description. worker in arm with fork necessitating two stitches” is a more accurate factual description.

o Context / Comment o Context / Comment

It is imperative that, where possible, a brief description of the context in which the event described took It is imperative that, where possible, a brief description of the context in which the event described took
place and / or any relevant comment on the events significance and severity. It may include place and / or any relevant comment on the events significance and severity. It may include
o a description of any possible ‘triggers’ to the event, it should also o a description of any possible ‘triggers’ to the event, it should also
o include environmental and staff characteristics to encourage a non-blaming culture, o include environmental and staff characteristics to encourage a non-blaming culture,
o the service user’s and staff’s reactions, and o the service user’s and staff’s reactions, and
o the potential an event may have had for more serious negative outcomes (i.e. near o the potential an event may have had for more serious negative outcomes (i.e. near
misses). Where this is not possible, an explanation should be given as to why it is not misses). Where this is not possible, an explanation should be given as to why it is not
documented. documented.

Assessors should establish whether the events listed have been corroborated or not. All reported events Assessors should establish whether the events listed have been corroborated or not. All reported events
should be included but assessors should note, where relevant, if reports are first or second hand or if should be included but assessors should note, where relevant, if reports are first or second hand or if
the evidence for a particular event is circumstantial or direct. The critical event history can be correlated the evidence for a particular event is circumstantial or direct. The critical event history can be correlated
and verified by other clinicians who are involved in the essential lifestyle plan and care programme and verified by other clinicians who are involved in the essential lifestyle plan and care programme
approach, thus providing a holistic approach to person centred planning. approach, thus providing a holistic approach to person centred planning.

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4.8 Things I Or Other People Are Worried About (Risk Factors) 4.8 Things I Or Other People Are Worried About (Risk Factors)

Risk factors are individual or social characteristics or circumstances, which may affect the probability of Risk factors are individual or social characteristics or circumstances, which may affect the probability of
a dangerous event occurring, either to themselves or others. In this section assessors should explicitly a dangerous event occurring, either to themselves or others. In this section assessors should explicitly
analyse the risk factors associated with the service user. This is perhaps the most difficult part of the analyse the risk factors associated with the service user. This is perhaps the most difficult part of the
assessment process and will entail the assessors sifting all the information they have collected in order assessment process and will entail the assessors sifting all the information they have collected in order
to look for patterns of behaviour and predictive factors. Research has shown that this can be done to look for patterns of behaviour and predictive factors. Research has shown that this can be done
effectively by examining information in four areas. These are; effectively by examining information in four areas. These are;

o Historical Factors. o Historical Factors.

o Clinical Factors. o Clinical Factors.
o Social Factors. o Social Factors.
o Actuarial Factors. o Actuarial Factors.

Listed below under each of these main headings is an explanation of what they should include. Each of Listed below under each of these main headings is an explanation of what they should include. Each of
these four main areas is divided into a number of sub-headings. These should be used as the assessors these four main areas is divided into a number of sub-headings. These should be used as the assessors
think appropriate. They are neither entirely prescriptive nor exhaustive. Assessors may add other sub- think appropriate. They are neither entirely prescriptive nor exhaustive. Assessors may add other sub-
headings as they think suit the particular person they are assessing. However, assessors should bear in headings as they think suit the particular person they are assessing. However, assessors should bear in
mind that the sub-headings given have been shown by research to be relevant to the prediction of risk. mind that the sub-headings given have been shown by research to be relevant to the prediction of risk.

It is important to hold the Service User at the centre of this assessment to ensure a person centred It is important to hold the Service User at the centre of this assessment to ensure a person centred
approach which takes into consideration the individual’s values and human rights. approach which takes into consideration the individual’s values and human rights.

a) Historical Factors a) Historical Factors

This section should contain an analysis of the significance of dangerous events that have previously This section should contain an analysis of the significance of dangerous events that have previously
occurred which are listed in the “Critical Event History”. Assessors should look for patterns in the occurred which are listed in the “Critical Event History”. Assessors should look for patterns in the
person’s previous behaviour. The individual’s behaviour should be put into context by considering their person’s previous behaviour. The individual’s behaviour should be put into context by considering their
belief systems and culture. This should be analysed firstly in terms of the frequency and severity of belief systems and culture. This should be analysed firstly in terms of the frequency and severity of
different types of dangerous events and secondly in relation to the context in which these events took different types of dangerous events and secondly in relation to the context in which these events took
place. place.

The Frequency and Severity of Different Types of Dangerous Events: The Frequency and Severity of Different Types of Dangerous Events:
This section should analyse previous dangerous events by seeing if they can be classified into different This section should analyse previous dangerous events by seeing if they can be classified into different
groups e.g. how many times has the person been involved in events such as: groups e.g. how many times has the person been involved in events such as:

• Sexual assault. • Sexual assault.

• Arson. • Arson.
• Violence. • Violence.
• Other Criminal Activity. • Other Criminal Activity.
• Damage to property. • Damage to property.
• Self-harm. • Self-harm.
• Verbal Abuse and Threats (by self or others). • Verbal Abuse and Threats (by self or others).
• Exploitation. • Exploitation.
• Victim of Abuse. • Victim of Abuse.

Categories may be further broken down as assessors think appropriate, e.g. violence could be sub- Categories may be further broken down as assessors think appropriate, e.g. violence could be sub-
divided into violence against support staff, other service users and family members. Only relevant divided into violence against support staff, other service users and family members. Only relevant
categories should be used. Assessors do not need to comment on categories of event that the service categories should be used. Assessors do not need to comment on categories of event that the service
user has not been involved in. user has not been involved in.

For each category of dangerous event assessors should analyse their frequency (i.e. how a particular For each category of dangerous event assessors should analyse their frequency (i.e. how a particular
number / sort of event has been spread out over time) and severity. This includes whether a particular number / sort of event has been spread out over time) and severity. This includes whether a particular
category of event represents a continuing trend or has only occurred at some specific time in the past, category of event represents a continuing trend or has only occurred at some specific time in the past,
together with analysing whether particular events are increasing or decreasing in severity. together with analysing whether particular events are increasing or decreasing in severity.

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Context of Events Context of Events
For each category of dangerous event assessors should analyse if there are any similarities in the For each category of dangerous event assessors should analyse if there are any similarities in the
context in which they occurred. Assessors should analyse whether any particular type of supervision or context in which they occurred. Assessors should analyse whether any particular type of supervision or
lack of it appears to be connected with potentially dangerous events. In cases of violence or abuse on lack of it appears to be connected with potentially dangerous events. In cases of violence or abuse on
others, assessors should analyse any similarity in the characteristics of victims (e.g. age, race, gender, others, assessors should analyse any similarity in the characteristics of victims (e.g. age, race, gender,
impairment or relationship to service user). The personal demographics of the instigator, the victim and impairment or relationship to service user). The personal demographics of the instigator, the victim and
the individual recording the incident should all be recorded. The risk screen may also highlight any the individual recording the incident should all be recorded. The risk screen may also highlight any
particular risks relating to or from the person relating to equality and diversity. particular risks relating to or from the person relating to equality and diversity.

b) Clinical Factors b) Clinical Factors

This section should contain an analysis of clinical factors that may affect the risks posed by or to the This section should contain an analysis of clinical factors that may affect the risks posed by or to the
service user. Under this heading, the assessors may include the following: service user. Under this heading, the assessors may include the following:

Mental Health Diagnosis and Treatment Mental Health Diagnosis and Treatment
Assessors should clearly state any previous or present clinical symptoms and mental health diagnosis. Assessors should clearly state any previous or present clinical symptoms and mental health diagnosis.
This is particularly important in the case of psychopathy, psychosis or ‘personality disorder’. This is particularly important in the case of psychopathy, psychosis or ‘personality disorder’.

In recent years there has been a move away from purely focusing on the diagnosis someone is given. In recent years there has been a move away from purely focusing on the diagnosis someone is given.
Such authors as Bentall (2003) have advocated the adoption of an approach that is symptom/complaint Such authors as Bentall (2003) have advocated the adoption of an approach that is symptom/complaint
focused and takes into account such factors as the person’s social environment and life experiences (see focused and takes into account such factors as the person’s social environment and life experiences (see
next section). Furthermore, there is a growing evidence base to suggest that the person’s subjective next section). Furthermore, there is a growing evidence base to suggest that the person’s subjective
experience and understanding of the symptoms, specifically in psychosis, is paramount in informing experience and understanding of the symptoms, specifically in psychosis, is paramount in informing
treatment and intervention. (Campbell & Morrison, 2007; Pitt, Kilbride, Nothard, Welford, and Morrison, treatment and intervention. (Campbell & Morrison, 2007; Pitt, Kilbride, Nothard, Welford, and Morrison,
2007; Morrison, Renton, Dunn, Williams & Bentall, 2003) 2007; Morrison, Renton, Dunn, Williams & Bentall, 2003)
Thus, assessors should explore the individual symptoms associated with any diagnosis and how the Thus, assessors should explore the individual symptoms associated with any diagnosis and how the
Service User makes sense of and understands their experiences. Service User makes sense of and understands their experiences.

Both past and current research findings suggest that ethnic minority groups, specifically black Both past and current research findings suggest that ethnic minority groups, specifically black
Caribbean, black African and other black groups, are over represented in psychiatric hospitals; these Caribbean, black African and other black groups, are over represented in psychiatric hospitals; these
groups being two-three times more likely than the general population to be admitted (MIND, 2006). groups being two-three times more likely than the general population to be admitted (MIND, 2006).
Furthermore, Afro Caribbean people are between two-eight times more likely to be given a diagnosis of Furthermore, Afro Caribbean people are between two-eight times more likely to be given a diagnosis of
schizophrenia (MIND, 2006). One explanation for this may relate to the way in which the person’s schizophrenia (MIND, 2006). One explanation for this may relate to the way in which the person’s
experiences are interpreted, suggesting a possible bias amongst those who are responsible for diagnosis experiences are interpreted, suggesting a possible bias amongst those who are responsible for diagnosis
and treatment (MIND, 2006). and treatment (MIND, 2006).

Under the Human Rights Act (1998), Article 14 protects the individual against discrimination and states Under the Human Rights Act (1998), Article 14 protects the individual against discrimination and states
that an individual should not be discriminated against on any grounds such as ethnic background, sex, that an individual should not be discriminated against on any grounds such as ethnic background, sex,
colour and language. Thus, assessors should take into consideration such factors as the person’s ethnic colour and language. Thus, assessors should take into consideration such factors as the person’s ethnic
background, religion, language and other socio-cultural factors when assessing the Service User’s background, religion, language and other socio-cultural factors when assessing the Service User’s
mental health, past and present mental health, past and present

The degree of learning disability and any specific clinical factors associated with this should also be The degree of learning disability and any specific clinical factors associated with this should also be
described in detail. It should be acknowledged that both learning disability and certain diagnostic described in detail. It should be acknowledged that both learning disability and certain diagnostic
categories such as schizophrenia are believed to confound the detection of the other (Smiley, 2005). categories such as schizophrenia are believed to confound the detection of the other (Smiley, 2005).
Smiley (2005) has highlighted that people who are diagnosed with what is considered to be a severe Smiley (2005) has highlighted that people who are diagnosed with what is considered to be a severe
mental illness, such as schizophrenia, often perform poorly on tests of intelligence. Consequently the mental illness, such as schizophrenia, often perform poorly on tests of intelligence. Consequently the
person may be diagnosed with having a learning disability. Furthermore, a person who is functioning at person may be diagnosed with having a learning disability. Furthermore, a person who is functioning at
a low level and experiencing psychotic symptoms may have the low level of functioning attributed to the a low level and experiencing psychotic symptoms may have the low level of functioning attributed to the
presence of psychotic symptoms rather than an underlying learning disability. Smiley (2005) and presence of psychotic symptoms rather than an underlying learning disability. Smiley (2005) and
Whittaker and Read (2006) also suggested that there are further difficulties with dual diagnosis in Whittaker and Read (2006) also suggested that there are further difficulties with dual diagnosis in
relation to diagnostic overshadowing, whereby mental health difficulties are ascribed to a learning relation to diagnostic overshadowing, whereby mental health difficulties are ascribed to a learning
disability. disability.

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It is important for assessors to consider that labels of Learning Disability or mental health diagnoses It is important for assessors to consider that labels of Learning Disability or mental health diagnoses
might significantly negatively impact on the person’s self-esteem, identity, opportunities and therefore might significantly negatively impact on the person’s self-esteem, identity, opportunities and therefore
on their risky behaviours. on their risky behaviours.

Current clinical intervention Current clinical intervention

For current clinical treatment being received, and that given in the past, assessors should explore how For current clinical treatment being received, and that given in the past, assessors should explore how
the Service User has engaged with intervention and treatment plans. It may also be useful to explore the Service User has engaged with intervention and treatment plans. It may also be useful to explore
whether treatment options were discussed in collaboration with the Service User and what information whether treatment options were discussed in collaboration with the Service User and what information
they were provided with to help inform their decision. they were provided with to help inform their decision.

Assessors should consider balancing the Service User’s autonomy to decline treatment rather than Assessors should consider balancing the Service User’s autonomy to decline treatment rather than
viewing any such action as non-compliance. Assessment should explore whether the intervention/ viewing any such action as non-compliance. Assessment should explore whether the intervention/
treatment plans hold the person at the centre of the intervention and take into consideration their treatment plans hold the person at the centre of the intervention and take into consideration their
human rights. human rights.

Interpersonal style. Interpersonal style.

This section should look at how the Service User’s interpersonal and relational style may affect the This section should look at how the Service User’s interpersonal and relational style may affect the
perceived level of risk to themselves or others. For example such personality traits as impulsiveness, perceived level of risk to themselves or others. For example such personality traits as impulsiveness,
anger and hostility may, either generally or in particular circumstances, increase risk. Reference should anger and hostility may, either generally or in particular circumstances, increase risk. Reference should
also be made to the person’s ability to exercise self control. Such factors should be put in the context of also be made to the person’s ability to exercise self control. Such factors should be put in the context of
events that have either previously taken place or may take place in the future. In assessing the Service events that have either previously taken place or may take place in the future. In assessing the Service
User’s interpersonal and relational style it may be helpful to consider early and current attachments, User’s interpersonal and relational style it may be helpful to consider early and current attachments,
trauma and family circumstances. trauma and family circumstances.

Insight Insight
Assessors should analyse the degree to which the Service User is aware of the dangers they pose to Assessors should analyse the degree to which the Service User is aware of the dangers they pose to
others or themselves, this can be assessed by their inclusion in the process. It is also important to look others or themselves, this can be assessed by their inclusion in the process. It is also important to look
at the Service User’s understanding of what has happened and their awareness of the consequences of at the Service User’s understanding of what has happened and their awareness of the consequences of
their actions on both themselves and others. The degree to which such awareness may influence their their actions on both themselves and others. The degree to which such awareness may influence their
behaviour should also be explored. It is important to continue to assess the Service User’s degree of behaviour should also be explored. It is important to continue to assess the Service User’s degree of
insight as this may change over time depending on the individual’s psychological well being. insight as this may change over time depending on the individual’s psychological well being.

Acquiescence Acquiescence
It is well documented that people with learning disabilities are prone to acquiescence, suggestibility and It is well documented that people with learning disabilities are prone to acquiescence, suggestibility and
confabulation (Proser & Bromley, 1998; Kebbell, Hatton, Johnson & O’Kelly, 2001; Finlay & Lyons, confabulation (Proser & Bromley, 1998; Kebbell, Hatton, Johnson & O’Kelly, 2001; Finlay & Lyons,
2002). People with Learning Disabilities in general often have had contact with services from an early 2002). People with Learning Disabilities in general often have had contact with services from an early
age, recognise those in charge of their care as authority figures, and are dependent upon staff for their age, recognise those in charge of their care as authority figures, and are dependent upon staff for their
physical and emotional wellbeing and friendship (Goble, 1999). Thus, Service Users engaging in this physical and emotional wellbeing and friendship (Goble, 1999). Thus, Service Users engaging in this
assessment process may be more likely to agree and ‘passively comply’ with the assessors to ensure assessment process may be more likely to agree and ‘passively comply’ with the assessors to ensure
their ongoing ‘friendships’ with staff. their ongoing ‘friendships’ with staff.

Finlay and Lyons (2002) have explored the most likely causes of acquiescence and suggested that it Finlay and Lyons (2002) have explored the most likely causes of acquiescence and suggested that it
may be the result of multiple factors including; difficulty understanding the question, not knowing the may be the result of multiple factors including; difficulty understanding the question, not knowing the
answer and interactional demands placed on the individual during the interview. Thus, assessors answer and interactional demands placed on the individual during the interview. Thus, assessors
should, when including the Service User in this assessment process, ensure full consideration of the should, when including the Service User in this assessment process, ensure full consideration of the
relationship between the Service User and staff members, the Service User and the assessor(s), the way relationship between the Service User and staff members, the Service User and the assessor(s), the way
in which the information is presented in the assessment. Furthermore, when including the Service User in which the information is presented in the assessment. Furthermore, when including the Service User
in this process, the assessors should use reflection, allow the expression of uncertainty and check in this process, the assessors should use reflection, allow the expression of uncertainty and check
answers (Finlay & Lyons, 2002). answers (Finlay & Lyons, 2002).

Attitudes Attitudes
This section should look at the Service User’s attitude towards their own behaviour or their attitude This section should look at the Service User’s attitude towards their own behaviour or their attitude
towards others that may engender risk, e.g. does the person usually show remorse? Whilst this may be towards others that may engender risk, e.g. does the person usually show remorse? Whilst this may be
related to their interpersonal style and degree of insight it is important to distinguish between these related to their interpersonal style and degree of insight it is important to distinguish between these
elements as they may all contribute in different ways towards risk. Where there are clear links between elements as they may all contribute in different ways towards risk. Where there are clear links between
these elements assessors should analyse these in detail and explain how they are linked. these elements assessors should analyse these in detail and explain how they are linked.

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The attitudes of all staff and clinicians involved in the risk plan should be clearly documented to ensure The attitudes of all staff and clinicians involved in the risk plan should be clearly documented to ensure
a comprehensive, unbiased perspective of the risk history and future plan. a comprehensive, unbiased perspective of the risk history and future plan.

Physical Health Diagnosis and Treatment Physical Health Diagnosis and Treatment
Assessors should detail any physical health problems that may impact upon the person’s risk behaviour, Assessors should detail any physical health problems that may impact upon the person’s risk behaviour,
paying particular attention to conditions such as epilepsy or diabetes. Any relationship between the paying particular attention to conditions such as epilepsy or diabetes. Any relationship between the
person’s physical and mental health should also be considered. person’s physical and mental health should also be considered.

Inequalities in health for people with learning difficulties should also be highlighted. ‘Once a day’ (DH, Inequalities in health for people with learning difficulties should also be highlighted. ‘Once a day’ (DH,
1995), ‘Signposts for Success’ (DH, 1996) and ‘Death by Indifferenc’e (Mencap, 2007) illustrate the 1995), ‘Signposts for Success’ (DH, 1996) and ‘Death by Indifferenc’e (Mencap, 2007) illustrate the
differing patterns of health needs for people with learning difficulties. Each person should have a differing patterns of health needs for people with learning difficulties. Each person should have a
developed Health Action Plan, as identified in the Valuing People white paper (DH, 2001). The assessor developed Health Action Plan, as identified in the Valuing People white paper (DH, 2001). The assessor
may wish to identify, amend, create or analyse the Health Action Plan in relation to the person’s risk may wish to identify, amend, create or analyse the Health Action Plan in relation to the person’s risk
behaviour. In order to propose a physical intervention, the physical Health needs of the person should behaviour. In order to propose a physical intervention, the physical Health needs of the person should
be considered. e.g. if physical restraint is to be proposed for a person with Down’s Syndrome then a be considered. e.g. if physical restraint is to be proposed for a person with Down’s Syndrome then a
screen for atlanto-axial instability should be undertaken. The assessor may wish to reflect on the impact screen for atlanto-axial instability should be undertaken. The assessor may wish to reflect on the impact
of such an intervention plan. of such an intervention plan.

If the person travels through the criminal justice system, there is a role for the health care professional. If the person travels through the criminal justice system, there is a role for the health care professional.
Police within local custody suites are striving for the safer handling and detention of prisoners. If a Police within local custody suites are striving for the safer handling and detention of prisoners. If a
person has specific health needs or requirements then these can be written down and given to the desk person has specific health needs or requirements then these can be written down and given to the desk
sergeant as part of the risk management plan. If a person is to be detained in prison, it would be the sergeant as part of the risk management plan. If a person is to be detained in prison, it would be the
role of the health care professional to inform the relevant parties of any physical health risks. If a person role of the health care professional to inform the relevant parties of any physical health risks. If a person
is to be assessed within prison, there is a toolkit currently available developed by Marshall, Simpson & is to be assessed within prison, there is a toolkit currently available developed by Marshall, Simpson &
Stevens (2000). This is known as the toolkit for health care needs in prison. Stevens (2000). This is known as the toolkit for health care needs in prison.

Overall, the role of the assessor is: Overall, the role of the assessor is:
• to identify any physical health needs and their impact on a person’s previous risk behaviour • to identify any physical health needs and their impact on a person’s previous risk behaviour
• to identify components of a Health Action Plan. • to identify components of a Health Action Plan.
• to screen the person for any possible adverse physical effects of proposed interventions and • to screen the person for any possible adverse physical effects of proposed interventions and
• to raise awareness or put in place signposts for members of the criminal justice system to identify • to raise awareness or put in place signposts for members of the criminal justice system to identify
the specific health needs of the person. the specific health needs of the person.

c) Social Factors c) Social Factors

This section should contain information from the assessment of the service user’s social situation that This section should contain information from the assessment of the service user’s social situation that
may affect their risk behaviour. Of particular interest here are not only previous social factors (such as may affect their risk behaviour. Of particular interest here are not only previous social factors (such as
childhood abuse) which may be giving rise to current risks, but also current circumstances which may childhood abuse) which may be giving rise to current risks, but also current circumstances which may
ameliorate or exacerbate risks. It is important that, wherever possible, a collaborative approach to ameliorate or exacerbate risks. It is important that, wherever possible, a collaborative approach to
assessment is employed. Moreover, previous and current contexts should be evaluated by incorporating assessment is employed. Moreover, previous and current contexts should be evaluated by incorporating
person-centred, human rights-driven strategies, as discussed in previous sections of this document. person-centred, human rights-driven strategies, as discussed in previous sections of this document.

Childhood Adversity Childhood Adversity

Adverse events in childhood have been linked to behavioural and other difficulties in adulthood. Where Adverse events in childhood have been linked to behavioural and other difficulties in adulthood. Where
possible, and appropriate, assessors should thoroughly examine and evaluate the circumstances of the possible, and appropriate, assessors should thoroughly examine and evaluate the circumstances of the
service user’s childhood. Assessors should be well versed in the relevant literature surrounding the service user’s childhood. Assessors should be well versed in the relevant literature surrounding the
possible antecedent/historical events known to increase the risk of identified presenting behaviours. Of possible antecedent/historical events known to increase the risk of identified presenting behaviours. Of
particular relevance here are whether violations of an individual’s human rights have occurred in the particular relevance here are whether violations of an individual’s human rights have occurred in the
past, and how these circumstances have possibly triggered or exacerbated current behaviours. Of past, and how these circumstances have possibly triggered or exacerbated current behaviours. Of
particular importance is how specific patterns of current behaviour that may have started in childhood particular importance is how specific patterns of current behaviour that may have started in childhood
may or may not be linked to certain adverse circumstances. Whilst assessors should not indulge in idle may or may not be linked to certain adverse circumstances. Whilst assessors should not indulge in idle
speculation about such links, they should point out that links may exist and the evidence for them. For speculation about such links, they should point out that links may exist and the evidence for them. For
example, there is wide ranging literature base for adverse events and circumstances and their example, there is wide ranging literature base for adverse events and circumstances and their
relationship to current behaviours in those with learning disabilities. These include: relationship to current behaviours in those with learning disabilities. These include:

• Impact of institutionalised care (DH, 2001; Emerson, 2005) • Impact of institutionalised care (DH, 2001; Emerson, 2005)

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 • Impact of negative historical relationships with staff (Flynn and Brown, 2005) • Impact of negative historical relationships with staff (Flynn and Brown, 2005)
• Importance of role models (Russell, 1998) and their impact e.g. guidance in conflict resolution. • Importance of role models (Russell, 1998) and their impact e.g. guidance in conflict resolution.
(see McConkey, 2005) (see McConkey, 2005)
• Impact of gender, culture, ethnicity, sexuality, and reactions in those without a learning • Impact of gender, culture, ethnicity, sexuality, and reactions in those without a learning
disability (Grant & Whittell, 2000) disability (Grant & Whittell, 2000)
• Bullying • Bullying
• Poorly supported transitions and the impact of them • Poorly supported transitions and the impact of them
• Dispersed community housing and over reliance of 1 or 2 people in the absence of adequate • Dispersed community housing and over reliance of 1 or 2 people in the absence of adequate
social networks (Srivastava, 2001; McConkey, 2005) social stability, social support or social social networks (Srivastava, 2001; McConkey, 2005) social stability, social support or social
interactions (see Newton et. al., 1994) interactions (see Newton et. al., 1994)
• Social and economic deprivation • Social and economic deprivation

Situational Factors Situational Factors

This section should look at types of social or family situations and interactions that affect the person’s This section should look at types of social or family situations and interactions that affect the person’s
risk behaviour. Class, cultural, ethnic, religious, sexual and other diversities should be recognised and risk behaviour. Class, cultural, ethnic, religious, sexual and other diversities should be recognised and
assessors should strive to move their practice away from a ‘Euro-centric’ approach, whilst being mindful assessors should strive to move their practice away from a ‘Euro-centric’ approach, whilst being mindful
of diversity within minority/minoritised identities. This may be particularly salient when assessing, for of diversity within minority/minoritised identities. This may be particularly salient when assessing, for
example, individuals from minority backgrounds living in majority-white British supported example, individuals from minority backgrounds living in majority-white British supported
accommodation accommodation

Consideration should be given to the interpersonal skills and communication abilities of others towards Consideration should be given to the interpersonal skills and communication abilities of others towards
the person being assessed (importantly both the carers family, friends etc and those undertaking the the person being assessed (importantly both the carers family, friends etc and those undertaking the
assessment) The literature on family communication styles and high vs. low Expressed Emotion, (e.g. assessment) The literature on family communication styles and high vs. low Expressed Emotion, (e.g.
Brown, 1985) may be useful. This again may also be information worthy of collection from individuals Brown, 1985) may be useful. This again may also be information worthy of collection from individuals
who previously (but no longer) work with that person, alongside role models and/or important others. who previously (but no longer) work with that person, alongside role models and/or important others.

Environmental Factors Environmental Factors

This would encompass a wide range of factors to do with the service user’s physical environment that This would encompass a wide range of factors to do with the service user’s physical environment that
may engender risk. This might include the layout of the care environment; its proximity to sources of may engender risk. This might include the layout of the care environment; its proximity to sources of
danger (e.g. main roads) or the proximity of other environments where the person might indulge in risk danger (e.g. main roads) or the proximity of other environments where the person might indulge in risk
behaviours. behaviours.

From the clinical examination, it will have become clear whether or not the individual sees weapons, From the clinical examination, it will have become clear whether or not the individual sees weapons,
including his or her own body, as a means of solving problems and whether the person has fantasies including his or her own body, as a means of solving problems and whether the person has fantasies
involving weapons. The question so far as risk management is concerned has to do with the extent to involving weapons. The question so far as risk management is concerned has to do with the extent to
which such weapons are available and can be controlled. Assessors should examine access to possible which such weapons are available and can be controlled. Assessors should examine access to possible
victims, weapons, and other potential risk situations. Risk increases when individuals are discharged to victims, weapons, and other potential risk situations. Risk increases when individuals are discharged to
situations similar to those involved in the index offence. Again, where possible the person assessed situations similar to those involved in the index offence. Again, where possible the person assessed
should be involved in this process as much as is possible, and this approach should again be should be involved in this process as much as is possible, and this approach should again be
collaborative. Risk management presents challenges in terms of working with people with Learning collaborative. Risk management presents challenges in terms of working with people with Learning
Disabilities because the promotion of independence and choice necessarily will include an element of risk Disabilities because the promotion of independence and choice necessarily will include an element of risk
(Styring and Grant, 2005). The challenge, however, is to achieve this balance under the guidance of the (Styring and Grant, 2005). The challenge, however, is to achieve this balance under the guidance of the
person’s human rights, whilst also protecting the public; in other words, achieving risk management person’s human rights, whilst also protecting the public; in other words, achieving risk management
versus public protection. versus public protection.

Relationship Stability Relationship Stability

This section should look at nature and stability of relationships formed with family, friends and paid This section should look at nature and stability of relationships formed with family, friends and paid
carers. The presence of patient, tolerant, and encouraging relatives can, of course, be of enormous carers. The presence of patient, tolerant, and encouraging relatives can, of course, be of enormous
assistance in maintaining a plan. The same obviously holds true of mental health and other assistance in maintaining a plan. The same obviously holds true of mental health and other
professionals able to lend assistance. A great deal depends on being able to supply a clean, comfortable professionals able to lend assistance. A great deal depends on being able to supply a clean, comfortable
and safe environment. It is generally found that social support works to protect against violent crime. As and safe environment. It is generally found that social support works to protect against violent crime. As
cited above, a large body of evidence concerns the importance of interpersonal relationships and their cited above, a large body of evidence concerns the importance of interpersonal relationships and their
stability in the protection against adverse behaviours. Assessment should again be sensitive, respectful, stability in the protection against adverse behaviours. Assessment should again be sensitive, respectful,
and person-centred where undertaken, preferably by an assessor who is (at least to some degree) and person-centred where undertaken, preferably by an assessor who is (at least to some degree)
aware of Personal Relationships and Sexuality issues. aware of Personal Relationships and Sexuality issues.

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Substance Misuse Substance Misuse
Research suggests that alcohol and drug abuse amongst people with Learning Disabilities is generally at Research suggests that alcohol and drug abuse amongst people with Learning Disabilities is generally at
low levels (Lund, 1985) although in more independent living circumstances the use of alcohol may be low levels (Lund, 1985) although in more independent living circumstances the use of alcohol may be
higher (see Hatton and Taylor, 2005). However, it is important for any usage to be explored, assessed, higher (see Hatton and Taylor, 2005). However, it is important for any usage to be explored, assessed,
and reported, and in doing so the assessors need to describe the nature of any drug or alcohol problem and reported, and in doing so the assessors need to describe the nature of any drug or alcohol problem
the service user has and how this is related to any identifiable risks. Such assessments should be the service user has and how this is related to any identifiable risks. Such assessments should be
undertaken sensitively, enquiring for example how often the person drinks, how much they drink, when undertaken sensitively, enquiring for example how often the person drinks, how much they drink, when
they drink and what the consequences of this may be. they drink and what the consequences of this may be.

Where possible, assessors should attempt to apply recommended techniques which are utilised in Drug Where possible, assessors should attempt to apply recommended techniques which are utilised in Drug
and Alcohol services (such as Motivational Interviewing, etc.). A human rights based approach needs to and Alcohol services (such as Motivational Interviewing, etc.). A human rights based approach needs to
acknowledge that limiting access to such substances is possibly in violation of an individual’s freedom of acknowledge that limiting access to such substances is possibly in violation of an individual’s freedom of
choice, and thus a collaborative approach, adopted by specialised agencies alongside the person being choice, and thus a collaborative approach, adopted by specialised agencies alongside the person being
assessed, where possible allows for clear and realistic agreements to be reached between all parties assessed, where possible allows for clear and realistic agreements to be reached between all parties
regarding both the use and monitoring of substances. Again, where possible, such an approach needs to regarding both the use and monitoring of substances. Again, where possible, such an approach needs to
be undertaken in a systematic, evidence-based manner, where collaborative, non-didactic, empathy- be undertaken in a systematic, evidence-based manner, where collaborative, non-didactic, empathy-
based supervisory approaches are employed by stakeholders. based supervisory approaches are employed by stakeholders.

Collaboration with Services Collaboration with Services

In this part assessors need to outline the way in which the service user is able to or prepared to In this part assessors need to outline the way in which the service user is able to or prepared to
collaborate with services which are provided for them, and the implications this may have for any risks collaborate with services which are provided for them, and the implications this may have for any risks
identified. Exploration should be undertaken if poor collaboration is identified (e.g. as this may be due to identified. Exploration should be undertaken if poor collaboration is identified (e.g. as this may be due to
inappropriateness of previous interventions, breakdown in communication and understanding; staff inappropriateness of previous interventions, breakdown in communication and understanding; staff
difficulties etc.). It is paramount that, for example, staff teams’ willingness and/or their ability to difficulties etc.). It is paramount that, for example, staff teams’ willingness and/or their ability to
collaborate both with the individual and with the outlined plans are also documented at every stage; collaborate both with the individual and with the outlined plans are also documented at every stage;
such information can also be informed by previous successes / deemed ‘failures’ in collaborative such information can also be informed by previous successes / deemed ‘failures’ in collaborative
enterprise. Whether current or past plans have been person-centred, whether the individual has enterprise. Whether current or past plans have been person-centred, whether the individual has
participated in (or been offered meaningful choice etc) should also be considered and reported. participated in (or been offered meaningful choice etc) should also be considered and reported.

Stress Stress
Stress-coping models (e.g. Lazarus and Folkman, 1984; Orr et. al., 1991) can also be employed as Stress-coping models (e.g. Lazarus and Folkman, 1984; Orr et. al., 1991) can also be employed as
frameworks for understanding how individuals and others respond to such stressors, and how such frameworks for understanding how individuals and others respond to such stressors, and how such
situations may affect others around the individual; reactions which might become crucial antecedents to situations may affect others around the individual; reactions which might become crucial antecedents to
exacerbating stress in the person being assessed. Moreover, identifying and supporting the self- exacerbating stress in the person being assessed. Moreover, identifying and supporting the self-
understanding of individuals within these systems can lead to ‘explanatory or organising frameworks for understanding of individuals within these systems can lead to ‘explanatory or organising frameworks for
individuals which evolve over time’ (Grant, 2005). Such understanding additionally could promote more individuals which evolve over time’ (Grant, 2005). Such understanding additionally could promote more
functional, person-centred coping strategies over the life course. functional, person-centred coping strategies over the life course.

This part of the assessment entails trying to forecast what sources of stress the individual is likely to This part of the assessment entails trying to forecast what sources of stress the individual is likely to
encounter. Stresses can range from things that are difficult to predict such as deaths of close relatives, encounter. Stresses can range from things that are difficult to predict such as deaths of close relatives,
financial losses, and environmental catastrophes and everyday occurrences that may be stressful to that financial losses, and environmental catastrophes and everyday occurrences that may be stressful to that
particular individual, such as changes in activities or routines, environmental, staff or day centre particular individual, such as changes in activities or routines, environmental, staff or day centre
changes. Particular vulnerabilities need to be isolated and considered. You may therefore need to take changes. Particular vulnerabilities need to be isolated and considered. You may therefore need to take
account of; account of;

o How the person responds to stress or pressure. o How the person responds to stress or pressure.
o What helps the person to deal with stress? o What helps the person to deal with stress?
o How stressful situations may affect other family members or carers. o How stressful situations may affect other family members or carers.

By completing the risk management plan as part of the essential lifestyle plan or care programme By completing the risk management plan as part of the essential lifestyle plan or care programme
approach these factors will be covered therefore reducing the amount of overlap between the different approach these factors will be covered therefore reducing the amount of overlap between the different
items. items.

d) Actuarial Factors d) Actuarial Factors

As has been documented in the research and practice chapter of this document, it is uncertain, as the As has been documented in the research and practice chapter of this document, it is uncertain, as the
evidence base is narrow, how well the evidence base reflects the learning disability population. Although evidence base is narrow, how well the evidence base reflects the learning disability population. Although

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some research data shows that certain behaviours are more likely in people with particular traits, the some research data shows that certain behaviours are more likely in people with particular traits, the
research is particularly limited in describing the personal characteristics such as culture, race, sexuality, research is particularly limited in describing the personal characteristics such as culture, race, sexuality,
therefore may not fit particular traits of people. These are listed under particular dangerous behaviours therefore may not fit particular traits of people. These are listed under particular dangerous behaviours
below. In this section the assessors should highlight whether or not, and if so how, the service user below. In this section the assessors should highlight whether or not, and if so how, the service user
“fits” the data regarding particular dangerous behaviours. Assessors should specify, for each particular “fits” the data regarding particular dangerous behaviours. Assessors should specify, for each particular
danger listed that is thought to be a risk for the service user, the degree of “fit” with the list of danger listed that is thought to be a risk for the service user, the degree of “fit” with the list of
characteristics shown for that danger. This can be done in a number of different ways to suit the characteristics shown for that danger. This can be done in a number of different ways to suit the
circumstances of the assessment. Assessors should generally point out how many factors for a circumstances of the assessment. Assessors should generally point out how many factors for a
particular danger are listed and how many of these apply to the person being assessed. It may be particular danger are listed and how many of these apply to the person being assessed. It may be
useful to include a list of those that apply or the entire list with an indication of those that apply. useful to include a list of those that apply or the entire list with an indication of those that apply.

Actuarial data is not available for all dangers, and what is available cannot be regarded as Actuarial data is not available for all dangers, and what is available cannot be regarded as
comprehensive. Nor is it possible to automatically assume that because there is a good ‘fit’ with comprehensive. Nor is it possible to automatically assume that because there is a good ‘fit’ with
actuarial data the person will necessarily indulge in a particular dangerous behaviour. A good ‘fit’ means actuarial data the person will necessarily indulge in a particular dangerous behaviour. A good ‘fit’ means
that the person should be regarded as being at a significantly greater risk of engaging in the dangerous that the person should be regarded as being at a significantly greater risk of engaging in the dangerous
behaviour than a person who is not. behaviour than a person who is not.

Data is given here which relates to both learning disability specifically, people who have committed Data is given here which relates to both learning disability specifically, people who have committed
suicide, people with mental health problems and the general population. The data given is only a guide suicide, people with mental health problems and the general population. The data given is only a guide
and not a definitive answer. and not a definitive answer.

General Criminal Offending and Learning Disability General Criminal Offending and Learning Disability
For People with a Learning Disability those at a higher risk of all types of criminal offences are more For People with a Learning Disability those at a higher risk of all types of criminal offences are more
likely to have a mild learning disability (Leonard et. al., 2005) and; likely to have a mild learning disability (Leonard et. al., 2005) and;

• Be younger. • Be younger.
• Be male. • Be male.
• Be Unemployed, • Be Unemployed,
• Have a history of social disadvantage • Have a history of social disadvantage
• Have self-reported behavioural problems dating back to childhood, • Have self-reported behavioural problems dating back to childhood,
• Have limited academic achievement at school, • Have limited academic achievement at school,
• A history of hyperactivity/impulsivity/risk-taking behaviours, • A history of hyperactivity/impulsivity/risk-taking behaviours,
• Have substance misuse problems, • Have substance misuse problems,
• To experience social exclusion in adolescence and adulthood. • To experience social exclusion in adolescence and adulthood.

(Holland et. al., 2002) (Holland et. al., 2002)

Within the above more persistent or serious offenders with learning disabilities tend to; Within the above more persistent or serious offenders with learning disabilities tend to;

o Have difficult early life experiences and backgrounds. o Have difficult early life experiences and backgrounds.
o Have interpersonal difficulties/”personality disorder”. o Have interpersonal difficulties/”personality disorder”.
o Commit offences other than the index offence. o Commit offences other than the index offence.
o Experience under-socialisation. o Experience under-socialisation.
o Have poor internal controls. o Have poor internal controls.

There is some evidence that offenders against the person have a better prognosis than property There is some evidence that offenders against the person have a better prognosis than property
offenders, in terms of re-offending. Female offenders are reported to be mostly involved in property offenders, in terms of re-offending. Female offenders are reported to be mostly involved in property
offences and \ or sexual offences (soliciting, prostitution and incest). Compared with males, the female offences and \ or sexual offences (soliciting, prostitution and incest). Compared with males, the female
offender with a learning disability has much more in common with the non-disabled offender. offender with a learning disability has much more in common with the non-disabled offender.

Arson and Learning Disability Arson and Learning Disability

People with a Learning Disability who have committed arson have been shown to be more likely to People with a Learning Disability who have committed arson have been shown to be more likely to
have; have;

o Previously self-harmed o Previously self-harmed

o Difficulties with sexual relationships, sexual feelings or their sexuality. o Difficulties with sexual relationships, sexual feelings or their sexuality.

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 o Long term behaviour problems. o Long term behaviour problems.
o Been separated from their parents early in life. o Been separated from their parents early in life.
o Engaged in some form of damage to property. o Engaged in some form of damage to property.
o Have a chromosomal disorder, for example Kleinfelter`s syndrome, epilepsy. o Have a chromosomal disorder, for example Kleinfelter`s syndrome, epilepsy.

Sexual Offending and Learning Disability Sexual Offending and Learning Disability
People with a Learning Disability who have been involved in sexual offences are more likely to; People with a Learning Disability who have been involved in sexual offences are more likely to;

o Be male. o Be male.
o Be socially isolated (i.e. the degree of isolation perceived by the offender). o Be socially isolated (i.e. the degree of isolation perceived by the offender).
o Not be in any day care or employment programme. o Not be in any day care or employment programme.
o Have been physically abused. o Have been physically abused.
o Have been sexually abused. o Have been sexually abused.

As there is evidence that there is a link between sexual offending and having been physically/sexually As there is evidence that there is a link between sexual offending and having been physically/sexually
abused, assessors need to consider the implications of this for the rest of their assessment. abused, assessors need to consider the implications of this for the rest of their assessment.

Suicide and the General Population Suicide and the General Population
People who commit suicide have been shown to be more likely to have to following characteristics. People who commit suicide have been shown to be more likely to have to following characteristics.

Be: Be:
o Male. o Male.
o Older-Younger. o Older-Younger.
o Unemployed. o Unemployed.
o Single\widowed\divorced. o Single\widowed\divorced.
o At the onset of an acute phase of a mental health difficulty o At the onset of an acute phase of a mental health difficulty

Have: Have:
o Previously or recently attempted suicide. o Previously or recently attempted suicide.
o A history of mental health difficulties, particularly; o A history of mental health difficulties, particularly;
- Affective disorder. - Affective disorder.
- Psychosis. - Psychosis.
- Interpersonal difficulties/”Personality disorder”. - Interpersonal difficulties/”Personality disorder”.
o Alcohol dependence. o Alcohol dependence.
o Be an In- or Out-patient. o Be an In- or Out-patient.
o Discharge oneself from hospital against medical advice. o Discharge oneself from hospital against medical advice.
o Have been discharged between 1 week and 3 months. o Have been discharged between 1 week and 3 months.
o Had recent GP contact. o Had recent GP contact.

It should also be borne in mind that suicide is more likely in spring/early summer. Also about two thirds It should also be borne in mind that suicide is more likely in spring/early summer. Also about two thirds
of women take overdoses of paracetamol, whilst a third of men die from the effects of car exhaust of women take overdoses of paracetamol, whilst a third of men die from the effects of car exhaust
fumes. fumes.

Mental Heath Difficulties and Violence Mental Heath Difficulties and Violence
For people suffering from mental health difficulties the following factors appear to be linked with an For people suffering from mental health difficulties the following factors appear to be linked with an
increased risk of violence to others; increased risk of violence to others;

o Having a history of violent behaviour. o Having a history of violent behaviour.

o Being younger when committed the first offence. o Being younger when committed the first offence.
o Being separated from parents before 16 years old. o Being separated from parents before 16 years old.
o Having high levels of anger/hostility. o Having high levels of anger/hostility.
o Having a clinical diagnosis and active symptoms. o Having a clinical diagnosis and active symptoms.
o Non compliance with treatment and/or failing to attend appointments. o Non compliance with treatment and/or failing to attend appointments.
o Concurrent substance misuse. o Concurrent substance misuse.
o Homelessness. o Homelessness.
o Unemployment. o Unemployment.

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 o The presence of situational factors, particularly those that have been associated with past o The presence of situational factors, particularly those that have been associated with past
violence. violence.
o Lack of a close relationships. o Lack of a close relationships.
o Difficult early life experiences at home and school. o Difficult early life experiences at home and school.

Violence and Aggression in the General Population Violence and Aggression in the General Population
In general, looking at the whole population, people who commit acts of violence and aggression tend to In general, looking at the whole population, people who commit acts of violence and aggression tend to
be; be;

o Youths. o Youths.
o Male. o Male.
o Of low socio-economic status. o Of low socio-economic status.
o Of low educational level. o Of low educational level.

4.9 What Does All This Mean? (Analysis and Summary) 4.9 What Does All This Mean? (Analysis and Summary)

This is the part of the assessment where the assessor attempts to pull all the risk factor information This is the part of the assessment where the assessor attempts to pull all the risk factor information
together. Assessors should present a formulation for the person as a whole; together. Assessors should present a formulation for the person as a whole;

o An analysis of whether the historical, social, clinical and actuarial risk factors tend to point to the o An analysis of whether the historical, social, clinical and actuarial risk factors tend to point to the
same indication of likely risk or not. same indication of likely risk or not.

o How the various categories might be linked; o How the various categories might be linked;

o How patterns have developed, and o How patterns have developed, and

o What the psychological, social, or physical “pay off” or benefits might be, e.g. ‘whilst the o What the psychological, social, or physical “pay off” or benefits might be, e.g. ‘whilst the
episodes of aggression have reduced over time, they seem to have been replaced by more episodes of aggression have reduced over time, they seem to have been replaced by more
frequent fire setting, which could be a more effective strategy for getting admitted to a more frequent fire setting, which could be a more effective strategy for getting admitted to a more
secure and predictable environment’. secure and predictable environment’.

For each category of dangerous behaviour described assessors should identify any patterns or trends For each category of dangerous behaviour described assessors should identify any patterns or trends
associated with that behaviour. This should include, for each category of behaviour: associated with that behaviour. This should include, for each category of behaviour:

o A summary of the significant events over time; general trends e.g. whether they are increasing o A summary of the significant events over time; general trends e.g. whether they are increasing
or decreasing in frequency or severity. or decreasing in frequency or severity.
o Any circumstances that make the behaviour more, or less likely e.g. “more often than not this o Any circumstances that make the behaviour more, or less likely e.g. “more often than not this
has happened after he has been drinking alcohol”; “these problems rarely occur when given has happened after he has been drinking alcohol”; “these problems rarely occur when given
one-to-one support”; “tends to happen more often soon after visits home to parents” one-to-one support”; “tends to happen more often soon after visits home to parents”
o Who is usually the target of the behaviour e.g. “can be anyone in the wrong place at the wrong o Who is usually the target of the behaviour e.g. “can be anyone in the wrong place at the wrong
time” or “only targets vulnerable people who cannot defend themselves” time” or “only targets vulnerable people who cannot defend themselves”
o The person’s typical reaction to the events e.g. “is generally showing some remorse or empathy o The person’s typical reaction to the events e.g. “is generally showing some remorse or empathy
for the victim”; “is showing signs of exercising more self control over this behaviour”. for the victim”; “is showing signs of exercising more self control over this behaviour”.
o A description of any evidence of “build up” or “early warning signs” in mood or behaviour, e.g. o A description of any evidence of “build up” or “early warning signs” in mood or behaviour, e.g.
‘usually only follows a period of prolonged low mood lasting more than three days’; or whether ‘usually only follows a period of prolonged low mood lasting more than three days’; or whether
dangerous acts tend to come “out of the blue” or are preceded by a pattern of less dangerous dangerous acts tend to come “out of the blue” or are preceded by a pattern of less dangerous
behaviours, e.g. ‘usually starts off by shouting and screaming, building up to damage to behaviours, e.g. ‘usually starts off by shouting and screaming, building up to damage to
property, and culminating in violent attacks’. property, and culminating in violent attacks’.

The formulation could also include ideas as to why behaviours may have been absent for certain periods The formulation could also include ideas as to why behaviours may have been absent for certain periods
e.g. “There was a period of 3 or 4 years when no sexual offending took place, and this also coincided e.g. “There was a period of 3 or 4 years when no sexual offending took place, and this also coincided
with a time when he was in a stable relationship with a girlfriend.” with a time when he was in a stable relationship with a girlfriend.”

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4.10 Looking At My Risks, What Options Have I Got? (Significance of Risk) 4.10 Looking At My Risks, What Options Have I Got? (Significance of Risk)

The previously completed risk screen (‘Keeping Me Safe and Well Assessment’) will have identified areas The previously completed risk screen (‘Keeping Me Safe and Well Assessment’) will have identified areas
of risk. In addition to informing the formulation, identified risk factors and human rights will also inform of risk. In addition to informing the formulation, identified risk factors and human rights will also inform
choice of placement. For each housing/placement option available, assessors should consider how each choice of placement. For each housing/placement option available, assessors should consider how each
area of risk is likely to impact on the sustainability and viability of the placement. Please see ‘Keeping Me area of risk is likely to impact on the sustainability and viability of the placement. Please see ‘Keeping Me
Safe and Well Assessment Manual’ (Appendix 1 of this document) to identify relevant humans rights Safe and Well Assessment Manual’ (Appendix 1 of this document) to identify relevant humans rights
involved in the risk and document these in the third column. involved in the risk and document these in the third column.

Whilst there will inevitably be a degree of subjectivity involved in estimating the significance of risk, Whilst there will inevitably be a degree of subjectivity involved in estimating the significance of risk,
decision making concerning risk can be enhanced by attempts to quantify such elements as likelihood decision making concerning risk can be enhanced by attempts to quantify such elements as likelihood
and severity. In this part of the assessment, assessors should therefore explicitly quantify the and severity. In this part of the assessment, assessors should therefore explicitly quantify the
significance of the risks presented by the service user in relation to each of the options seriously significance of the risks presented by the service user in relation to each of the options seriously
considered for managing the risks identified. This exercise should also be completed for each area of considered for managing the risks identified. This exercise should also be completed for each area of
risk (e.g. arson, absconding, violence to others) identified. risk (e.g. arson, absconding, violence to others) identified.

There are two fundamental factors to consider when calculating the significance of a particular risk. There are two fundamental factors to consider when calculating the significance of a particular risk.
These are the: These are the:
o Likelihood of the risk occurring in the period covered by the risk assessment o Likelihood of the risk occurring in the period covered by the risk assessment
And And
o Severity of its consequences o Severity of its consequences

When arriving at likelihood estimation there are several important considerations which you will have When arriving at likelihood estimation there are several important considerations which you will have
already looked at in your assessment:- already looked at in your assessment:-
o Is there any known history to this particular risk? o Is there any known history to this particular risk?
o How often has it occurred in the past and with what frequency? o How often has it occurred in the past and with what frequency?
o Are there any known triggers and are they likely to occur within the risk period? o Are there any known triggers and are they likely to occur within the risk period?

The assessment of likelihood can only be made with reference to a set of assumptions, e.g. The assessment of likelihood can only be made with reference to a set of assumptions, e.g.
o Where the person will live. o Where the person will live.
o The expected level of support. o The expected level of support.

These form the context in which the estimate applies. Assumptions about this context should be clearly These form the context in which the estimate applies. Assumptions about this context should be clearly
stated. stated.

Likelihood should then be scored either1, 2 or 3, according to the following criteria: Likelihood should then be scored either1, 2 or 3, according to the following criteria:
1 = Unlikely to happen in the next six months. 1 = Unlikely to happen in the next six months.
2 = Evens (50%) chance of happening in the next six months. 2 = Evens (50%) chance of happening in the next six months.
3 = More than 50 % chance of happening in the next six months. 3 = More than 50 % chance of happening in the next six months.

Severity should also be scored either 1, 2 or 3, according to the following criteria:- Severity should also be scored either 1, 2 or 3, according to the following criteria:-

1 = Minor 1 = Minor
o The risks that the service user or others are exposed to are no greater than for the general o The risks that the service user or others are exposed to are no greater than for the general
population, population,
Or Or
o Where any harm that results (physical or psychological) would not require professional support o Where any harm that results (physical or psychological) would not require professional support
(e.g. medical, clinical, on-call etc) (e.g. medical, clinical, on-call etc)

2 = Serious 2 = Serious
o Physical injury to the service user or others which would require medical attention (e.g. GP, o Physical injury to the service user or others which would require medical attention (e.g. GP,
AED, etc) Psychological trauma which impinges on the service user’s or others’ quality of life and AED, etc) Psychological trauma which impinges on the service user’s or others’ quality of life and
sense of well being, and would require professional support sense of well being, and would require professional support
Or Or
o Behaviour which may lead to breakdown of current placement o Behaviour which may lead to breakdown of current placement

3 = Major 3 = Major

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 o Physical injury to the service user or others which would require their admission to hospital or o Physical injury to the service user or others which would require their admission to hospital or
result in death result in death
Or Or
o Psychological trauma to the service user or others which would require their admission to o Psychological trauma to the service user or others which would require their admission to
hospital hospital
Or Or
o Behaviour which would result in criminal prosecution and imprisonment or sectioning under the o Behaviour which would result in criminal prosecution and imprisonment or sectioning under the
Mental Health Act (2007). Mental Health Act (2007).

Significance is then calculated quite simply by multiplying one number by the other i.e.: Significance is then calculated quite simply by multiplying one number by the other i.e.:

Significance = likelihood x Severity Significance = likelihood x Severity

Obviously the higher the number the more significant the risk, with 9 representing the most significant Obviously the higher the number the more significant the risk, with 9 representing the most significant
and 1 representing the least significant (N.B. Total scores of only 1, 2, 3, 4, 6 or 9 can be obtained). and 1 representing the least significant (N.B. Total scores of only 1, 2, 3, 4, 6 or 9 can be obtained).

4.11 Where’s the Best Place for Me to Live? 4.11 Where’s the Best Place for Me to Live?

Where more than one placement option has been considered in section 10, the relative balance of risk Where more than one placement option has been considered in section 10, the relative balance of risk
and benefit associated with each housing option should be presented in this section, along with the and benefit associated with each housing option should be presented in this section, along with the
assessors’ comments and recommendations associated with each option. For the preferred option, a assessors’ comments and recommendations associated with each option. For the preferred option, a
management plan which seeks to further enhance benefit and reduce risk needs to be described in the management plan which seeks to further enhance benefit and reduce risk needs to be described in the
next section. next section.

4.12 What Legal Documents Are Important In My Risk Plan? 4.12 What Legal Documents Are Important In My Risk Plan?

This section should consider in general how legal powers, such as those under the Mental Health Act This section should consider in general how legal powers, such as those under the Mental Health Act
(2007) have been used in the past and may be used in the future as part of the overall risk (2007) have been used in the past and may be used in the future as part of the overall risk
management plan. Particular attention and consideration should be paid to:- management plan. Particular attention and consideration should be paid to:-
o The Service User’s capacity relevant to any decisions being made o The Service User’s capacity relevant to any decisions being made
o The Service User’s current legal status. o The Service User’s current legal status.
o Supervised Discharge. o Supervised Discharge.
o Guardianship. o Guardianship.
o Court of Protection. o Court of Protection.
o Section 117 After-Care. o Section 117 After-Care.
o Probation Order. o Probation Order.
o Bail Order. o Bail Order.
o Criminal Procedure (Insanity and Unfitness to plead) Act (1991). o Criminal Procedure (Insanity and Unfitness to plead) Act (1991).
o Deprivation of Liberty Guidelines (2009) o Deprivation of Liberty Guidelines (2009)

It may be relevant to discuss in general terms whether the service user has a mental disorder within the It may be relevant to discuss in general terms whether the service user has a mental disorder within the
meaning of the Mental Health Act even if none of the Act’s powers are to be used. If it is proposed that meaning of the Mental Health Act even if none of the Act’s powers are to be used. If it is proposed that
some legal measure be taken, there needs to be an explanation of specifically how this might contribute some legal measure be taken, there needs to be an explanation of specifically how this might contribute
to the overall risk management plan. The issue of the service user’s capacity to give their legal (i.e. to the overall risk management plan. The issue of the service user’s capacity to give their legal (i.e.
informed) consent both in general and to particular issues relevant to them may also need to be informed) consent both in general and to particular issues relevant to them may also need to be
considered. The Mental Capacity Act (2005) may also be relevant here. considered. The Mental Capacity Act (2005) may also be relevant here.

In using a human rights based approach, it will also be important, under the right to a fair hearing, to In using a human rights based approach, it will also be important, under the right to a fair hearing, to
share with the Service User their rights to challenge any decisions made about them under the MHA. share with the Service User their rights to challenge any decisions made about them under the MHA.
These discussions should be documented. It may also be relevant to review the outcome of any These discussions should be documented. It may also be relevant to review the outcome of any
previous Mental Health Review Tribunals when considering detaining a person under the Mental Health previous Mental Health Review Tribunals when considering detaining a person under the Mental Health
Act (including guardianship). Act (including guardianship).

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4.13 My Risk Management Plan 4.13 My Risk Management Plan

In formulating the Risk Management Plan it is good practice to consult with and involve those people In formulating the Risk Management Plan it is good practice to consult with and involve those people
who will be expected to deliver and monitor it. In particular it is imperative that, where there is a who will be expected to deliver and monitor it. In particular it is imperative that, where there is a
Responsible Clinician (RC) involved, the Risk Management Plan is drawn up with their full consultation Responsible Clinician (RC) involved, the Risk Management Plan is drawn up with their full consultation
and agreement. Consultation should also take place with actual or potential service providers and carers and agreement. Consultation should also take place with actual or potential service providers and carers
/ family members. However, the final contents of the plan remain the responsibility of the assessors. / family members. However, the final contents of the plan remain the responsibility of the assessors.

The risk management plan should detail the practical arrangements that the assessors deem necessary The risk management plan should detail the practical arrangements that the assessors deem necessary
to manage the risks identified in the previous sections. We advocate that the Risk Management Plan to manage the risks identified in the previous sections. We advocate that the Risk Management Plan
should be integrated with other support plans such as the person’s Essential Lifestyle Plan as a process should be integrated with other support plans such as the person’s Essential Lifestyle Plan as a process
of best practice. of best practice.

Within the Risk Management Plan the following areas should be considered: Within the Risk Management Plan the following areas should be considered:

a) Support Levels a) Support Levels

This should include a consideration of the number of hours of support the service user receives and the This should include a consideration of the number of hours of support the service user receives and the
level of support (i.e. 1:1, 2:1, etc), including: level of support (i.e. 1:1, 2:1, etc), including:

o Usual support levels and whether this is constant throughout the day, week or month. o Usual support levels and whether this is constant throughout the day, week or month.
o Provision for increasing support levels to manage short term crises, including additional support o Provision for increasing support levels to manage short term crises, including additional support
that may be deployed via the on-call service (agency or directorate). that may be deployed via the on-call service (agency or directorate).
o Consider whether or not it is appropriate to draw on the support of family or friends. o Consider whether or not it is appropriate to draw on the support of family or friends.
o The importance of the continuity, consistency and quality of support. o The importance of the continuity, consistency and quality of support.
o Characteristics of staff employed o Characteristics of staff employed

b) Triggers b) Triggers
Any reliably occurring triggers for particular behaviours should be documented. Challenging behaviours Any reliably occurring triggers for particular behaviours should be documented. Challenging behaviours
are often the Service User’s best attempts to solve a problem and by examining the critical event history are often the Service User’s best attempts to solve a problem and by examining the critical event history
and looking at your formulation you should be able create hypotheses or to make ‘respectful guesses’ and looking at your formulation you should be able create hypotheses or to make ‘respectful guesses’
about the triggers to behaviour even where you are not certain. Clinical judgement should be exercised about the triggers to behaviour even where you are not certain. Clinical judgement should be exercised
here. here.

c) Proactive Strategies c) Proactive Strategies

These are actions or interventions that seek to reduce or minimise the occurrence of risk behaviours, These are actions or interventions that seek to reduce or minimise the occurrence of risk behaviours,
including: including:
o Avoiding triggers and high risk situations. o Avoiding triggers and high risk situations.
o Therapeutic input, such as cognitive-behavioural therapy, counselling and contingency o Therapeutic input, such as cognitive-behavioural therapy, counselling and contingency
management. management.
o Skills teaching, such as anger and stress management. o Skills teaching, such as anger and stress management.
o Scheduling routines. o Scheduling routines.
o Medication. o Medication.
o Managing the environment e.g. avoidance of crowds, reduction of noise. o Managing the environment e.g. avoidance of crowds, reduction of noise.
o Provision for monitoring the person’s behaviour/mental health (e.g. using scatter plots, ABC o Provision for monitoring the person’s behaviour/mental health (e.g. using scatter plots, ABC
charts, relapse scales and standardised tools). charts, relapse scales and standardised tools).
o Effective communication and teamwork. o Effective communication and teamwork.
o Support given to staff teams (e.g. training, de-briefing and staff supervision). o Support given to staff teams (e.g. training, de-briefing and staff supervision).

d) Reactive Strategies d) Reactive Strategies

These are actions or interventions that may be employed in response to the occurrence of a risk These are actions or interventions that may be employed in response to the occurrence of a risk
behaviour, including: behaviour, including:
o Use of low arousal diffusion and distraction techniques. o Use of low arousal diffusion and distraction techniques.
o Use of recognised restraint techniques (e.g. MVA). o Use of recognised restraint techniques (e.g. MVA).
o On-call services, including the Learning Disabilities Directorate, the Emergency Duty Team and o On-call services, including the Learning Disabilities Directorate, the Emergency Duty Team and
agency specific on-call services. agency specific on-call services.
o Input and support from family and friends (where appropriate). o Input and support from family and friends (where appropriate).
o Emergency admission to health or social services facility. o Emergency admission to health or social services facility.

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 o Use of agreed protocols (for example, accessing GP or accident and emergency departments, o Use of agreed protocols (for example, accessing GP or accident and emergency departments,
and monitoring physical health). and monitoring physical health).
o Consider the point at which police may need to become involved. o Consider the point at which police may need to become involved.

e) Human Rights considerations e) Human Rights considerations

First, document the human rights involved in the risk itself (‘Keeping Me Safe and Well Assessment’ First, document the human rights involved in the risk itself (‘Keeping Me Safe and Well Assessment’
Manual – in Appendix 1 of this document) so that you are aware of the human rights you are trying to Manual – in Appendix 1 of this document) so that you are aware of the human rights you are trying to
protect. The aim of your management strategies is to protect the human rights which are at risk if no protect. The aim of your management strategies is to protect the human rights which are at risk if no
management strategy is put in place. management strategy is put in place.

Secondly, the management strategies you have developed also need to be considered to see which Secondly, the management strategies you have developed also need to be considered to see which
rights are being raised. Human rights issues which may be involved in common management strategies rights are being raised. Human rights issues which may be involved in common management strategies
can be found in the ‘Human Rights in Risk Management Strategies Guidance’ in Appendix 2. can be found in the ‘Human Rights in Risk Management Strategies Guidance’ in Appendix 2.

You will need to document: You will need to document:

o Will the strategy raise any human rights? o Will the strategy raise any human rights?
o If the strategy will result in the restriction of a right, whose right will this be? o If the strategy will result in the restriction of a right, whose right will this be?
o What type of right will be involved in the strategy i.e. absolute, non-absolute or Article 5? o What type of right will be involved in the strategy i.e. absolute, non-absolute or Article 5?
o If absolute, the strategy should not be implemented. o If absolute, the strategy should not be implemented.
o If it’s a limited right will the strategy be compliant with limitations set out in the convention o If it’s a limited right will the strategy be compliant with limitations set out in the convention
o If it’s a non-absolute right, will the restriction be lawful, necessary and proportionate? o If it’s a non-absolute right, will the restriction be lawful, necessary and proportionate?
o Does the strategy require a balanced decision process? o Does the strategy require a balanced decision process?

The ‘Summary of Human Rights in Strategies Flowchart’ in Appendix 3 will help you to consider: The ‘Summary of Human Rights in Strategies Flowchart’ in Appendix 3 will help you to consider:

a) if a management strategy has human rights implications a) if a management strategy has human rights implications
b) which human rights are implicated b) which human rights are implicated
c) Whether those rights are absolute, non-absolute or Article 5. c) Whether those rights are absolute, non-absolute or Article 5.

For each strategy you will need to show that you have balanced: For each strategy you will need to show that you have balanced:

1) The Service User’s competing rights i.e. those involved in the risk itself vs. those involved in the 1) The Service User’s competing rights i.e. those involved in the risk itself vs. those involved in the
proposed management plan proposed management plan
2) The rights of the Service User with their staff or carers and the wider community. 2) The rights of the Service User with their staff or carers and the wider community.

You may wish to use the ‘Human Rights Decision Making Form’ in Appendix 4 to help you think about You may wish to use the ‘Human Rights Decision Making Form’ in Appendix 4 to help you think about
how to document your decision making process. how to document your decision making process.

If for whatever reason you are unable to mitigate the trigger or to identify individualised proactive If for whatever reason you are unable to mitigate the trigger or to identify individualised proactive
strategies, you are at a higher risk of breaching the person’s human rights. You should identify particular strategies, you are at a higher risk of breaching the person’s human rights. You should identify particular
areas where rights may be most at risk. areas where rights may be most at risk.

If you are putting in place protective measures as part of your positive duty to protect the Service User If you are putting in place protective measures as part of your positive duty to protect the Service User
e.g. to prevent suspected sexual abuse, you should be aware that you may be infringing the human e.g. to prevent suspected sexual abuse, you should be aware that you may be infringing the human
rights of family carers or others but these should be balanced against each other. rights of family carers or others but these should be balanced against each other.

f) Legal Powers f) Legal Powers

Assessors should detail the relevant sections of the Mental Health Act, Mental Capacity Act (including the Assessors should detail the relevant sections of the Mental Health Act, Mental Capacity Act (including the
Deprivation of Liberty Safeguards) or other legal powers that will or may be utilised to assist in Deprivation of Liberty Safeguards) or other legal powers that will or may be utilised to assist in
managing the degree of risk presented by the service user. This should describe what specific power, in managing the degree of risk presented by the service user. This should describe what specific power, in
which way and in what circumstance is to be used, including: which way and in what circumstance is to be used, including:

o Guardianship (e.g. requiring the service user to reside in a specified place). o Guardianship (e.g. requiring the service user to reside in a specified place).
o Supervised discharge (e.g. details of appointments the service user must attend and where the o Supervised discharge (e.g. details of appointments the service user must attend and where the
service user would be conveyed to if necessary). service user would be conveyed to if necessary).
o Details of section 17 leave (Mental Health Act). o Details of section 17 leave (Mental Health Act).

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 o Use of detention under sections (2) or (3) in an emergency situation. o Use of detention under sections (2) or (3) in an emergency situation.
o Supervision and Treatment Order (Criminal Procedure Act, 1991). o Supervision and Treatment Order (Criminal Procedure Act, 1991).

Fundamentally, this should be underpinned by the Human Rights Act (1998) and the principles Fundamentally, this should be underpinned by the Human Rights Act (1998) and the principles
contained within the articles. Assessors should give consideration to the fact that all public bodies have contained within the articles. Assessors should give consideration to the fact that all public bodies have
a positive obligation to protect the rights of Service Users; in addition to a duty to refrain from taking a positive obligation to protect the rights of Service Users; in addition to a duty to refrain from taking
action that may infringe a Service User’s human rights (DH, 2007). action that may infringe a Service User’s human rights (DH, 2007).

g) Networking and Communication g) Networking and Communication

A number of enquiries have highlighted the potentially fatal mistakes that can arise out of poor A number of enquiries have highlighted the potentially fatal mistakes that can arise out of poor
communication between different agencies. The management of risk requires a collaborative, multi- communication between different agencies. The management of risk requires a collaborative, multi-
agency approach that details the roles and responsibilities of all those involved in delivering the plan, agency approach that details the roles and responsibilities of all those involved in delivering the plan,
including the following: including the following:

o Carers and family members. o Carers and family members.

o Voluntary and private sector organisations. o Voluntary and private sector organisations.
o Service commissioners / purchasers. o Service commissioners / purchasers.
o Probation services. o Probation services.
o Court diversion schemes. o Court diversion schemes.
o Police. o Police.
o Forensic services (for example, Low, Medium or High-secure Units). o Forensic services (for example, Low, Medium or High-secure Units).
o On-call services (Learning Disabilities Directorate, Emergency Duty Team, and Agency-specific o On-call services (Learning Disabilities Directorate, Emergency Duty Team, and Agency-specific
in-house on-call). in-house on-call).
o Multi-agency Public Protection Arrangements (MAPPA) o Multi-agency Public Protection Arrangements (MAPPA)

Assessors should detail what sort of information needs to be given to whom, and in what time scale, Assessors should detail what sort of information needs to be given to whom, and in what time scale,
e.g. if a person is thought to have absconded, what length of time should elapse before the police are e.g. if a person is thought to have absconded, what length of time should elapse before the police are
informed. It may be beneficial to have one main point of contact for most information, together with a informed. It may be beneficial to have one main point of contact for most information, together with a
back up plan for when that person is not available. back up plan for when that person is not available.

h) Training Implications h) Training Implications

By their very nature, many of the interventions employed within the risk management plan may require By their very nature, many of the interventions employed within the risk management plan may require
additional training for those involved in delivering direct care to the service user, including the following: additional training for those involved in delivering direct care to the service user, including the following:
o Studio III Management of Violence and Aggression. o Studio III Management of Violence and Aggression.
o Recording and monitoring methods. o Recording and monitoring methods.
o Health surveillance. o Health surveillance.
o Offending behaviour. o Offending behaviour.
o Sexual abuse. o Sexual abuse.
o Self-injurious behaviour. o Self-injurious behaviour.
o Psycho-social interventions. o Psycho-social interventions.
o Understanding formulations o Understanding formulations
o Basic behavioural teaching o Basic behavioural teaching

4.14 Will the Risk Decision Help me? (Benefits of Risk Decision to the Service User) 4.14 Will the Risk Decision Help me? (Benefits of Risk Decision to the Service User)

It is recognised that in any consideration of the options available to manage the risks that an individual It is recognised that in any consideration of the options available to manage the risks that an individual
presents, some options carry more risks of harm than others. However, in many cases, a riskier option presents, some options carry more risks of harm than others. However, in many cases, a riskier option
will also entail an increased benefit to the service user. It is important, therefore, when more than one will also entail an increased benefit to the service user. It is important, therefore, when more than one
option is being considered to state the positive benefits that are likely to result from each option. For option is being considered to state the positive benefits that are likely to result from each option. For
example to:- example to:-
o Learn from mistakes and accept the natural consequences of behaviour. o Learn from mistakes and accept the natural consequences of behaviour.
o Improve self-control and learn to take responsibility. o Improve self-control and learn to take responsibility.
o Enhance the quality of the service user’s decision making. o Enhance the quality of the service user’s decision making.
o Gain independence and reduce the support required from others. o Gain independence and reduce the support required from others.
o Minimise the negative effects of overprotection. o Minimise the negative effects of overprotection.
o Broaden one’s experience. o Broaden one’s experience.
o Promote the dignity of risk. o Promote the dignity of risk.

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 o Increase opportunities for community presence, participation and choice. o Increase opportunities for community presence, participation and choice.
o Improve quality of life. o Improve quality of life.

Be explicit and reflective, however, regarding whose ‘values’ you are considering (i.e. is this really what Be explicit and reflective, however, regarding whose ‘values’ you are considering (i.e. is this really what
the service user wants or are you ‘imposing’ the values of your service?). It is also necessary to the service user wants or are you ‘imposing’ the values of your service?). It is also necessary to
consider the likelihood of realising each of the potential benefits. consider the likelihood of realising each of the potential benefits.

4.15 How Will My Plan Be Put Into Place, How Will My Plan Be Monitored and When Will 4.15 How Will My Plan Be Put Into Place, How Will My Plan Be Monitored and When Will
My Plan Be Looked At Again? (Implementation, Benchmarking and Review) My Plan Be Looked At Again? (Implementation, Benchmarking and Review)

This section should contain details of how the risk management plan is to be implemented, monitored This section should contain details of how the risk management plan is to be implemented, monitored
and reviewed. and reviewed.

Implementation Implementation
This is the process by which the necessary resources or services are secured in order to put the plan This is the process by which the necessary resources or services are secured in order to put the plan
into operation. It may be dependent on a number of factors including; into operation. It may be dependent on a number of factors including;
o Negotiations with service providers. o Negotiations with service providers.
o Further care management processes that need to be completed (i.e. Service Specifications, o Further care management processes that need to be completed (i.e. Service Specifications,
Funding Applications, Care Planning Meetings). Funding Applications, Care Planning Meetings).
o Legal matters which may be outstanding (e.g. court appearances, Mental Health Review o Legal matters which may be outstanding (e.g. court appearances, Mental Health Review
Tribunals, Guardianship applications) Tribunals, Guardianship applications)

Monitoring Monitoring
This is the process by which the delivery of the risk management plan is supported and controlled on a This is the process by which the delivery of the risk management plan is supported and controlled on a
continuing basis. The type and level of monitoring should relate to the scale of intervention and the continuing basis. The type and level of monitoring should relate to the scale of intervention and the
complexity of the service user’s needs. Information gathered during this process can then be used at complexity of the service user’s needs. Information gathered during this process can then be used at
formal review meetings. Plans for monitoring should detail both how information about the on-going formal review meetings. Plans for monitoring should detail both how information about the on-going
effectiveness of the plan is to be collected and how minor adjustments to the plan may be made, effectiveness of the plan is to be collected and how minor adjustments to the plan may be made,
including; including;
o Contacts between the clinician, service user and service providers. o Contacts between the clinician, service user and service providers.
o Contacts between Social Worker, service user and service providers. o Contacts between Social Worker, service user and service providers.
o Contacts between Consultant, service user and service providers. o Contacts between Consultant, service user and service providers.
o Care management meetings other than formal reviews (e.g. section 117 meetings). o Care management meetings other than formal reviews (e.g. section 117 meetings).
o Clear recording procedures (e.g. behaviour charts, recording of medication use, physical o Clear recording procedures (e.g. behaviour charts, recording of medication use, physical
restraint, staff turn-over, etc.). restraint, staff turn-over, etc.).

Benchmarking Benchmarking
This process evaluates the extent to which a human rights based approach is implemented by services This process evaluates the extent to which a human rights based approach is implemented by services
and incorporated into the Service User’s life. The benchmarking tool should be completed annually. Year and incorporated into the Service User’s life. The benchmarking tool should be completed annually. Year
one, two and three standards have been developed against which, the delivery of complex care will be one, two and three standards have been developed against which, the delivery of complex care will be
assessed. Thus an acceptable level of human rights based care provision and Service User involvement assessed. Thus an acceptable level of human rights based care provision and Service User involvement
at year one would not be acceptable at year three. In addition, the tool contains certain ‘trigger’ at year one would not be acceptable at year three. In addition, the tool contains certain ‘trigger’
questions, where a score of zero would necessitate immediate action by the service, i.e. unacceptable questions, where a score of zero would necessitate immediate action by the service, i.e. unacceptable
practice (regardless of the overall score for that section). The results should be fed back to the MDT and practice (regardless of the overall score for that section). The results should be fed back to the MDT and
commissioners. commissioners.

The tool can be completed by The tool can be completed by

• CPA co-ordinators, • CPA co-ordinators,
• Clinicians, • Clinicians,
• Social workers, • Social workers,
• Allied mental health professionals, • Allied mental health professionals,
• Commissioners. • Commissioners.

Reviewing Reviewing
This is the process by which changing needs are identified and services adapted accordingly. The risk This is the process by which changing needs are identified and services adapted accordingly. The risk
management plan should be designed to last for a specific period after which both the assessment and management plan should be designed to last for a specific period after which both the assessment and

53 53
plan are reviewed in the light information gathered during the monitoring process. This section should plan are reviewed in the light information gathered during the monitoring process. This section should
detail; detail;
o Who will be the principle Care Manager? o Who will be the principle Care Manager?
o Who is responsible for organising reviews? o Who is responsible for organising reviews?
o How often formal reviews will be. o How often formal reviews will be.
o Who will go to reviews? o Who will go to reviews?
o Who will Chair review meetings. o Who will Chair review meetings.
o Who is responsible for updating the JOMG? o Who is responsible for updating the JOMG?

4.16 What Do I Think Of My Plan? (HRBA) 4.16 What Do I Think Of My Plan? (HRBA)

This should record the service user’s views on the proposed risk management plan, particularly the This should record the service user’s views on the proposed risk management plan, particularly the
balance to be struck between the risks and benefits involved. If the Service User expresses dissent or balance to be struck between the risks and benefits involved. If the Service User expresses dissent or
an attitude of non-compliance any alternative suggestions they have should be recorded. Where any an attitude of non-compliance any alternative suggestions they have should be recorded. Where any
such suggestions have been incorporated into the plan they should be clearly indicated here. such suggestions have been incorporated into the plan they should be clearly indicated here.
If there are problems in getting the Service User’s views due to communication difficulties, this should If there are problems in getting the Service User’s views due to communication difficulties, this should
be clearly described, together with the efforts made to overcome them (e.g. the use of an advocate). be clearly described, together with the efforts made to overcome them (e.g. the use of an advocate).
Where possible the lead or co-assessors should ascertain these by means of face-to-face contact. If this Where possible the lead or co-assessors should ascertain these by means of face-to-face contact. If this
is not possible and the observations and opinions of the Service User’s views have been sought from is not possible and the observations and opinions of the Service User’s views have been sought from
other sources (such as the current service providers) this should be made clear. other sources (such as the current service providers) this should be made clear.

4.17 What Do The People Who Care For Me Think Of My Plan? (HRBA) 4.17 What Do The People Who Care For Me Think Of My Plan? (HRBA)

Carer in this context means: Carer in this context means:

o Any person who is defined as a carer under the Carers Act. o Any person who is defined as a carer under the Carers Act.
o Next of kin who have significant contact with the Service User. o Next of kin who have significant contact with the Service User.
o Any other informal carer the assessors feel it is necessary to consult with. o Any other informal carer the assessors feel it is necessary to consult with.

This should record the carer’s views on the proposed risk management plan, particularly the balance to This should record the carer’s views on the proposed risk management plan, particularly the balance to
be struck between the risks and benefits involved. Any areas of disagreement should be noted. Any be struck between the risks and benefits involved. Any areas of disagreement should be noted. Any
suggestions from carers that have been incorporated in the final plan should also be noted. suggestions from carers that have been incorporated in the final plan should also be noted.

4.18 What Do My Staff Think Of My Plan? (HRBA) 4.18 What Do My Staff Think Of My Plan? (HRBA)

This section should record the perspectives of the agencies and staff that support the individual on a This section should record the perspectives of the agencies and staff that support the individual on a
daily basis. This should record staffs views on the proposed risk management plan, particularly the daily basis. This should record staffs views on the proposed risk management plan, particularly the
balance to be struck between the risks and benefits involved. Any areas of disagreement should be balance to be struck between the risks and benefits involved. Any areas of disagreement should be
noted. Any suggestions from staff that have been incorporated in the final plan should also be noted. noted. Any suggestions from staff that have been incorporated in the final plan should also be noted.

4.19 Who Is Allowed To See My Plan? 4.19 Who Is Allowed To See My Plan?

The assessors should complete a list of people / agencies that are to receive a copy of the assessment The assessors should complete a list of people / agencies that are to receive a copy of the assessment
and / or risk management plan. In considering who should be circulated with a copy of the document and / or risk management plan. In considering who should be circulated with a copy of the document
assessors should bear in mind that it will contain sensitive and confidential information. The normal assessors should bear in mind that it will contain sensitive and confidential information. The normal
rules regarding confidentiality and access that apply to health and social service work in general and rules regarding confidentiality and access that apply to health and social service work in general and
records in particular also apply to the risk assessment and management plan. records in particular also apply to the risk assessment and management plan.

This is potentially a complex area of law and policy which assessors may need to discuss with their line This is potentially a complex area of law and policy which assessors may need to discuss with their line
managers. Assessors should ensure they are aware of, and where appropriate to refer to; managers. Assessors should ensure they are aware of, and where appropriate to refer to;
o The Liverpool and Sefton Interagency Agreement on Confidentiality and the Sharing of o The Liverpool and Sefton Interagency Agreement on Confidentiality and the Sharing of
Information for People in Contact with Mental Health Services (December 1998). Information for People in Contact with Mental Health Services (December 1998).
o Department of Health Circular NO. LAC (88)17: Personal Social Services: Confidentiality of o Department of Health Circular NO. LAC (88)17: Personal Social Services: Confidentiality of
Personal Information. Personal Information.

54 54
 o Access to Personal File Act 1987. o Access to Personal File Act 1987.
o Data Protection Act 1984. o Data Protection Act 1984.
o Access to Health Records Act 1990. o Access to Health Records Act 1990.

In light of the above it may be possible and appropriate to share parts of the assessment / plan with In light of the above it may be possible and appropriate to share parts of the assessment / plan with
other agencies / individuals and not others. The risk management plan section of the document, for other agencies / individuals and not others. The risk management plan section of the document, for
example, may be easily reproduced as a separate document for circulation. example, may be easily reproduced as a separate document for circulation.

Issues of confidentiality and what is circulated to whom should all be noted in this section. Issues of confidentiality and what is circulated to whom should all be noted in this section.

4.20 Signatures of Assessors 4.20 Signatures of Assessors

All the assessors should sign and date the document to signify their agreement with its contents. All the assessors should sign and date the document to signify their agreement with its contents.

4.21 Plan Approvers / Recommendations 4.21 Plan Approvers / Recommendations

Having considered the assessment and plan the designated people on the JOMG should tick the box Having considered the assessment and plan the designated people on the JOMG should tick the box
indicating if the Risk Assessment and management plan has been approved or not. They should sign in indicating if the Risk Assessment and management plan has been approved or not. They should sign in
the space provided on behalf of Liverpool Social Services and Liverpool Health Authority. The the space provided on behalf of Liverpool Social Services and Liverpool Health Authority. The
assessment and plan should only be signed as approved if no significant changes are necessary in order assessment and plan should only be signed as approved if no significant changes are necessary in order
for it to be put into operation. for it to be put into operation.

If the assessment / plan is not approved, the comments section should be used to indicate, in as much If the assessment / plan is not approved, the comments section should be used to indicate, in as much
detail as possible, what further work needs to be done to facilitate its approval. detail as possible, what further work needs to be done to facilitate its approval.

If the assessment / plan is agreed, the comments section should not generally be used. However, it If the assessment / plan is agreed, the comments section should not generally be used. However, it
may be used in exceptional circumstances to recommend minor adjustments to the assessment / plan. may be used in exceptional circumstances to recommend minor adjustments to the assessment / plan.
Signatories should bear in mind that such comments on an approved plan are only advisory, and will not Signatories should bear in mind that such comments on an approved plan are only advisory, and will not
be binding on the assessors and/or those responsible for putting the plan into operation. If any changes be binding on the assessors and/or those responsible for putting the plan into operation. If any changes
are necessary before any plan is put into operation, then the assessment / plan should not be approved. are necessary before any plan is put into operation, then the assessment / plan should not be approved.

55 55
 THE KEEPING ME SAFE AND THE KEEPING ME SAFE AND
WELL SCREEN WELL SCREEN
(HR-JRAMP) (HR-JRAMP)

My name: Insert photograph here My name: Insert photograph here

---------------------------------------- ----------------------------------------

1. ABOUT ME 1. ABOUT ME

My Birthday: My Birthday:
Where I live now: Where I live now:
My Religion: My Religion:
My Gender: My Gender:
My Ethnicity: My Ethnicity:
My Sexual Orientation: My Sexual Orientation:

56 56
2. WHO IS FILLING THIS IN? 2. WHO IS FILLING THIS IN?

Name Position Location Line Lead Name Position Location Line Lead
assessor / assessor /
Manager Manager
co assessor co assessor
Service Service
User User

3. WHERE DID THIS 3. WHERE DID THIS

INFORMATION COME FROM? INFORMATION COME FROM?

57 57
4. WHY IS THE ASSESSMENT 4. WHY IS THE ASSESSMENT
BEING CARRIED OUT NOW? BEING CARRIED OUT NOW?

5. WHEN WILL MY RISK PLAN BE 5. WHEN WILL MY RISK PLAN BE

LOOKED AT AGAIN? LOOKED AT AGAIN?

6. MY WISHES 6. MY WISHES

Include any information that has been completed with the Service User to Include any information that has been completed with the Service User to
highlight their wishes (such as the ‘listen to me’ workbook or an ELP) highlight their wishes (such as the ‘listen to me’ workbook or an ELP)

58 58
USE SPREADSHEET.DOC FOR CRITICAL EVENT HISTORY USE SPREADSHEET.DOC FOR CRITICAL EVENT HISTORY

7. ABOUT MY LIFE (CRITICAL 7. ABOUT MY LIFE (CRITICAL

EVENT HISTORY) EVENT HISTORY)
The Service User has the right to apply and view what The Service User has the right to apply and view what
has been written. has been written.

Date Event Comment Date Event Comment

59 59
8. THINGS ME OR OTHER PEOPLE 8. THINGS ME OR OTHER PEOPLE
ARE WORRIED ABOUT ARE WORRIED ABOUT
(RISK FACTORS) (RISK FACTORS)

a. Historical Factors a. Historical Factors

b. Clinical Factors b. Clinical Factors

c. Social Factors c. Social Factors

If a negative staff attitude is noticed in the critical event history, this should be If a negative staff attitude is noticed in the critical event history, this should be
documented here. It should also be noted if it seems like the staff do not treat the documented here. It should also be noted if it seems like the staff do not treat the
person with FREDA when they respond to incidents. person with FREDA when they respond to incidents.

60 60
d. Actuarial Factors d. Actuarial Factors

9. WHAT DOES ALL THIS MEAN? 9. WHAT DOES ALL THIS MEAN?
(ANALYSIS AND SUMMARY) (ANALYSIS AND SUMMARY)

61 61
10. AFTER LOOKING AT MY ‘RISKS,’ 10. AFTER LOOKING AT MY ‘RISKS,’
WHAT OPTIONS HAVE I GOT? WHAT OPTIONS HAVE I GOT?

OPTION 1: OPTION 1:

RISK AREA Relevant human RISK AREA Relevant human

Significance

Significance
rights involved rights involved

Likelihood

Likelihood
in risk in risk

Severity

Severity
(see risk screen (see risk screen
guidelines for guidelines for
prompts) prompts)

62 62
OPTION 2: OPTION 2:

RISK AREA Relevant human RISK AREA Relevant human

Significance

Significance
rights involved rights involved

Likelihood

Likelihood
in risk in risk

Severity

Severity
(see risk screen (see risk screen
guidelines for guidelines for
prompts) prompts)

OPTION 3: OPTION 3:

RISK AREA Relevant human RISK AREA Relevant human

Significance

Significance
rights involved rights involved
Likelihood

Likelihood
in risk in risk
Severity

Severity
(see risk screen (see risk screen
guidelines for guidelines for
prompts) prompts)

63 63
OPTION 4: OPTION 4:

RISK AREA Relevant human RISK AREA Relevant human

Significance

Significance
rights involved rights involved

Likelihood

Likelihood
in risk in risk

Severity

Severity
(see risk screen (see risk screen
guidelines for guidelines for
prompts) prompts)

11. LOOKING AT MY OPTIONS 11. LOOKING AT MY OPTIONS

64 64
12. WHAT LEGAL DOCUMENTS ARE IMPORTANT IN 12. WHAT LEGAL DOCUMENTS ARE IMPORTANT IN
MY RISK PLAN? MY RISK PLAN?

E.g. the Human Rights Act, The Mental Capacity Act E.g. the Human Rights Act, The Mental Capacity Act
(including the deprivation of liberty guidelines), the (including the deprivation of liberty guidelines), the
Mental Health Act. Mental Health Act.

13. MY RISK MANAGEMENT PLAN 13. MY RISK MANAGEMENT PLAN

The Service User’s wishes regarding how their risks are The Service User’s wishes regarding how their risks are
managed should be incorporated into this section: This managed should be incorporated into this section: This
can be achieved in a variety of ways, e.g: can be achieved in a variety of ways, e.g:
• The ‘listen to me’ workbook • The ‘listen to me’ workbook
• Information from an Essential • Information from an Essential
Lifestyle Plan Lifestyle Plan
• A staying well plan • A staying well plan
• An advanced statement • An advanced statement
• Information from the risk screen • Information from the risk screen
(role plays etc) (role plays etc)

The management plan should document which human The management plan should document which human
rights are relevant to the area of risk and to the rights are relevant to the area of risk and to the
management of that risk. management of that risk.

65 65
 14. – HOW WILL MY PLAN BE PUT INTO PLACE? 14. – HOW WILL MY PLAN BE PUT INTO PLACE?
- HOW WILL MY PLAN BE MONITORED? - HOW WILL MY PLAN BE MONITORED?
- WHEN WILL MY PLAN BE LOOKED AT - WHEN WILL MY PLAN BE LOOKED AT
AGAIN? AGAIN?

15. WILL THE RISK DECISION HELP ME? 15. WILL THE RISK DECISION HELP ME?
(BENEFIT OF RISK DECISION TO THE SERVICE USER) (BENEFIT OF RISK DECISION TO THE SERVICE USER)

66 66
16. WHAT DO I THINK OF MY PLAN? 16. WHAT DO I THINK OF MY PLAN?

17. WHAT DO THE PEOPLE WHO CARE 17. WHAT DO THE PEOPLE WHO CARE
FOR ME THINK OF MY PLAN? FOR ME THINK OF MY PLAN?

67 67
18. WHAT DO MY STAFF THINK OF MY PLAN? 18. WHAT DO MY STAFF THINK OF MY PLAN?

19. WHO IS ALLOWED TO SEE MY PLAN? 19. WHO IS ALLOWED TO SEE MY PLAN?

Article 8: right to private and family life – who is this Article 8: right to private and family life – who is this
information available to? information available to?

68 68
21. PLAN APPROVAL / COMMENTS BY JOINT 21. PLAN APPROVAL / COMMENTS BY JOINT
INVESTMENT AND MANAGEMENT GROUP INVESTMENT AND MANAGEMENT GROUP

Tick Approved Not Approved Tick Approved Not Approved

Comment Comment

Liverpool Health Liverpool Social Services Liverpool Health Liverpool Social Services
Authority Authority Authority Authority
Name: (Print) Name: (Print)

Position: Position:

Signed: Signed:

Date: Date:

20. Assessors 20. Assessors

signatures to agree Lead Assessor Co-Assessor signatures to agree Lead Assessor Co-Assessor
document’s contents document’s contents

Name: (print) Name: (print)

Signed: Signed:

Date: Date:

69 69
6 References & Further Reading 6 References & Further Reading

Alaszewski, H., & Alaszewski, A. (2005). Person centred planning and risk. Challenging the boundaries. Alaszewski, H., & Alaszewski, A. (2005). Person centred planning and risk. Challenging the boundaries.
In P. Cambridge and S. Carnaby (Eds.), Person centred planning and care management with people with In P. Cambridge and S. Carnaby (Eds.), Person centred planning and care management with people with
learning disabilities (pp 183-197). London: Jessica Kingsley. learning disabilities (pp 183-197). London: Jessica Kingsley.

Alberg C., Hatfield B., & Huxley P. (eds). (1996) Learning materials on mental health: Risk assessment.. Alberg C., Hatfield B., & Huxley P. (eds). (1996) Learning materials on mental health: Risk assessment..
Manchester. University of Manchester. Manchester. University of Manchester.

Bailey, S., Ridley, J., and Greenhill, B. (2010). Challenging behaviour: a human rights-based approach. Bailey, S., Ridley, J., and Greenhill, B. (2010). Challenging behaviour: a human rights-based approach.
Advances in Mental Health and Intellectual Disabilities, Volume 4, Issue 2, June 2010. Advances in Mental Health and Intellectual Disabilities, Volume 4, Issue 2, June 2010.

Bentall, R.P. (2003). Madness explained. Psychosis and human nature. London, England: Allen Lane. Bentall, R.P. (2003). Madness explained. Psychosis and human nature. London, England: Allen Lane.
Penguin Press. Penguin Press.

Bluglass, R & Bowden, P (1990). Principle and Practice of Forensic Psychiatry. Churchill Livingstone, Bluglass, R & Bowden, P (1990). Principle and Practice of Forensic Psychiatry. Churchill Livingstone,
London London

Brayne, H. & Martin, G. (1990). Law for social workers. Oxford. Oxford University Press. Brayne, H. & Martin, G. (1990). Law for social workers. Oxford. Oxford University Press.

Bush, A. (2007). Submission to the Joint Committee on Human Rights: The human rights of adults with Bush, A. (2007). Submission to the Joint Committee on Human Rights: The human rights of adults with
learning disabilities – a call for evidence. Clinical Psychology & People with Learning Disabilities. 5 (3). learning disabilities – a call for evidence. Clinical Psychology & People with Learning Disabilities. 5 (3).
16-20 16-20

Campbell, L. & Morrison, A. (2007). The subjective experience of paranoia: Comparing the experiences Campbell, L. & Morrison, A. (2007). The subjective experience of paranoia: Comparing the experiences
of patients with psychosis and individuals with no psychiatric history. Clinical Psychology and of patients with psychosis and individuals with no psychiatric history. Clinical Psychology and
Psychotherapy, 14, 63-77. Psychotherapy, 14, 63-77.

Cantor, D. Hill, M. A & Mclachlan, E. K. (1989). Suicide and related behaviour from river bridges: A Cantor, D. Hill, M. A & Mclachlan, E. K. (1989). Suicide and related behaviour from river bridges: A
clinical perspective. British Journal of Psychiatry, 155, 829-835 clinical perspective. British Journal of Psychiatry, 155, 829-835

Care Quality Commission (2009) Voices into action: how the Care Quality Commission is going to involve Care Quality Commission (2009) Voices into action: how the Care Quality Commission is going to involve
people. Care Quality Commission. Available from: people. Care Quality Commission. Available from:
http://www.cqc.org.uk/_db/_documents/A4_Report_2009_01.pdf [Accessed 24th October 2010] http://www.cqc.org.uk/_db/_documents/A4_Report_2009_01.pdf [Accessed 24th October 2010]

Carson, D. (1995) Calculated risk. Community Care.26-27 Carson, D. (1995) Calculated risk. Community Care.26-27

Clare, I C H. (1993). Issues in the Assessment and Treatment of Male Sex Offenders with Mild Learning Clare, I C H. (1993). Issues in the Assessment and Treatment of Male Sex Offenders with Mild Learning
Disabilities. Sexual and Marital Therapy, 8 (2), 167-180 Disabilities. Sexual and Marital Therapy, 8 (2), 167-180

Clare, I C H. and Murphy, G. (1993) The Assessment of Risk and Dangerousness as Applied to People Clare, I C H. and Murphy, G. (1993) The Assessment of Risk and Dangerousness as Applied to People
With Learning Disabilities Considered at Risk of Offending. Hester Adrian Research Centre With Learning Disabilities Considered at Risk of Offending. Hester Adrian Research Centre

Clare, I. C. H. & Murphy, I. G. H. (1998) Working with offenders or alleged offenders with intellectual Clare, I. C. H. & Murphy, I. G. H. (1998) Working with offenders or alleged offenders with intellectual
disabilities. In: Emerson, E. Hatton, C. Bromley, J. & Caine, A. (Eds.). Clinical psychology and people disabilities. In: Emerson, E. Hatton, C. Bromley, J. & Caine, A. (Eds.). Clinical psychology and people
with intellectual disabilities, (pp. 154-176).Chichester, England: Wiley. with intellectual disabilities, (pp. 154-176).Chichester, England: Wiley.

Crawford, J. (2002) The institutional hazard of being a visible women. In: Dale, C. Storey, L. (Ed.), Care Crawford, J. (2002) The institutional hazard of being a visible women. In: Dale, C. Storey, L. (Ed.), Care
and treatment of offenders with a learning disability. A collection of papers from the first international and treatment of offenders with a learning disability. A collection of papers from the first international
conference University of Central Lancashire. (pp 121-130). Nursing Press international. Great Britain. conference University of Central Lancashire. (pp 121-130). Nursing Press international. Great Britain.

Davies, M. (1997). The Blackwell companion to social work. Oxford. Blackwell Publishers. Davies, M. (1997). The Blackwell companion to social work. Oxford. Blackwell Publishers.

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Day, K. (1990). Mental retardation: Clinical aspects and Management. In: Bluglass, R. Bowden, P. Day, K. (1990). Mental retardation: Clinical aspects and Management. In: Bluglass, R. Bowden, P.
(eds). (1990). Principle and Practice of Forensic Psychiatry. (pp. 399-418). Churchill Livingstone, (eds). (1990). Principle and Practice of Forensic Psychiatry. (pp. 399-418). Churchill Livingstone,
London. London.

Day, K. (1993). Crime and mental retardation: a review. In: Howells, K. Hollins, C. R. (eds.) Clinical Day, K. (1993). Crime and mental retardation: a review. In: Howells, K. Hollins, C. R. (eds.) Clinical
Approaches to the Mentally Disordered Offender. Cambridge: John Wyllie. Approaches to the Mentally Disordered Offender. Cambridge: John Wyllie.

Demetral, G. D. (1994). Diagrammatic assessment of ecological integration of sex offenders with Demetral, G. D. (1994). Diagrammatic assessment of ecological integration of sex offenders with
mental retardation in community residential facilities. Mental Retardation, 32(2), 141-145. mental retardation in community residential facilities. Mental Retardation, 32(2), 141-145.

Department of Health (DH)/NHSME (1994) Guidance on the discharge of mentally disordered offenders. Department of Health (DH)/NHSME (1994) Guidance on the discharge of mentally disordered offenders.
HSG/94/27, Department of Health/NHSME, London. HSG/94/27, Department of Health/NHSME, London.

Department of Health. (2001). Valuing people: a new strategy for learning disability for the 21st Department of Health. (2001). Valuing people: a new strategy for learning disability for the 21st
century. London. The Stationery Office. century. London. The Stationery Office.

Department of Health. (1993). Services for people with learning disabilities and challenging behaviour or Department of Health. (1993). Services for people with learning disabilities and challenging behaviour or
mental health needs: Report of project group. London. Department of Health. mental health needs: Report of project group. London. Department of Health.

Department of Health. (1995). Once a day. London. The Stationary Office. Department of Health. (1995). Once a day. London. The Stationary Office.

Department of Health. (1996). Signposts for success. London . The Stationery Office Department of Health. (1996). Signposts for success. London . The Stationery Office

Department of Health & The British Institute of Human Rights. (2007). Human rights in healthcare – A Department of Health & The British Institute of Human Rights. (2007). Human rights in healthcare – A
framework for local action. Department of Health Best Practice Guidance. framework for local action. Department of Health Best Practice Guidance.

Department of Health. (2007). Mental Capacity Act 2005 Deprivation of Liberty Safeguards. London. The Department of Health. (2007). Mental Capacity Act 2005 Deprivation of Liberty Safeguards. London. The
Stationery Office. Stationery Office.

Department of Health (2007). Best practice in managing risk. Principles and evidence for best practice in Department of Health (2007). Best practice in managing risk. Principles and evidence for best practice in
the assessment and management of risk to self and others in mental health services. London. The the assessment and management of risk to self and others in mental health services. London. The
Stationary Office. Stationary Office.

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mental health needs: Report of a Project Group (Chairman: Prof J L Mansell). Revised Edition. London: mental health needs: Report of a Project Group (Chairman: Prof J L Mansell). Revised Edition. London:
Department of Health. Department of Health.

Department of Health (Chairman: Darzi, A) (2008a). High Quality healthcare for all. NHS Next Stage Department of Health (Chairman: Darzi, A) (2008a). High Quality healthcare for all. NHS Next Stage
Review. London: Department of Health. Review. London: Department of Health.

Department of Health (2008b). (Chairman: J. Boyington) New Horizons for Mental Health Commissioning Department of Health (2008b). (Chairman: J. Boyington) New Horizons for Mental Health Commissioning
– An Opportunity to Help Shape the Agenda. London: Department of Health. – An Opportunity to Help Shape the Agenda. London: Department of Health.

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128-149). Open University Press. 128-149). Open University Press.

Swanson, J,W. (1994) Mental Disorder, Substance Abuse and Community Violence: An epidemiological Swanson, J,W. (1994) Mental Disorder, Substance Abuse and Community Violence: An epidemiological
approach. In J, Monahan, H, J Steadman (eds) Violence and mental disoder: Developments in risk approach. In J, Monahan, H, J Steadman (eds) Violence and mental disoder: Developments in risk
assessment (pp. 101-136) Chicago, IL, US: University of Chicago Press. assessment (pp. 101-136) Chicago, IL, US: University of Chicago Press.

Toker-Lester (2003). Getting Better: Book 2 – Taking your medicines. Mersey Care NHS Trust Toker-Lester (2003). Getting Better: Book 2 – Taking your medicines. Mersey Care NHS Trust

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Topping-Morris, B. (1995). No place for restraint in care. Nursing Standard, 91, 22-23. Topping-Morris, B. (1995). No place for restraint in care. Nursing Standard, 91, 22-23.

Turner, S. (1998) The Assessment of Risk and Dangerousness as Applied to People With Learning Turner, S. (1998) The Assessment of Risk and Dangerousness as Applied to People With Learning
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Turner, S. (2000). Forensic risk assessment in intellectual disabilities: The evidence base and current Turner, S. (2000). Forensic risk assessment in intellectual disabilities: The evidence base and current
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Ward, L., & Townsley, R. (2005). ‘It’s about a dialogue…’ Working with people with learning difficulties Ward, L., & Townsley, R. (2005). ‘It’s about a dialogue…’ Working with people with learning difficulties
to develop accessible information. British Journal of Learning Disabilities, 33, 59-64. to develop accessible information. British Journal of Learning Disabilities, 33, 59-64.

Webster, C.D., & Eaves, D. (1994). The HCR-20 Scheme; the assessment of dangerousness and risk. Webster, C.D., & Eaves, D. (1994). The HCR-20 Scheme; the assessment of dangerousness and risk.
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Weigel, L. Langdon, P.E. Collins, S. O’Brien. Y (2006). Challenging behaviour in learning disability – Weigel, L. Langdon, P.E. Collins, S. O’Brien. Y (2006). Challenging behaviour in learning disability –
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45(2) 45(2)

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7 Appendices 7 Appendices

Appendix 1 Keeping Me Safe and Well Assessment Manual Appendix 1 Keeping Me Safe and Well Assessment Manual

This is the manual for the Keeping Me Safe and Well This is the manual for the Keeping Me Safe and Well
risk assessment. Additional recording documents risk assessment. Additional recording documents
and pictures are available from the authors. and pictures are available from the authors.

Appendix 2 Human Rights in Risk Management Strategies Appendix 2 Human Rights in Risk Management Strategies

Appendix 3 Human Rights in Strategies Flowchart Appendix 3 Human Rights in Strategies Flowchart

Appendix 4 Human Rights Decision Making Form Appendix 4 Human Rights Decision Making Form

78 78
Appendix 1: Keeping Me Safe and Well Manual ( insert revised version) Appendix 1: Keeping Me Safe and Well Manual ( insert revised version)

79 79
keeping me safe_Layout 1 02/03/2011 14:46 Page 1 keeping me safe_Layout 1 02/03/2011 14:46 Page 1

Improving Mental Health Improving Mental Health

KEEPING ME SAFE AND WELL KEEPING ME SAFE AND WELL

ASSESSMENT MANUAL ASSESSMENT MANUAL

A HUMAN RIGHTS BASED APPROACH A HUMAN RIGHTS BASED APPROACH

keeping me safe_Layout 1 02/03/2011 14:46 Page 2 keeping me safe_Layout 1 02/03/2011 14:46 Page 2

Contents Page Contents Page

Introduction 3 Introduction 3
Why Is Service User Involvement in Risk Assessment Important? 3 Why Is Service User Involvement in Risk Assessment Important? 3
Facilitating Service User Involvement 4 Facilitating Service User Involvement 4
Personalising the Risk Assessment 6 Personalising the Risk Assessment 6
Assessing Risk: Likelihood and Severity 7 Assessing Risk: Likelihood and Severity 7
Completing the Risk Assessment 8 Completing the Risk Assessment 8
Explaining Risk, Rights and the Scoring System. 8 Explaining Risk, Rights and the Scoring System. 8
Recording and Worked Example 9 Recording and Worked Example 9
Risk Areas: Questions, Prompts and Human Rights Involved 10-55 Risk Areas: Questions, Prompts and Human Rights Involved 10-55
Risk to self 10-23 Risk to self 10-23
Risk to others 24-35 Risk to others 24-35
Risk from others 4252 Risk from others 4252
Risk to property 53-55 Risk to property 53-55
Sharing the Summary 56 Sharing the Summary 56

Authors, 2008 Also available:- Authors, 2008 Also available:-

Amy Lee 1) Human Rights Risk Assessment and Amy Lee 1) Human Rights Risk Assessment and
Management Plan Management Plan
Kulvinder Kaur Kulvinder Kaur
2) Human Rights Benchmarking Tool 2) Human Rights Benchmarking Tool
Dr. Alex Cookson Dr. Alex Cookson
3) Speaking Up for Myself Group 3) Speaking Up for Myself Group
Dr. Beth Greenhill Dr. Beth Greenhill
4) Standing Up for My Rights Booklet 4) Standing Up for My Rights Booklet
5) Accessible Information Pack 5) Accessible Information Pack
Authors of Revision, 2011 Authors of Revision, 2011
Jenna Vyas Jenna Vyas
This manual is a Mersey Care NHS Trust This manual is a Mersey Care NHS Trust
Michelle Redman publication and should not be reproduced without Michelle Redman publication and should not be reproduced without
Jennifer Eaton the author’s permission. The manual can however Jennifer Eaton the author’s permission. The manual can however
be printed and used clinically as part of a validation be printed and used clinically as part of a validation
Dr. Beth Greenhill process. If you wish to take part in our validation Dr. Beth Greenhill process. If you wish to take part in our validation
project please contact us, as below. The validation project please contact us, as below. The validation
process will contribute to any further revisions to process will contribute to any further revisions to
Contributors: the document. Contributors: the document.
Revision Workshop Participants, 2011 Revision Workshop Participants, 2011
Georgia Fair, Lindsey Tirant, Kathy Fearns, Ged Georgia Fair, Lindsey Tirant, Kathy Fearns, Ged
Carney, Jenna Vyas, Michelle Redman, Simon For further information and Carney, Jenna Vyas, Michelle Redman, Simon For further information and
Grindy, Jennifer Eaton, Richard Whitehead, Dr. Beth training opportunities contact:- Grindy, Jennifer Eaton, Richard Whitehead, Dr. Beth training opportunities contact:-
Greenhill [email protected] Greenhill [email protected]
[email protected] [email protected]
Contributors: Contributors:
Calderstones Foundation NHS Trust, 2011 Calderstones Foundation NHS Trust, 2011
© <2008> Mersey Care NHS Trust. All rights reserved. © <2008> Mersey Care NHS Trust. All rights reserved.
We would also like to thank Sam Hall, Helen This material may be copied for use within NHS We would also like to thank Sam Hall, Helen This material may be copied for use within NHS
Duperouzel and Service Users from Calderstones organisations only on the understanding that Mersey Duperouzel and Service Users from Calderstones organisations only on the understanding that Mersey
Partnership NHS Foundation Trust for piloting and Care NHS Trust is acknowledged as the developer of Partnership NHS Foundation Trust for piloting and Care NHS Trust is acknowledged as the developer of
providing constructive feedback on the 2008 the material on all copies and that this copyright providing constructive feedback on the 2008 the material on all copies and that this copyright
statement is retained. statement is retained.
version version

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Introduction Introduction
Why Is Service User Involvement in Risk The ‘Keeping Me Safe and Well Assessment’7, is Why Is Service User Involvement in Risk The ‘Keeping Me Safe and Well Assessment’7, is
Assessment Important? designed to assess risk whilst applying a HRBA. In Assessment Important? designed to assess risk whilst applying a HRBA. In
our service, it is used with all service users to our service, it is used with all service users to
“We looked at the problems I had first, the violence identify people who may need the support of a risk “We looked at the problems I had first, the violence identify people who may need the support of a risk
and stuff because I wasn’t very well. My health management plan. The risk assessment was and stuff because I wasn’t very well. My health management plan. The risk assessment was
worker wrote the stuff on the board, cutting myself, developed in conjunction with service users, worker wrote the stuff on the board, cutting myself, developed in conjunction with service users,
hanging myself and having a shower; that was a experienced clinical practitioners, ‘People First’ hanging myself and having a shower; that was a experienced clinical practitioners, ‘People First’
problem, falling wasn’t a problem (pointing to the (Liverpool), and the British Institute of Human problem, falling wasn’t a problem (pointing to the (Liverpool), and the British Institute of Human
risk assessment pictures). I can’t read so I drew the Rights, as part of the ‘Human Rights In Healthcare risk assessment pictures). I can’t read so I drew the Rights, as part of the ‘Human Rights In Healthcare
pictures, I’m good at drawing. The pictures helped Project’8. It has been revised to include feedback pictures, I’m good at drawing. The pictures helped Project’8. It has been revised to include feedback
me understand. My health worker went through following a pilot study involving Mersey Care staff me understand. My health worker went through following a pilot study involving Mersey Care staff
everything from the beginning and explained it. and service users at Calderstones Partnership NHS everything from the beginning and explained it. and service users at Calderstones Partnership NHS
We then looked at each problem to see if it was Foundation Trust10. We then looked at each problem to see if it was Foundation Trust10.
something to worry about. Green meant that you The risk assessment looks at four areas of risk; something to worry about. Green meant that you The risk assessment looks at four areas of risk;
are ok; you are not worried about that. Red was risks to self, risks to others and risks from others are ok; you are not worried about that. Red was risks to self, risks to others and risks from others
something to worry about and orange was in and risks to property. Within each area of risk, something to worry about and orange was in and risks to property. Within each area of risk,
between the two. We scribbled the colours common risk issues and difficulties (for example between the two. We scribbled the colours common risk issues and difficulties (for example
underneath each problem together.” self harm, physical aggression, abuse issues) are underneath each problem together.” self harm, physical aggression, abuse issues) are
(Service User, describing her risk assessment) itemised. The human rights which may be engaged (Service User, describing her risk assessment) itemised. The human rights which may be engaged
by risk or difficulty are made explicit. by risk or difficulty are made explicit.
The need for involving service users is made The need for involving service users is made
Service user perspectives are often excluded from explicit within the assessment and facilitated by Service user perspectives are often excluded from explicit within the assessment and facilitated by
traditional approaches to risk assessment, which the format, which includes pictures, accessible traditional approaches to risk assessment, which the format, which includes pictures, accessible
focus on professional views of risks and language and a ‘traffic light system’ to support focus on professional views of risks and language and a ‘traffic light system’ to support
challenging behaviour1. This manual takes a service users in expressing their own perception of challenging behaviour1. This manual takes a service users in expressing their own perception of
different approach; that of a human rights how risky the particular behaviour is. Alongside the different approach; that of a human rights how risky the particular behaviour is. Alongside the
perspective. traffic light system, there is a ‘risk matrix’, allowing perspective. traffic light system, there is a ‘risk matrix’, allowing
A human rights based approach (HRBA) to risk the practitioner to consider the likelihood and the A human rights based approach (HRBA) to risk the practitioner to consider the likelihood and the
assessment balances the human rights of service potential impact of the risk behaviour. The guidance assessment balances the human rights of service potential impact of the risk behaviour. The guidance
users, their carers, and members of their notes encourage creative engagement with service users, their carers, and members of their notes encourage creative engagement with service
communities. This is so we can, in effect, manage users, for example through role plays. communities. This is so we can, in effect, manage users, for example through role plays.
risk more positively. A HRBA looks at risk through a risk more positively. A HRBA looks at risk through a
‘Human Rights’ lens, identifies relevant equality and ‘Human Rights’ lens, identifies relevant equality and
diversity issues, and maximises service user diversity issues, and maximises service user
participation and empowerment. participation and empowerment.
Human rights principles are now explicit in not only Human rights principles are now explicit in not only
the NHS constitution2 but also in informing the the NHS constitution2 but also in informing the
approach of the Care Quality Commission3. We approach of the Care Quality Commission3. We
believe that our emphasis on service user inclusion, believe that our emphasis on service user inclusion,
which forms such an essential part of a human which forms such an essential part of a human
rights based approach to healthcare, also fits well rights based approach to healthcare, also fits well
with government policy for service user with government policy for service user
involvement4, best practice in risk management involvement4, best practice in risk management
and the recent White Paper, “Equity and and the recent White Paper, “Equity and
Excellence: Liberating the NHS”6. Excellence: Liberating the NHS”6.

1 Langan., J & Lindow, V. (2004). ’Living with Risk’, Joseph Rowntree Foundation: Policy Press. 1 Langan., J & Lindow, V. (2004). ’Living with Risk’, Joseph Rowntree Foundation: Policy Press.
2 Department of Heath (2009b). NHS 2010-2015: from good to great. preventative, people-centred, productive. London: Department of Health. 2 Department of Heath (2009b). NHS 2010-2015: from good to great. preventative, people-centred, productive. London: Department of Health.
3 Care Quality Commission (2009) Voices into action: how the Care Quality Commission is going to involve people. Care Quality Commission. 3 Care Quality Commission (2009) Voices into action: how the Care Quality Commission is going to involve people. Care Quality Commission.
4 Department of Health (Chairman: Darzi, A) (2008a). High Quality healthcare for all. NHS Next Stage Review. London: Department of Health. 4 Department of Health (Chairman: Darzi, A) (2008a). High Quality healthcare for all. NHS Next Stage Review. London: Department of Health.
5 Department of Health (2008b). (Chairman: J. Boyington) New Horizons for Mental Health Commissioning – An Opportunity to Help Shape the Agenda. London: 5 Department of Health (2008b). (Chairman: J. Boyington) New Horizons for Mental Health Commissioning – An Opportunity to Help Shape the Agenda. London:
Department of Health. Department of Health.
6 Department of Health. (2009a). Valuing People Now: From Progress to Transformation - A Consultation on the Next Three Years of Learning Disability Policy. London: 6 Department of Health. (2009a). Valuing People Now: From Progress to Transformation - A Consultation on the Next Three Years of Learning Disability Policy. London:
Department of Health. Department of Health.
7 Department of Health (2007). Best practice in managing risk. Principles and evidence for best practice in the assessment and management of risk to self and others in 7 Department of Health (2007). Best practice in managing risk. Principles and evidence for best practice in the assessment and management of risk to self and others in
mental health services. London. The Stationary Office. mental health services. London. The Stationary Office.
8 Department of Health (2010) Equity and excellence: liberating the NHS, London, Department of Health. 8 Department of Health (2010) Equity and excellence: liberating the NHS, London, Department of Health.
9 Lee, A. Kaur, K. Cookson, A & Greenhill, B. (2008). The Keeping Me Safe and Well Screen. 9 Lee, A. Kaur, K. Cookson, A & Greenhill, B. (2008). The Keeping Me Safe and Well Screen.
http://www.dh.gov.uk/en/Managingyourorganisation/Equalityandhumanrights/Humanrights/DH_088783 http://www.dh.gov.uk/en/Managingyourorganisation/Equalityandhumanrights/Humanrights/DH_088783
10 Department of Health & The British Institute of Human Rights. (2007; 2008). Human rights in healthcare – A framework for local action. Department of Health, Best 10 Department of Health & The British Institute of Human Rights. (2007; 2008). Human rights in healthcare – A framework for local action. Department of Health, Best
Practice Guidance. Practice Guidance.
11 Roberts, A., Vyas, J., McEwan, L., Khawaja, Z., Evans, G., Punshon, C., Greenhill, B., (2010). A Human Rights Based Approach to Risk: Evaluating the Incorporation of the 11 Roberts, A., Vyas, J., McEwan, L., Khawaja, Z., Evans, G., Punshon, C., Greenhill, B., (2010). A Human Rights Based Approach to Risk: Evaluating the Incorporation of the
‘Keeping Me Safe and Well’ Risk Screen into Community Learning Disability Services ‘Keeping Me Safe and Well’ Risk Screen into Community Learning Disability Services
12 Hall, S. (2010). Evaluation Report Involving Service users in the Risk Assessment Process; The Keeping Me Safe and Well Screen. MSc. Dissertation. 12 Hall, S. (2010). Evaluation Report Involving Service users in the Risk Assessment Process; The Keeping Me Safe and Well Screen. MSc. Dissertation.

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This step-by-step risk assessment manual is accompanied by the following: This step-by-step risk assessment manual is accompanied by the following:

Record forms: Record forms:

for each service user, containing a shared summary sheet for each service user, containing a shared summary sheet

Picture booklet: Picture booklet:

to support communication to support communication

Traffic light picture card: Traffic light picture card:

to support the service user to assess their own risk. to support the service user to assess their own risk.

Traffic light scoring sheet: Traffic light scoring sheet:

to record the service user’s assessment of their risk. to record the service user’s assessment of their risk.

1.2 Facilitating Service User Involvement 1.2 Facilitating Service User Involvement
How much involvement should the service user • Attention span (e.g. how long can the person How much involvement should the service user • Attention span (e.g. how long can the person
have? concentrate for?) have? concentrate for?)
A human rights based approach to risk, means • Engagement (e.g. will the person engage with the A human rights based approach to risk, means • Engagement (e.g. will the person engage with the
ensuring service users are as involved as they can assessment?) ensuring service users are as involved as they can assessment?)
possibly be in their own risk assessment process. possibly be in their own risk assessment process.
Whether the service user participates fully or • Insight (e.g. if the person has problems with Whether the service user participates fully or • Insight (e.g. if the person has problems with
contributes to a small aspect of their risk physical violence, do they realise they could be contributes to a small aspect of their risk physical violence, do they realise they could be
assessment, some involvement will almost always causing risk to themselves or others?) assessment, some involvement will almost always causing risk to themselves or others?)
be possible. However, we recognise that when • Remorse (e.g. if the person has hurt somebody, be possible. However, we recognise that when • Remorse (e.g. if the person has hurt somebody,
someone with a learning disability first accesses do they say sorry and mean it?) someone with a learning disability first accesses do they say sorry and mean it?)
our service, they might not be able to take part in our service, they might not be able to take part in
every aspect of their risk assessment process. Their • Suggestibility (e.g. is the person able to say ‘no’ every aspect of their risk assessment process. Their • Suggestibility (e.g. is the person able to say ‘no’
ability to engage might be affected in different and expect this to be heard or do they feel as ability to engage might be affected in different and expect this to be heard or do they feel as
ways. though they have to agree and say ‘yes’?) ways. though they have to agree and say ‘yes’?)
Timing can be key when considering at what level Timing can be key when considering at what level
the service user can participate in the risk the service user can participate in the risk
Who should complete the risk assessment? assessment and requires good clinical judgement Who should complete the risk assessment? assessment and requires good clinical judgement
Speaking to the service user to find out who they about what the service user can tolerate. Speaking to the service user to find out who they about what the service user can tolerate.
would like to be involved in their risk assessment is Where full participation isn’t possible, the would like to be involved in their risk assessment is Where full participation isn’t possible, the
essential. They may want to complete the screen practitioner would be expected to work through the essential. They may want to complete the screen practitioner would be expected to work through the
with their health worker. They may also want, or risk assessment on the service user’s behalf with with their health worker. They may also want, or risk assessment on the service user’s behalf with
indeed choose not to have, input from family the help of family members, the person’s advocate indeed choose not to have, input from family the help of family members, the person’s advocate
members, advocacy services or chosen support or chosen support staff. A ‘service user consultant’, members, advocacy services or chosen support or chosen support staff. A ‘service user consultant’,
staff. Local Authority and other agencies may also or ‘expert by experience’, could become involved if staff. Local Authority and other agencies may also or ‘expert by experience’, could become involved if
need to contribute. the person is unable to participate. Over time, or need to contribute. the person is unable to participate. Over time, or
as service user’s capacity for engagement as service user’s capacity for engagement
develops, they should become more actively develops, they should become more actively
Is a person able to become actively involved? involved. Is a person able to become actively involved? involved.
A number of elements may be helpful in considered The continuum below shows the journey a service A number of elements may be helpful in considered The continuum below shows the journey a service
how best to involve the service user in their risk user may go on in relation to their risk assessment. how best to involve the service user in their risk user may go on in relation to their risk assessment.
assessment. These may include thinking about the The ‘gold standard’ is for the service user to lead assessment. These may include thinking about the The ‘gold standard’ is for the service user to lead
person’s: and be fully involved with the whole process. person’s: and be fully involved with the whole process.
Although this is the aim, the level of inclusion may Although this is the aim, the level of inclusion may
• Psychological state (e.g. is depression or anxiety move back and forth along the continuum • Psychological state (e.g. is depression or anxiety move back and forth along the continuum
preventing the person from engaging with the depending on the presentation of the service user preventing the person from engaging with the depending on the presentation of the service user
assessment?) at any given time. assessment?) at any given time.

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Figure 1. Continuum of service user involvement Figure 1. Continuum of service user involvement

Led and initiated Service Service Service Service Service user is Led and initiated Service Service Service Service Service user is
by the practitioner. user user is user user is fully involved by the practitioner. user user is user user is fully involved
Service user is not Consultant asked if chooses involved in with the Service user is not Consultant asked if chooses involved in with the
aware of the is involved they who wants aspects of process (i.e. the aware of the is involved they who wants aspects of process (i.e. the
process want to to be the process process is process want to to be the process process is
participate Involved in adapted so it is participate Involved in adapted so it is
the process accessible. The the process accessible. The
service user has service user has
a choice as to a choice as to
who is involved) who is involved)

Non-inclusive Fully-inclusive Non-inclusive Fully-inclusive

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1.3 Personalising the ‘Keeping 1.3 Personalising the ‘Keeping

Me Safe and Well’ Assessment Me Safe and Well’ Assessment
The ‘Keeping Me Safe and Well’ Assessment can Picture Booklet The ‘Keeping Me Safe and Well’ Assessment can Picture Booklet
be personalised for each service user. Service be personalised for each service user. Service
Users and clinicians involved in the pilot project The booklet can also be used to facilitate Users and clinicians involved in the pilot project The booklet can also be used to facilitate
suggested a number of creative solutions to aid communication. It may be particularly useful, for suggested a number of creative solutions to aid communication. It may be particularly useful, for
service user involvement after assessing the example, with individuals who have difficulty service user involvement after assessing the example, with individuals who have difficulty
person’s communication skills. Actively involving reading, or for whom English is not their first person’s communication skills. Actively involving reading, or for whom English is not their first
the service user in their own risk assessment will language. the service user in their own risk assessment will language.
increase accessibility, engagement and, ultimately, For some service users, it might be more increase accessibility, engagement and, ultimately, For some service users, it might be more
ownership of the service user’s care. meaningful to work collaboratively producing ownership of the service user’s care. meaningful to work collaboratively producing
shared pictures. Explaining each risk area and then shared pictures. Explaining each risk area and then
working with the person to draw a picture to working with the person to draw a picture to
Improving accessibility of the risk assessment capture it’s meaning can be effective. For example: Improving accessibility of the risk assessment capture it’s meaning can be effective. For example:
in ‘physical health’, if the service user has a risk in ‘physical health’, if the service user has a risk
Assessing the skills of each service user individually relating to asthma, they might draw a picture of an Assessing the skills of each service user individually relating to asthma, they might draw a picture of an
will allow you to conduct your assessment to fit the inhaler. This might help the person think of the risks will allow you to conduct your assessment to fit the inhaler. This might help the person think of the risks
service users needs. Questions to consider may be: that are important for them. service users needs. Questions to consider may be: that are important for them.
• Does the person communicate verbally? • Does the person communicate verbally?
• Do they speak English as a first language? Traffic Light Picture Card • Do they speak English as a first language? Traffic Light Picture Card
• Can they read? Service users may also want to use the ‘traffic light’ • Can they read? Service users may also want to use the ‘traffic light’
• Do they understand spoken language? picture card, by pointing to the relevant light to • Do they understand spoken language? picture card, by pointing to the relevant light to
show the perceived level of risk. The traffic light can show the perceived level of risk. The traffic light can
• If they do not communicate verbally, do they also be used by the assessor as a prompt to • If they do not communicate verbally, do they also be used by the assessor as a prompt to
have any other ways of communicating? explain the different levels of risk. have any other ways of communicating? explain the different levels of risk.
• Picture cards • Picture cards
• Sounds Traffic Light Scoring Sheet • Sounds Traffic Light Scoring Sheet
• Behaviours This scoring sheet enables service users to indicate • Behaviours This scoring sheet enables service users to indicate
• Signs to the assessor what they perceive the level of risk • Signs to the assessor what they perceive the level of risk
to be. Service users can use this sheet in a number to be. Service users can use this sheet in a number
of ways from colouring in the relevant ‘light’ or of ways from colouring in the relevant ‘light’ or
marking it with an ‘x’. Some service users used red, marking it with an ‘x’. Some service users used red,
Wording Wording
orange and green pen to colour the relevant traffic orange and green pen to colour the relevant traffic
Although the words in the risk assessment are light in, depending on the risk, .and reported that Although the words in the risk assessment are light in, depending on the risk, .and reported that
simplified, it might be the case that the service user this was helpful. simplified, it might be the case that the service user this was helpful.
needs more of an explanation. Alternatively they needs more of an explanation. Alternatively they
might need it displayed in a way that is more might need it displayed in a way that is more
meaningful to them. For example, if in the meaningful to them. For example, if in the
‘Transport’ section the risk is related to refusing to ‘Transport’ section the risk is related to refusing to
wear a seatbelt, make sure you highlight this. Use wear a seatbelt, make sure you highlight this. Use
the person’s words and language because this is the person’s words and language because this is
likely to make the process more meaningful. You likely to make the process more meaningful. You
might need to negotiate this with the person. Each might need to negotiate this with the person. Each
question in the manual contains a list of prompt question in the manual contains a list of prompt
questions that can be used to gather information questions that can be used to gather information
from the service user. This list is not exhaustive and from the service user. This list is not exhaustive and
should be used as a guide. should be used as a guide.

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Assessing Risk: Likelihood and Severity Assessing Risk: Likelihood and Severity

The ‘Keeping Me Safe And Well’ assessment 3. Major The ‘Keeping Me Safe And Well’ assessment 3. Major
should be completed for ALL service users by the should be completed for ALL service users by the
practitioner within 6 WEEKS of allocation. • Physical injury to the client or others which would practitioner within 6 WEEKS of allocation. • Physical injury to the client or others which would
require their admission to hospital (including require their admission to hospital (including
When assessing the risk, take into account both the death). When assessing the risk, take into account both the death).
likelihood of the risk occurring and also the severity likelihood of the risk occurring and also the severity
of the consequences. • Psychological trauma to the client or others of the consequences. • Psychological trauma to the client or others
which would require their admission to hospital. which would require their admission to hospital.

Likelihood Likelihood
• Behaviour which would results in criminal • Behaviour which would results in criminal
When considering likelihood, only take into account prosecution and imprisonment or sectioning When considering likelihood, only take into account prosecution and imprisonment or sectioning
the next six months. You should look at events over under the Mental Health Act. the next six months. You should look at events over under the Mental Health Act.
the last 6 months to make an estimate of likelihood the last 6 months to make an estimate of likelihood
over the next 6 months. over the next 6 months.
Scoring Scoring

The scoring for likelihood is as follows: The total score is obtained by multiplying the The scoring for likelihood is as follows: The total score is obtained by multiplying the
likelihood score by the severity score, eg 2 x 2 = 4. likelihood score by the severity score, eg 2 x 2 = 4.
The scores correspond to the traffic light system as The scores correspond to the traffic light system as
1. Unlikely follows: 1 or 2 is green, 3 or 4 is amber and 6 and 9 1. Unlikely follows: 1 or 2 is green, 3 or 4 is amber and 6 and 9
It is unlikely that the risk will happen is red. It is unlikely that the risk will happen is red.
in the next 6 months. in the next 6 months.
Example: For somebody who has offended with Example: For somebody who has offended with
children in the past, but who is now in a closely children in the past, but who is now in a closely
2. Up to 50% chance 2. Up to 50% chance
supervised package of support, the likelihood of supervised package of support, the likelihood of
There is up to 50% chance that the risk the risk happening might be low (a score of 1), There is up to 50% chance that the risk the risk happening might be low (a score of 1),
will occur in the next 6 months. but the severity of the risk if it were to occur will occur in the next 6 months. but the severity of the risk if it were to occur
would be major (a score of 3). Therefore, the would be major (a score of 3). Therefore, the
3. More than 50% chance combined risk would be 3, or amber. 3. More than 50% chance combined risk would be 3, or amber.
There is more than a 50% chance of the There is more than a 50% chance of the
risk occurring in the next 6 months. risk occurring in the next 6 months.

When is a Risk Management Plan Needed? When is a Risk Management Plan Needed?
Severity Severity
If a Service User scores more than 4 on a risk area, If a Service User scores more than 4 on a risk area,
When considering severity the scoring is as When considering severity the scoring is as
a risk management plan will be needed. Please use a risk management plan will be needed. Please use
follows:- follows:-
the shared summary at the back of the record form the shared summary at the back of the record form
1. Minor to highlight any significant risks (i.e. above a score 1. Minor to highlight any significant risks (i.e. above a score
of 4). Please also indicate if person’s risk has a low of 4). Please also indicate if person’s risk has a low
• The risks that the client or others are exposed to score as a result of current intervention, for • The risks that the client or others are exposed to score as a result of current intervention, for
are no greater than for the general population example because of high levels of staff support or are no greater than for the general population example because of high levels of staff support or
• Where any harm that results (Physical or observation. • Where any harm that results (Physical or observation.
psychological) would not require professional When a service user scores 9 in more than 3 areas, psychological) would not require professional When a service user scores 9 in more than 3 areas,
support (e.g. medical, clinical, on-call etc). this may be an indication that an HR-JRAMP is support (e.g. medical, clinical, on-call etc). this may be an indication that an HR-JRAMP is
needed. This should be discussed, before needed. This should be discussed, before
proceeding, with your line manager. proceeding, with your line manager.
2. Serious 2. Serious
• Physical injury to the client or others which would • Physical injury to the client or others which would
require medical attention (e.g. GP) require medical attention (e.g. GP)
• Psychological trauma which impinges on the • Psychological trauma which impinges on the
clients or others quality of life and sense of well- clients or others quality of life and sense of well-
being, and would require professional support. being, and would require professional support.
• Behaviour which may lead to breakdown of • Behaviour which may lead to breakdown of
current placement. current placement.

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3 Completing the Risk Assessment 3 Completing the Risk Assessment

3.1 Explaining Risk, Rights and the Scoring System 3.1 Explaining Risk, Rights and the Scoring System

Please turn to the “Explaining Risk, Rights and the Scoring System” Please turn to the “Explaining Risk, Rights and the Scoring System”
section in the picture booklet. section in the picture booklet.

Before you start the assessment it may be helpful Before you start the assessment it may be helpful
to explain the overall process to the service user and carers. to explain the overall process to the service user and carers.

Talk through each of the sections using the picture booklet: Talk through each of the sections using the picture booklet:

What is a risk? What is a risk?

What is this plan about? What is this plan about?

What are human rights? What are human rights?

What is traffic light scoring? What is traffic light scoring?

What will staff look for? What will staff look for?

This will give the service user the opportunity to ask any This will give the service user the opportunity to ask any
questions and to fully understand what the assessment is about. questions and to fully understand what the assessment is about.

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3.2 Recording and Worked Example 3.2 Recording and Worked Example

Each question in the risk assessment asks you to work with the person to rate their risk and to identify the Each question in the risk assessment asks you to work with the person to rate their risk and to identify the
human rights implications of each area of risk. human rights implications of each area of risk.
This manual lists the human rights that could be affected for each area of risk. If a significant risk is This manual lists the human rights that could be affected for each area of risk. If a significant risk is
recognised the assessor must record which human rights may be engaged (See Figure 2). recognised the assessor must record which human rights may be engaged (See Figure 2).
Figure 2 provides an example of how to fill in the record form. It demonstrates how to reference the human Figure 2 provides an example of how to fill in the record form. It demonstrates how to reference the human
rights that have been engaged following the recognition of a significant risk. rights that have been engaged following the recognition of a significant risk.

Figure 2: Example of question on record sheet Figure 2: Example of question on record sheet

Physical Health “John has had numerous hospital Physical Health “John has had numerous hospital
admissions over the last 6 months admissions over the last 6 months
Please include details of identified risk Please include details of identified risk
relating to his asthma” relating to his asthma”

Likelihood Likelihood
Please score here on the likelihood 3 Please score here on the likelihood 3
it will happen again 1-3 it will happen again 1-3

Severity Severity
Please score here on the severity of 3 Please score here on the severity of 3
consequences consequences

Total Total
Please multiple the likelihood score 9 Please multiple the likelihood score 9
by the severity score by the severity score

Service User Rating red Service User Rating red

Please indicate level of risk by amber Please indicate level of risk by amber
circling the word or relevant light circling the word or relevant light
green green

Human Rights Implication(s) Human Rights Implication(s)

Please indicate which human rights are Please indicate which human rights are
at risk of being infringed using the act
“ 2, 8, 14” at risk of being infringed using the act
“ 2, 8, 14”
number(s). (Human rights articles are number(s). (Human rights articles are
listed below each question). listed below each question).

In this example John’s asthma has posed a significant risk for him within the last six months. He scored 3 In this example John’s asthma has posed a significant risk for him within the last six months. He scored 3
for the likelihood that he should be admitted to hospital again and a score of 3 for the severity of for the likelihood that he should be admitted to hospital again and a score of 3 for the severity of
consequences. consequences.
Multiplying the likelihood and severity together gave John a total score of 9 for Physical Health. Multiplying the likelihood and severity together gave John a total score of 9 for Physical Health.
Using the human rights listed in the manual the assessor was able to identify that the following human Using the human rights listed in the manual the assessor was able to identify that the following human
rights may be engaged: Right to life (Article 2), Right to respect for private and family life (Article 8) and rights may be engaged: Right to life (Article 2), Right to respect for private and family life (Article 8) and
Prohibition of discrimination (Article 14). Prohibition of discrimination (Article 14).

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Risk Areas: Questions, Prompts Risk Areas: Questions, Prompts

and Human Rights Involved and Human Rights Involved
Section 1: Risks to Self Section 1: Risks to Self

Please turn to ‘Section 1: Risks to Self’, in the picture booklet Please turn to ‘Section 1: Risks to Self’, in the picture booklet
This section focuses on the potential risks to the service user. This section focuses on the potential risks to the service user.

1) Physical health 1) Physical health

Prompt questions Prompt questions
• Do you have diabetes or epilepsy? • Do you have diabetes or epilepsy?
• Do you go to hospital a lot? • Do you go to hospital a lot?
• Are you in pain? • Are you in pain?
• Have you been ill? • Have you been ill?
• Have you been hurt? • Have you been hurt?
• Do you feel well? • Do you feel well?

Human rights which may be engaged: Human rights which may be engaged:

FREDA: Fairness, Respect, Equality, Dignity, Article 3: Prohibition of torture, inhuman and FREDA: Fairness, Respect, Equality, Dignity, Article 3: Prohibition of torture, inhuman and
Autonomy. degrading treatment- e.g. Are facilities available to Autonomy. degrading treatment- e.g. Are facilities available to
enable persons with physical health needs to be enable persons with physical health needs to be
Is the person being treated with dignity, equality, cared for effectively? (e.g. hoists or changing Is the person being treated with dignity, equality, cared for effectively? (e.g. hoists or changing
autonomy with regards to their physical health? facilities). Are there enough staff available to ensure autonomy with regards to their physical health? facilities). Are there enough staff available to ensure
aspects of the person’s physical health needs are aspects of the person’s physical health needs are
met with dignity? (e.g. if incontinent, is the person met with dignity? (e.g. if incontinent, is the person
Article 2: Right to life- changed on a regular basis so they do not have to Article 2: Right to life- changed on a regular basis so they do not have to
• Does the person have access to appropriate sit in wet clothing?). If not, this could be classed as • Does the person have access to appropriate sit in wet clothing?). If not, this could be classed as
health care services? inhuman or degrading treatment. health care services? inhuman or degrading treatment.

• Has the person been refused any treatment for • Has the person been refused any treatment for
physical health on grounds of their disability? Is Article 8: Right to respect for private and family physical health on grounds of their disability? Is Article 8: Right to respect for private and family
the person supported to make informed choices life – A physical health problem could have an the person supported to make informed choices life – A physical health problem could have an
around medical treatment (e.g. attending the impact on the person’s physical and psychological around medical treatment (e.g. attending the impact on the person’s physical and psychological
doctors)? well-being. doctors)? well-being.
• Is the person supported to access medical • Is the person supported to access medical
checks / clinics? In extreme cases, a denial of checks / clinics? In extreme cases, a denial of
any of these things could lead to death. Article14: Prohibition of discrimination – e.g. any of these things could lead to death. Article14: Prohibition of discrimination – e.g.
does the person have access to medical treatment does the person have access to medical treatment
they need regardless of their learning disability? they need regardless of their learning disability?

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2) Medication 2) Medication
Prompt questions Prompt questions
• Do you have problems with your • Do you have problems with your
medication? medication?
• Do you always take your medication? • Do you always take your medication?
• Do you forget to take your medication? • Do you forget to take your medication?
• Do you take more medication than you • Do you take more medication than you
need to? need to?
• Do you ever feel ill after taking your • Do you ever feel ill after taking your
medication? medication?
• Does anyone crush your medication or • Does anyone crush your medication or
mix it in food/drink? mix it in food/drink?

Human rights which may be engaged: Human rights which may be engaged:

FREDA: Fairness, Respect, Equality, Dignity and Article 8: Right to respect for private and family FREDA: Fairness, Respect, Equality, Dignity and Article 8: Right to respect for private and family
Autonomy life – e.g. is information about the person’s Autonomy life – e.g. is information about the person’s
medication shared only on a ‘need-to-know’ basis? medication shared only on a ‘need-to-know’ basis?
Is the person treated with dignity and respect with Does the person have any input into their Is the person treated with dignity and respect with Does the person have any input into their
regard to their medication? e.g. are they able to medication? Have they been involved in regard to their medication? e.g. are they able to medication? Have they been involved in
take it in private? discussions of these areas? (Do they have take it in private? discussions of these areas? (Do they have
capacity?) Is the person given respect and privacy capacity?) Is the person given respect and privacy
while taking their medication? Are they given while taking their medication? Are they given
Article 2: Right to life – e.g. Does the person have information as to why they are on any medication, Article 2: Right to life – e.g. Does the person have information as to why they are on any medication,
access to any regular medication (e.g. is diabetes / and to what side effects may occur? Is medication access to any regular medication (e.g. is diabetes / and to what side effects may occur? Is medication
epilepsy medication given at the correct time with used as a form of restraint for the person, and if so, epilepsy medication given at the correct time with used as a form of restraint for the person, and if so,
the correct doses etc). Is medication easily have they consented and if not, is the restraint the correct doses etc). Is medication easily have they consented and if not, is the restraint
available if the person has a head ache or an upset proportionate to the person’s difficulty? available if the person has a head ache or an upset proportionate to the person’s difficulty?
stomach etc? Does the person have access to stomach etc? Does the person have access to
appropriate mainstream health services? appropriate mainstream health services?

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Risk Areas: Questions, Prompts Risk Areas: Questions, Prompts

and Human Rights Involved and Human Rights Involved
Section 1: Risks to Self Section 1: Risks to Self

3) Transport (public and 3) Transport (public and

private) private)
Prompt questions Prompt questions
• Are you ok travelling in a car? • Are you ok travelling in a car?
• Do you find it difficult to sit in • Do you find it difficult to sit in
a car for a long time? a car for a long time?
• Do people worry you are not safe on • Do people worry you are not safe on
your bike? your bike?
• Are you able to cross the road safely? • Are you able to cross the road safely?
• How much support do you need to • How much support do you need to
travel safely? travel safely?
• Do people say they need to lock doors • Do people say they need to lock doors
to keep you safe? to keep you safe?

Human rights which may be engaged: Human rights which may be engaged:

FREDA: Fairness, Respect, Equality, Dignity and Autonomy FREDA: Fairness, Respect, Equality, Dignity and Autonomy
If it is the persons wish not to get into a vehicle is this wish respected? If it is the persons wish not to get into a vehicle is this wish respected?

Article 8: Right to respect for private and family life - Is the person able to make their own choices with Article 8: Right to respect for private and family life - Is the person able to make their own choices with
regards to transport? If not this could potentially impact upon their psychological well being. E.g. Are the regards to transport? If not this could potentially impact upon their psychological well being. E.g. Are the
doors to the property locked because of the person’s lack of road safety? Is the person able to leave the doors to the property locked because of the person’s lack of road safety? Is the person able to leave the
property whenever they wish? If not, does the person understand why and have they been involved in property whenever they wish? If not, does the person understand why and have they been involved in
discussions regarding this? discussions regarding this?

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4) Mobility 4) Mobility
Prompt questions Prompt questions
• Do you need to use a walking • Do you need to use a walking
frame/stick/wheelchair? frame/stick/wheelchair?
• Do you fall over? • Do you fall over?
• Is there someone to help you if you fall? • Is there someone to help you if you fall?
• Do you need help to get around? • Do you need help to get around?

Human rights which may be engaged: Human rights which may be engaged:

FREDA: Fairness, Respect, Equality, Dignity, Article 8: Right to respect for private and family FREDA: Fairness, Respect, Equality, Dignity, Article 8: Right to respect for private and family
Autonomy life – e.g. is personal care undertaken with respect, Autonomy life – e.g. is personal care undertaken with respect,
dignity and privacy? Is the place the person resides dignity and privacy? Is the place the person resides
Is the person treated with fairness and respect fully equipped for any mobility difficulties they may Is the person treated with fairness and respect fully equipped for any mobility difficulties they may
despite any mobility problems? E.g. are facilities have? (E.g. disabled access, room calls, kitchen despite any mobility problems? E.g. are facilities have? (E.g. disabled access, room calls, kitchen
available to ensure persons are cared for effectively equipment that is suitable for disabled persons etc). available to ensure persons are cared for effectively equipment that is suitable for disabled persons etc).
(e.g. hoists or changing facilities). Is there appropriate disabled access to the (e.g. hoists or changing facilities). Is there appropriate disabled access to the
property? Is the person free to leave the property property? Is the person free to leave the property
when they want to? Are there enough staff available when they want to? Are there enough staff available
Article 2: Right to life – e.g. has the person been to ensure the person gets out as frequently as they Article 2: Right to life – e.g. has the person been to ensure the person gets out as frequently as they
refused any treatment on grounds of their require? refused any treatment on grounds of their require?
disability? disability?

Article 3: Prohibition of torture, inhuman and Article 3: Prohibition of torture, inhuman and
degrading treatment- e.g. are there enough staff degrading treatment- e.g. are there enough staff
available to ensure the person does not suffer available to ensure the person does not suffer
‘degrading’ treatment? (e.g. if the person needs ‘degrading’ treatment? (e.g. if the person needs
help changing or eating). help changing or eating).

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Risk Areas: Questions, Prompts Risk Areas: Questions, Prompts

and Human Rights Involved and Human Rights Involved
Section 1: Risks to Self Section 1: Risks to Self

5) Safety at home 5) Safety at home

Prompt questions Prompt questions
Do people worry about your safety with Do people worry about your safety with
household objects, e.g. household objects, e.g.
• Bleach • Bleach
• Sharp knives • Sharp knives
• Electrical items • Electrical items

Human rights which may be engaged: Human rights which may be engaged:

FREDA: Fairness, Respect, Equality, Dignity, Article 2: Right to life – e.g. if the person is in FREDA: Fairness, Respect, Equality, Dignity, Article 2: Right to life – e.g. if the person is in
Autonomy danger of seriously harming or killing themselves Autonomy danger of seriously harming or killing themselves
due to a domestic hazard, are procedures in place due to a domestic hazard, are procedures in place
Is the person treated with fairness, dignity and to prevent this happening? (E.g. are sharp knives Is the person treated with fairness, dignity and to prevent this happening? (E.g. are sharp knives
respect with regard to their issues around domestic locked away?) respect with regard to their issues around domestic locked away?)
hazard? For example, is the person prevented from hazard? For example, is the person prevented from
making hot drinks/food or using electrical making hot drinks/food or using electrical
equipment? Are certain things locked away to equipment? Are certain things locked away to
prevent the person from using them? If this is the Article 8: Right to respect for private and family prevent the person from using them? If this is the Article 8: Right to respect for private and family
case, is it proportionate to the person’s difficulties? life – Either the risk itself or the strategies in place case, is it proportionate to the person’s difficulties? life – Either the risk itself or the strategies in place
In shared accommodation, does this impede on the could have implications towards the person’s In shared accommodation, does this impede on the could have implications towards the person’s
quality of life of other service users who do not psychological well being. Is enough being done to quality of life of other service users who do not psychological well being. Is enough being done to
have a problem with domestic hazards? reduce this as much as possible? E.g. if the person have a problem with domestic hazards? reduce this as much as possible? E.g. if the person
is restricted in making hot drinks, could they be is restricted in making hot drinks, could they be
supervised to do it? supervised to do it?

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6) Getting lost 6) Getting lost

Prompt questions Prompt questions
• Sometimes when you go out on your • Sometimes when you go out on your
own do you find it hard to get back own do you find it hard to get back
home? home?
• Can you remember the bus number, or • Can you remember the bus number, or
where to get the bus from to get home? where to get the bus from to get home?
• Can you remember your address? • Can you remember your address?
• Do you forget to take your phone with • Do you forget to take your phone with
you? you?
• Do you run out of money to get home? • Do you run out of money to get home?
• Do you need support to go out? • Do you need support to go out?

Human rights which may be engaged: Human rights which may be engaged:

FREDA: Fairness, Respect, Equality, Dignity, Autonomy FREDA: Fairness, Respect, Equality, Dignity, Autonomy
Is the person treated with fairness and autonomy despite a risk of being stranded? For example, are the Is the person treated with fairness and autonomy despite a risk of being stranded? For example, are the
doors to the property locked? Is the person able to leave the property when they wish (e.g. are there doors to the property locked? Is the person able to leave the property when they wish (e.g. are there
enough staff available to take the person out if they are not capable of going out alone?). enough staff available to take the person out if they are not capable of going out alone?).
Article 8: Right to respect for private and family life – The risk of being stranded could have implications Article 8: Right to respect for private and family life – The risk of being stranded could have implications
towards the person’s psychological well being. Is enough been done to prevent this from happening? .e.g. towards the person’s psychological well being. Is enough been done to prevent this from happening? .e.g.
Are staff available to go out with the person if they so wish? Are staff available to go out with the person if they so wish?

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Risk Areas: Questions, Prompts Risk Areas: Questions, Prompts

and Human Rights Involved and Human Rights Involved
Section 1: Risks to Self Section 1: Risks to Self

7) Not looking after myself 7) Not looking after myself

Prompt questions Prompt questions
• Do you look after yourself properly? • Do you look after yourself properly?
• Do you eat or drink when you should or • Do you eat or drink when you should or
do you eat/drink more than you should? do you eat/drink more than you should?
• Do you wash when you should? • Do you wash when you should?
• Do you look after your money? • Do you look after your money?
• Do you change your clothes regularly? • Do you change your clothes regularly?

Human rights which may be engaged: Human rights which may be engaged:

FREDA: Fairness, Respect, Equality, Dignity, Article 2: Right to life – If self neglect becomes FREDA: Fairness, Respect, Equality, Dignity, Article 2: Right to life – If self neglect becomes
Autonomy extreme, this could potentially lead to death. Are Autonomy extreme, this could potentially lead to death. Are
appropriate steps in place to ensure this does not appropriate steps in place to ensure this does not
Is the person treated with equality and dignity happen? Is the person treated with equality and dignity happen?
regardless of their presentation? Is the person given regardless of their presentation? Is the person given
respect and privacy (by both staff and other service respect and privacy (by both staff and other service
users) whilst undertaking personal care? If the users) whilst undertaking personal care? If the
person refuses to do personal care, is this right Article 8: Right to respect for private and family person refuses to do personal care, is this right Article 8: Right to respect for private and family
respected? Is there a policy of restraint around the life – e.g. does the person have the opportunity to respected? Is there a policy of restraint around the life – e.g. does the person have the opportunity to
client in regard to personal care? Does the client make or get a drink / food when they want? Does client in regard to personal care? Does the client make or get a drink / food when they want? Does
have any input into this? Is the person encouraged the person have access to his / her own money? have any input into this? Is the person encouraged the person have access to his / her own money?
to eat / refused food? Are they able to spend their money on whatever to eat / refused food? Are they able to spend their money on whatever
they decide? they decide?

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8) Hurting myself 8) Hurting myself

Prompt questions Prompt questions
• Do you hurt yourself to cope with hard • Do you hurt yourself to cope with hard
feelings? feelings?
• Do you use objects to cut/bruise • Do you use objects to cut/bruise
yourself? yourself?
• Do you swallow things (not food or • Do you swallow things (not food or
drink)? drink)?
• Have you swallowed a substance? • Have you swallowed a substance?

Human rights which may be engaged: Human rights which may be engaged:

FREDA: Fairness, Respect, Equality, Dignity, Article 8: Right to respect for private and family FREDA: Fairness, Respect, Equality, Dignity, Article 8: Right to respect for private and family
Autonomy life - e.g. is all information about the person’s Autonomy life - e.g. is all information about the person’s
behaviour kept confidential? If not, is it just shared behaviour kept confidential? If not, is it just shared
Is the person treated with dignity and respect in the on a ‘need-to-know’ basis? Does the person have Is the person treated with dignity and respect in the on a ‘need-to-know’ basis? Does the person have
event of self harm? E.g. are they given the any say in which staff members intervene when event of self harm? E.g. are they given the any say in which staff members intervene when
opportunity to speak with staff after an incident? they are self harming? Also, is the person given opportunity to speak with staff after an incident? they are self harming? Also, is the person given
dignity when they are self-harming and privacy dignity when they are self-harming and privacy
where applicable? where applicable?
Article 2: Right to life – e.g. Are appropriate Article 2: Right to life – e.g. Are appropriate
interventions in place to avoid serious injury to the interventions in place to avoid serious injury to the
person? Does the person have access to suitable person? Does the person have access to suitable
healthcare services to get help? Or if the person is healthcare services to get help? Or if the person is
not causing serious harm, are their rights to make not causing serious harm, are their rights to make
informed choices respected? informed choices respected?

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Risk Areas: Questions, Prompts Risk Areas: Questions, Prompts

and Human Rights Involved and Human Rights Involved
Section 1: Risks to Self Section 1: Risks to Self

9) Not wanting 9) Not wanting

support/services support/services
Prompt questions Prompt questions
• Do you ever run away without • Do you ever run away without
telling anybody when you are not telling anybody when you are not
allowed to? allowed to?
• Do you ever leave your home • Do you ever leave your home
without telling anyone? without telling anyone?
• Do you ever leave your support • Do you ever leave your support
workers/carers/family when you workers/carers/family when you
are out and about? are out and about?

Human rights which may be engaged: Human rights which may be engaged:

FREDA: Fairness, Respect, Equality, Dignity, Autonomy FREDA: Fairness, Respect, Equality, Dignity, Autonomy
Is the person being treated with fairness respect equality dignity and autonomy in regard to the level of Is the person being treated with fairness respect equality dignity and autonomy in regard to the level of
support they receive i.e. too much or too little. support they receive i.e. too much or too little.

Article 5: Right to liberty and security– e.g. Are the doors to the property locked? Is the person able to Article 5: Right to liberty and security– e.g. Are the doors to the property locked? Is the person able to
request to leave the property? Is the person sectioned? If so, are they aware of their rights relating to request to leave the property? Is the person sectioned? If so, are they aware of their rights relating to
leaving the property? The actual fact of absconding does not impact on the right to liberty; this right leaving the property? The actual fact of absconding does not impact on the right to liberty; this right
becomes relevant with regards to the consequences of what might happen if the person does abscond. becomes relevant with regards to the consequences of what might happen if the person does abscond.

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10) Mental health 10) Mental health

Prompt questions Prompt questions
• Do you ever think that your mind does • Do you ever think that your mind does
not feel healthy? not feel healthy?
• Have you been crying a lot? • Have you been crying a lot?
• Have you been feeling angry? • Have you been feeling angry?
• Do you feel down? • Do you feel down?
• Have you been hearing and seeing • Have you been hearing and seeing
things that no one else can hear? things that no one else can hear?

Human rights which may be engaged: Human rights which may be engaged:

FREDA: Fairness, Respect, Equality, Dignity, Article 8: Right to respect for private and family FREDA: Fairness, Respect, Equality, Dignity, Article 8: Right to respect for private and family
Autonomy life – This risk could obviously have implications Autonomy life – This risk could obviously have implications
towards the person’s psychological well being. Is towards the person’s psychological well being. Is
Is the person treated with respect and dignity with physical restraint used as a means of preventing Is the person treated with respect and dignity with physical restraint used as a means of preventing
regard to their mental health problems? This challenging behaviour associated with any mental regard to their mental health problems? This challenging behaviour associated with any mental
includes treatment by staff, family and other service health problems? If so, does the client have any includes treatment by staff, family and other service health problems? If so, does the client have any
users. input into their medication / restraint? Have they users. input into their medication / restraint? Have they
been involved in discussion? been involved in discussion?

Article 5: Right to liberty and security– e.g. is the Article 5: Right to liberty and security– e.g. is the
person able to leave the property whenever they Article 14: Protection against discrimination – person able to leave the property whenever they Article 14: Protection against discrimination –
wish? Is the person sectioned? If so, have they e.g. does the person have access to appropriate wish? Is the person sectioned? If so, have they e.g. does the person have access to appropriate
been given information as to why, and do they healthcare services? If not, is this because the been given information as to why, and do they healthcare services? If not, is this because the
receive regular reviews/tribunals? person also has a learning disability? receive regular reviews/tribunals? person also has a learning disability?

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Risk Areas: Questions, Prompts Risk Areas: Questions, Prompts

and Human Rights Involved and Human Rights Involved
Section 1: Risks to Self Section 1: Risks to Self

11) Alcohol/substance abuse 11) Alcohol/substance abuse

Prompt questions Prompt questions
• Do people worry that you drink a lot of • Do people worry that you drink a lot of
alcohol or use drugs? alcohol or use drugs?
• Do you use alcohol to deal with hard • Do you use alcohol to deal with hard
feelings? feelings?

Human rights which may be engaged: Human rights which may be engaged:

FREDA: Fairness, Respect, Equality, Dignity, Article 8: Right to respect for private and family FREDA: Fairness, Respect, Equality, Dignity, Article 8: Right to respect for private and family
Autonomy life- e.g. is the person able to drink in his own Autonomy life- e.g. is the person able to drink in his own
home? If so, does this impede on the human rights home? If so, does this impede on the human rights
Is the person being treated with respect and dignity any other service users / carers living in the same Is the person being treated with respect and dignity any other service users / carers living in the same
in regard to alcohol/substance? Are they receiving place? Is the person supported in making informed in regard to alcohol/substance? Are they receiving place? Is the person supported in making informed
adequate support with this issue. choices regarding his or her drinking? adequate support with this issue. choices regarding his or her drinking?

Article 2: Right to life – e.g. are mainstream Article 2: Right to life – e.g. are mainstream
services available for the person to help with his or services available for the person to help with his or
her problems? (E.g. alcohol services?) her problems? (E.g. alcohol services?)

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12) Suicide 12) Suicide

Prompt questions Prompt questions
• Have you tried to kill yourself? • Have you tried to kill yourself?

Human rights which may be engaged: Human rights which may be engaged:

FREDA: Fairness, Respect, Equality, Dignity, Article 8: Right to respect for private and family FREDA: Fairness, Respect, Equality, Dignity, Article 8: Right to respect for private and family
Autonomy life – e.g. is confidential information about potential Autonomy life – e.g. is confidential information about potential
suicide just shared on a ‘need-to-know’ basis? suicide just shared on a ‘need-to-know’ basis?
Is the person taken seriously and treated with Is the person taken seriously and treated with
dignity in the event of attempted suicide? dignity in the event of attempted suicide?

Article 2: Right to life – e.g. have appropriate Article 2: Right to life – e.g. have appropriate
interventions been put in place to avoid serious interventions been put in place to avoid serious
injury to the person (with appropriate observations, injury to the person (with appropriate observations,
access to therapy / services to help with their access to therapy / services to help with their
feelings) feelings)

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Risk Areas: Questions, Prompts Risk Areas: Questions, Prompts

and Human Rights Involved and Human Rights Involved
Section 1: Risks to Self Section 1: Risks to Self

13) Para-suicide 13) Para-suicide

Prompt questions Prompt questions
• Do you tell people you are going to kill yourself, when really all you want is for them to help you with your • Do you tell people you are going to kill yourself, when really all you want is for them to help you with your
difficult feelings? difficult feelings?
• Have tried to kill yourself but really you have just wanted someone to help you with your difficult feelings. • Have tried to kill yourself but really you have just wanted someone to help you with your difficult feelings.

Human rights which may be engaged: Human rights which may be engaged:

FREDA: Fairness, Respect, Equality, Dignity, Article 8: Right to respect for private and family FREDA: Fairness, Respect, Equality, Dignity, Article 8: Right to respect for private and family
Autonomy life – e.g. is confidential information about para- Autonomy life – e.g. is confidential information about para-
suicide just shared on a ‘need-to-know’ basis’? Are suicide just shared on a ‘need-to-know’ basis’? Are
Is the person treated seriously and with dignity in any forms of restraint used in the event of para- Is the person treated seriously and with dignity in any forms of restraint used in the event of para-
the event of para suicide? suicide and if so, are these restraints proportionate the event of para suicide? suicide and if so, are these restraints proportionate
to the behaviour? to the behaviour?

Article 2: Right to life – e.g. have appropriate Article 2: Right to life – e.g. have appropriate
interventions been put in place to avoid serious interventions been put in place to avoid serious
injury to the person (access to a trusted person to injury to the person (access to a trusted person to
talk to, therapy etc) talk to, therapy etc)

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14) Any other risk to self 14) Any other risk to self
Please describe any other risks… for example restrictive practices, or ‘challenging behaviour’ Please describe any other risks… for example restrictive practices, or ‘challenging behaviour’

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Risk Areas: Questions, Prompts Risk Areas: Questions, Prompts

and Human Rights Involved and Human Rights Involved
Section 2: Risks to Others Section 2: Risks to Others

Please turn to ‘Section 2: Risks to Others’, in the picture booklet. Please turn to ‘Section 2: Risks to Others’, in the picture booklet.
This section focuses on the potential risks and human rights implications to individuals who come into This section focuses on the potential risks and human rights implications to individuals who come into
contact with the service user e.g. staff, other service users, family, the community contact with the service user e.g. staff, other service users, family, the community

1) Skin colour/and or culture 1) Skin colour/and or culture

Prompt questions Prompt questions
• Do you think that people who don’t come • Do you think that people who don’t come
from the same country or are a different from the same country or are a different
colour to you are not as good as you? colour to you are not as good as you?
• If you don’t understand why people are • If you don’t understand why people are
different, is it confusing? and can it make different, is it confusing? and can it make
you angry? you angry?
• Do you think of hitting people different to • Do you think of hitting people different to
you? you?
• Have you ever hit somebody because of • Have you ever hit somebody because of
their colour or culture? their colour or culture?

Human rights which may be engaged: Human rights which may be engaged:

FREDA: Fairness, Respect, Equality, Dignity and Article 14: Prohibition of Discrimination - The FREDA: Fairness, Respect, Equality, Dignity and Article 14: Prohibition of Discrimination - The
Autonomy person will be impeding the victim’s human right if Autonomy person will be impeding the victim’s human right if
they discriminate on grounds of any equality and they discriminate on grounds of any equality and
Is the person treated with dignity, respect and diversity issue? Is the person treated with dignity, respect and diversity issue?
equality despite any beliefs they may hold against equality despite any beliefs they may hold against
others? E.g. if a complaint is made against the others? E.g. if a complaint is made against the
person regarding how they treat another person, person regarding how they treat another person,
will they be informed about why it has happened, Article 8: Right to respect for private and family will they be informed about why it has happened, Article 8: Right to respect for private and family
and will they be made aware of the process and of life – This risk has the potential to impede in the and will they be made aware of the process and of life – This risk has the potential to impede in the
the outcome? victim’s psychological and physical wellbeing, as the outcome? victim’s psychological and physical wellbeing, as
well as their private life. well as their private life.

Article 3: Prohibition of torture, inhuman and Article 3: Prohibition of torture, inhuman and
degrading treatment- e.g. Do the person’s beliefs degrading treatment- e.g. Do the person’s beliefs
cause behaviour towards another person which cause behaviour towards another person which
may compromise their right? may compromise their right?

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2) Gender 2) Gender
Prompt questions Prompt questions
• Do you bully or hurt men because • Do you bully or hurt men because
women are better than men women are better than men
• Do you bully or hurt women because • Do you bully or hurt women because
you think men are better than women you think men are better than women

Human rights which may be engaged: Human rights which may be engaged:

FREDA: : Fairness, Respect, Equality, Dignity and Article 14: Prohibition of Discrimination - The FREDA: : Fairness, Respect, Equality, Dignity and Article 14: Prohibition of Discrimination - The
Autonomy person will be impeding the victim’s human right if Autonomy person will be impeding the victim’s human right if
they discriminate on grounds of any equality and they discriminate on grounds of any equality and
Is the person treated with dignity, respect and diversity issue? Is the person treated with dignity, respect and diversity issue?
equality despite any beliefs they may hold against equality despite any beliefs they may hold against
others? E.g. if a complaint is made against the others? E.g. if a complaint is made against the
person regarding how they treat another person, person regarding how they treat another person,
will they be informed about why it has happened, Article 8: Right to respect for private and family will they be informed about why it has happened, Article 8: Right to respect for private and family
and will they be made aware of the process and of life – This risk has the potential to impede in the and will they be made aware of the process and of life – This risk has the potential to impede in the
the outcome? victim’s psychological and physical wellbeing, as the outcome? victim’s psychological and physical wellbeing, as
well as their private life. well as their private life.

Article 3: Prohibition of torture, inhuman and Article 3: Prohibition of torture, inhuman and
degrading treatment- e.g. Do the person’s beliefs degrading treatment- e.g. Do the person’s beliefs
cause behaviour towards another person which cause behaviour towards another person which
may compromise their right? may compromise their right?

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Risk Areas: Questions, Prompts Risk Areas: Questions, Prompts

and Human Rights Involved and Human Rights Involved
Section 2: Risks to Others Section 2: Risks to Others

3) Religion 3) Religion
Prompt questions Prompt questions
• Do you think that people that don’t believe • Do you think that people that don’t believe
what you believe are not as good as you? what you believe are not as good as you?
• If you don’t understand what somebody • If you don’t understand what somebody
believes, is it confusing? Can it make you believes, is it confusing? Can it make you
angry? angry?
• Do you pick people because of their • Do you pick people because of their
beliefs or religion? beliefs or religion?
• Do you try and hurt them? • Do you try and hurt them?

Human rights which may be engaged: Human rights which may be engaged:

FREDA: Fairness, Respect, Equality, Dignity and Article 14: Prohibition of Discrimination - The FREDA: Fairness, Respect, Equality, Dignity and Article 14: Prohibition of Discrimination - The
Autonomy person will be impeding the victim’s human right if Autonomy person will be impeding the victim’s human right if
they discriminate on grounds of any equality and they discriminate on grounds of any equality and
Is the person treated with dignity, respect and diversity issue? Is the person treated with dignity, respect and diversity issue?
equality despite any beliefs they may hold against equality despite any beliefs they may hold against
others? E.g. if a complaint is made against the others? E.g. if a complaint is made against the
person regarding how they treat another person, person regarding how they treat another person,
will they be informed about why it has happened, Article 8: Right to respect for private and family will they be informed about why it has happened, Article 8: Right to respect for private and family
and will they be made aware of the process and of life – This risk has the potential to impede in the and will they be made aware of the process and of life – This risk has the potential to impede in the
the outcome? victim’s psychological and physical wellbeing, as the outcome? victim’s psychological and physical wellbeing, as
well as their private life. well as their private life.

Article 3: Prohibition of torture, inhuman and Article 3: Prohibition of torture, inhuman and
degrading treatment- e.g. Do the person’s beliefs degrading treatment- e.g. Do the person’s beliefs
cause behaviour towards another person which cause behaviour towards another person which
may compromise their right? may compromise their right?

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4) Language 4) Language
Prompt questions Prompt questions
• Do you pick on people because they talk a • Do you pick on people because they talk a
different language? different language?
• Do you hurt people because they speak a • Do you hurt people because they speak a
different language? different language?
• Do you talk in a language that others don’t • Do you talk in a language that others don’t
understand in order to exclude them? understand in order to exclude them?

Human rights which may be engaged: Human rights which may be engaged:

FREDA: Fairness, Respect, Equality, Dignity and Article 14: Prohibition of Discrimination - The FREDA: Fairness, Respect, Equality, Dignity and Article 14: Prohibition of Discrimination - The
Autonomy person will be impeding the victim’s human right if Autonomy person will be impeding the victim’s human right if
they discriminate on grounds of any equality and they discriminate on grounds of any equality and
Is the person treated with dignity, respect and diversity issue? Is the person treated with dignity, respect and diversity issue?
equality despite any beliefs they may hold against equality despite any beliefs they may hold against
others? E.g. if a complaint is made against the others? E.g. if a complaint is made against the
person regarding how they treat another person, person regarding how they treat another person,
will they be informed about why it has happened, Article 8: Right to respect for private and family will they be informed about why it has happened, Article 8: Right to respect for private and family
and will they be made aware of the process and of life – This risk has the potential to impede in the and will they be made aware of the process and of life – This risk has the potential to impede in the
the outcome? victim’s psychological and physical wellbeing, as the outcome? victim’s psychological and physical wellbeing, as
well as their private life. well as their private life.

Article 3: Prohibition of torture, inhuman and Article 3: Prohibition of torture, inhuman and
degrading treatment- e.g. Do the person’s beliefs degrading treatment- e.g. Do the person’s beliefs
cause behaviour towards another person which cause behaviour towards another person which
may compromise their right? may compromise their right?

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Risk Areas: Questions, Prompts Risk Areas: Questions, Prompts

and Human Rights Involved and Human Rights Involved
Section 2: Risks to Others Section 2: Risks to Others

5) Sexuality 5) Sexuality
Prompt questions Prompt questions
• Do you think that people who are gay, • Do you think that people who are gay,
lesbian or bisexual are not as good as lesbian or bisexual are not as good as
you? you?
• Do you ever pick on and/or hurt someone • Do you ever pick on and/or hurt someone
because they are gay, lesbian or bisexual? because they are gay, lesbian or bisexual?

Human rights which may be engaged: Human rights which may be engaged:

FREDA: Fairness, Respect, Equality, Dignity and Article 14: Prohibition of Discrimination - The FREDA: Fairness, Respect, Equality, Dignity and Article 14: Prohibition of Discrimination - The
Autonomy person will be impeding the victim’s human right if Autonomy person will be impeding the victim’s human right if
they discriminate on grounds of any equality and they discriminate on grounds of any equality and
Is the person treated with dignity, respect and diversity issue? Is the person treated with dignity, respect and diversity issue?
equality despite any beliefs they may hold against equality despite any beliefs they may hold against
others? E.g. if a complaint is made against the others? E.g. if a complaint is made against the
person regarding how they treat another person, person regarding how they treat another person,
will they be informed about why it has happened, Article 8: Right to respect for private and family will they be informed about why it has happened, Article 8: Right to respect for private and family
and will they be made aware of the process and of life – This risk has the potential to impede in the and will they be made aware of the process and of life – This risk has the potential to impede in the
the outcome? victim’s psychological and physical wellbeing, as the outcome? victim’s psychological and physical wellbeing, as
well as their private life. well as their private life.

Article 3: Prohibition of torture, inhuman and Article 3: Prohibition of torture, inhuman and
degrading treatment- e.g. Do the person’s beliefs degrading treatment- e.g. Do the person’s beliefs
cause behaviour towards another person which cause behaviour towards another person which
may compromise their right? may compromise their right?

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6) Disability 6) Disability
Prompt questions Prompt questions
• Do you think people in a wheelchair • Do you think people in a wheelchair
are not as good as you? are not as good as you?
• Do you pick on or hurt people with a • Do you pick on or hurt people with a
disability? disability?

Human rights which may be engaged: Human rights which may be engaged:

FREDA: Fairness, Respect, Equality, Dignity and Article 14: Prohibition of Discrimination - The FREDA: Fairness, Respect, Equality, Dignity and Article 14: Prohibition of Discrimination - The
Autonomy person will be impeding the victim’s human right if Autonomy person will be impeding the victim’s human right if
they discriminate on grounds of any equality and they discriminate on grounds of any equality and
Is the person treated with dignity, respect and diversity issue? Is the person treated with dignity, respect and diversity issue?
equality despite any beliefs they may hold against equality despite any beliefs they may hold against
others? E.g. if a complaint is made against the others? E.g. if a complaint is made against the
person regarding how they treat another person, person regarding how they treat another person,
will they be informed about why it has happened, Article 8: Right to respect for private and family will they be informed about why it has happened, Article 8: Right to respect for private and family
and will they be made aware of the process and of life – This risk has the potential to impede in the and will they be made aware of the process and of life – This risk has the potential to impede in the
the outcome? victim’s psychological and physical wellbeing, as the outcome? victim’s psychological and physical wellbeing, as
well as their private life. well as their private life.

Article 3: Prohibition of torture, inhuman and Article 3: Prohibition of torture, inhuman and
degrading treatment- e.g. Do the person’s beliefs degrading treatment- e.g. Do the person’s beliefs
cause behaviour towards another person which cause behaviour towards another person which
may compromise their right? may compromise their right?

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Risk Areas: Questions, Prompts Risk Areas: Questions, Prompts

and Human Rights Involved and Human Rights Involved
Section 2: Risks to Others Section 2: Risks to Others

7) Dependants 7) Dependants
Prompt questions Prompt questions
• Do people worry that you do things to put • Do people worry that you do things to put
your children in danger? your children in danger?
• Do you sometimes forget to give your child • Do you sometimes forget to give your child
food or drink? food or drink?
• Do you find it hard to keep your child • Do you find it hard to keep your child
clean? clean?
• Do you find it hard to get your child to • Do you find it hard to get your child to
school? school?
• If you lose your temper, do you sometimes • If you lose your temper, do you sometimes
take it out on your child? take it out on your child?

Human rights which may be engaged: Human rights which may be engaged:

FREDA: Fairness, Respect, Equality, Dignity, Article 2: Right to Life – Neglect of a dependent FREDA: Fairness, Respect, Equality, Dignity, Article 2: Right to Life – Neglect of a dependent
Autonomy could potentially lead to death. Steps should be in Autonomy could potentially lead to death. Steps should be in
place to prevent this from happening. E.g. support place to prevent this from happening. E.g. support
Is the person’s family life respected? Are they should be available for the person in regard to their Is the person’s family life respected? Are they should be available for the person in regard to their
treated differently in terms of access to their child. treated differently in terms of access to their child.
children because of their learning disability? children because of their learning disability?

Article 2 of Protocol 1: Right to education – A risk Article 2 of Protocol 1: Right to education – A risk
Article 8: Right to respect for private and family to a dependent could potentially affect a child’s Article 8: Right to respect for private and family to a dependent could potentially affect a child’s
life – e.g. is the person supported or given the education. E.g. if the person finds it difficult to take life – e.g. is the person supported or given the education. E.g. if the person finds it difficult to take
opportunity to have a family life with their child? If the child to school. opportunity to have a family life with their child? If the child to school.
the child does not live with the person, do they the child does not live with the person, do they
have visiting rights to see the child? Are steps in have visiting rights to see the child? Are steps in
place to support the person to have a safe and place to support the person to have a safe and
productive family life with the child? Article 3: Prohibition of torture, inhuman and productive family life with the child? Article 3: Prohibition of torture, inhuman and
degrading treatment– Neglect or degrading degrading treatment– Neglect or degrading
treatment of the child could be construed as treatment of the child could be construed as
torture. torture.

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8) Children 8) Children
Prompt questions Prompt questions
• Do people worry that children might not be • Do people worry that children might not be
safe with you? safe with you?
• Do people say you are too rough to be • Do people say you are too rough to be
near children? near children?
• Do you like to play with children, but • Do you like to play with children, but
people say that you shouldn’t? people say that you shouldn’t?
• Do people say you can’t look after children • Do people say you can’t look after children
properly? properly?

Human rights which may be engaged: Human rights which may be engaged:

FREDA: Fairness, Respect, Equality, Dignity, Article 8: Right to respect for private and family FREDA: Fairness, Respect, Equality, Dignity, Article 8: Right to respect for private and family
Autonomy life – This risk might affect the child’s psychological Autonomy life – This risk might affect the child’s psychological
or physical well being. Steps should be put in place or physical well being. Steps should be put in place
Is the person treated with dignity and respect to prevent this from happening. Is the person treated with dignity and respect to prevent this from happening.
despite the potential risk to children? Do they have despite the potential risk to children? Do they have
a reputation around this risk? Does this then a reputation around this risk? Does this then
impede on the care they receive, or how they are impede on the care they receive, or how they are
treated by either staff members or other service Article 3: Prohibition of torture, inhuman and treated by either staff members or other service Article 3: Prohibition of torture, inhuman and
users? If any allegations have been made against degrading treatment- Child abuse could be users? If any allegations have been made against degrading treatment- Child abuse could be
the person, are they still treated as an equal by construed as torture of the child. the person, are they still treated as an equal by construed as torture of the child.
staff? And are they aware of their rights around staff? And are they aware of their rights around
allegations against them? allegations against them?
Article 2: Right to life – If the risk is severe Article 2: Right to life – If the risk is severe
enough, the risk could possible endanger the enough, the risk could possible endanger the
child’s life. child’s life.

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Risk Areas: Questions, Prompts Risk Areas: Questions, Prompts

and Human Rights Involved and Human Rights Involved
Section 2: Risks to Others Section 2: Risks to Others

9) Verbal 9) Verbal
aggression/intimidation aggression/intimidation
Prompt questions Prompt questions
• Do you get angry at people, which can • Do you get angry at people, which can
make them scared of you? make them scared of you?
• Do you say nasty things to people when • Do you say nasty things to people when
you are annoyed or upset? you are annoyed or upset?
• Do you shout at people when you are • Do you shout at people when you are
annoyed or upset? annoyed or upset?
• Do you get angry a lot? • Do you get angry a lot?
• Do you argue a lot? • Do you argue a lot?

Human rights which may be engaged: Human rights which may be engaged:

FREDA: FREDA: Fairness, Respect, Equality, Article 8: Right to respect for private and family FREDA: FREDA: Fairness, Respect, Equality, Article 8: Right to respect for private and family
Dignity, Autonomy life - Is there a policy of restraint around the person Dignity, Autonomy life - Is there a policy of restraint around the person
to prevent verbal aggression or intimidation? If so, to prevent verbal aggression or intimidation? If so,
Is the person treated with respect and autonomy by does the person have any input into this? Have Is the person treated with respect and autonomy by does the person have any input into this? Have
staff despite any verbal aggression or intimidation they been involved with any discussions? staff despite any verbal aggression or intimidation they been involved with any discussions?
they may display? they may display?

Article 8: Right to respect for private and family Article 8: Right to respect for private and family
Article 3: Prohibition of torture, inhuman and life – e.g. if the person is focussing the verbal Article 3: Prohibition of torture, inhuman and life – e.g. if the person is focussing the verbal
degrading treatment– e.g. is the person’s aggression on other service users living at the same degrading treatment– e.g. is the person’s aggression on other service users living at the same
behaviour compromising a carer /relative / or the address, are their human rights compromised? If behaviour compromising a carer /relative / or the address, are their human rights compromised? If
general public’s human right? Are there relevant so, is anything in place to prevent this? general public’s human right? Are there relevant so, is anything in place to prevent this?
care plans in place to try and protect this from care plans in place to try and protect this from
happening? happening?

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10) Physical violence 10) Physical violence

(no weapons) (no weapons)
Prompt questions Prompt questions
• If you are angry or frustrated, do you • If you are angry or frustrated, do you
sometimes hit out and hurt people? sometimes hit out and hurt people?

Human rights which may be engaged: Human rights which may be engaged:

FREDA: Fairness, Respect, Equality, Dignity, Article 3: Prohibition of torture, inhuman and FREDA: Fairness, Respect, Equality, Dignity, Article 3: Prohibition of torture, inhuman and
Autonomy degrading treatment– e.g. is the person likely to Autonomy degrading treatment– e.g. is the person likely to
focus this aggression towards carers / family / focus this aggression towards carers / family /
Is the person treated with fairness and respect with service users or the general public? If so, are any Is the person treated with fairness and respect with service users or the general public? If so, are any
regard to any potential violence? E.g. If the person care plans in place to prevent their human rights regard to any potential violence? E.g. If the person care plans in place to prevent their human rights
has a complaint made against them because of being compromised? has a complaint made against them because of being compromised?
their aggression, will it be investigated fully? Will their aggression, will it be investigated fully? Will
they be supported? Also, are there consequences Article 8: Right to respect for private and family they be supported? Also, are there consequences Article 8: Right to respect for private and family
with regard to violent outbursts? Removal of life – e.g. if the person is focussing the physical with regard to violent outbursts? Removal of life – e.g. if the person is focussing the physical
privileges etc may affect the persons equality or aggression on staff, family or other service users privileges etc may affect the persons equality or aggression on staff, family or other service users
respect. living at the same address, are their human rights respect. living at the same address, are their human rights
compromised? If so, is anything in place to prevent compromised? If so, is anything in place to prevent
Article 8: Right to respect for private and family this? Article 8: Right to respect for private and family this?
life - Is there a policy of restraint around the person life - Is there a policy of restraint around the person
to prevent verbal aggression or intimidation? If so, Article 2: Right to life – If the physical violence to prevent verbal aggression or intimidation? If so, Article 2: Right to life – If the physical violence
does the person have any input into this? Have becomes so extreme that it could result in a loss of does the person have any input into this? Have becomes so extreme that it could result in a loss of
they been involved with any discussions? life, then the victim’s ‘right to life’ may become they been involved with any discussions? life, then the victim’s ‘right to life’ may become
compromised. Precautions should be in place to compromised. Precautions should be in place to
prevent this from happening. prevent this from happening.

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Risk Areas: Questions, Prompts Risk Areas: Questions, Prompts

and Human Rights Involved and Human Rights Involved
Section 2: Risks to Others Section 2: Risks to Others

11) Physical violence (weapons) 11) Physical violence (weapons)

Prompt questions Prompt questions
• If you want to hurt someone, do you think • If you want to hurt someone, do you think
about what objects you are going to use? about what objects you are going to use?
• Do you use things like a chair or a knife? • Do you use things like a chair or a knife?

Human rights which may be engaged: Human rights which may be engaged:

FREDA: Fairness, Respect, Equality, Dignity, Article 3: Prohibition of torture, inhuman and FREDA: Fairness, Respect, Equality, Dignity, Article 3: Prohibition of torture, inhuman and
Autonomy degrading treatment– e.g. is the person likely to Autonomy degrading treatment– e.g. is the person likely to
focus this aggression towards carers / family / focus this aggression towards carers / family /
Is the person treated with fairness and respect with service users or the general public? If so, are any Is the person treated with fairness and respect with service users or the general public? If so, are any
regard to any potential violence? E.g. If the person care plans in place to prevent their human rights regard to any potential violence? E.g. If the person care plans in place to prevent their human rights
has a complaint made against them because of being compromised? has a complaint made against them because of being compromised?
their aggression, will it be investigated fully? Will their aggression, will it be investigated fully? Will
they be supported? Also, are there consequences they be supported? Also, are there consequences
with regard to violent outbursts? Removal of with regard to violent outbursts? Removal of
privileges etc may affect the persons equality or Article 8: Right to respect for private and family privileges etc may affect the persons equality or Article 8: Right to respect for private and family
respect. life – e.g. if the person is focussing the physical respect. life – e.g. if the person is focussing the physical
aggression on staff, family or other service users aggression on staff, family or other service users
living at the same address, are their human rights living at the same address, are their human rights
compromised? If so, is anything in place to prevent compromised? If so, is anything in place to prevent
Article 8: Right to respect for private and family this? Article 8: Right to respect for private and family this?
life - Is there a policy of restraint around the person life - Is there a policy of restraint around the person
to prevent verbal aggression or intimidation? If so, to prevent verbal aggression or intimidation? If so,
does the person have any input into this? Have does the person have any input into this? Have
they been involved with any discussions? Article 2: Right to life – If the physical violence they been involved with any discussions? Article 2: Right to life – If the physical violence
becomes so extreme that it could result in a loss of becomes so extreme that it could result in a loss of
life, then the victim’s ‘right to life’ may become life, then the victim’s ‘right to life’ may become
compromised. Precautions should be in place to compromised. Precautions should be in place to
prevent this from happening. prevent this from happening.

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12) Sexual behaviour 12) Sexual behaviour

Prompt questions Prompt questions
• Have you made someone do sexual things even when they didn’t want to? • Have you made someone do sexual things even when they didn’t want to?
• Have you made someone have sex with you? • Have you made someone have sex with you?
• Have you made someone touch your private parts? • Have you made someone touch your private parts?
• Do you ever do touch other’s private parts? • Do you ever do touch other’s private parts?

Human rights which may be engaged: Human rights which may be engaged:

FREDA: Fairness, Respect, Equality, Dignity, Article 3: Prohibition of torture, inhuman and FREDA: Fairness, Respect, Equality, Dignity, Article 3: Prohibition of torture, inhuman and
Autonomy degrading treatment– e.g. by sexually abusing Autonomy degrading treatment– e.g. by sexually abusing
someone, the person is treating them in an someone, the person is treating them in an
In the event of a sexual offence, will the person be inhuman and degrading way. In the event of a sexual offence, will the person be inhuman and degrading way.
treated as an equal and with dignity, freedom and treated as an equal and with dignity, freedom and
respect? E.g. are the doors locked as a way of respect? E.g. are the doors locked as a way of
preventing the person from going out to prevent preventing the person from going out to prevent
them from sexually offending? Are they sectioned? Article 8: Right to respect for private and family them from sexually offending? Are they sectioned? Article 8: Right to respect for private and family
If so, have they been given an understanding as to –By sexually abusing somebody, the person is If so, have they been given an understanding as to –By sexually abusing somebody, the person is
why? Have they been informed of their rights in effecting the person’s psychological and/or why? Have they been informed of their rights in effecting the person’s psychological and/or
regard to their section? physical well being. regard to their section? physical well being.

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Risk Areas: Questions, Prompts Risk Areas: Questions, Prompts

and Human Rights Involved and Human Rights Involved
Section 2: Risks to Others Section 2: Risks to Others

13) Taking other 13) Taking other

people's things people's things
Prompt questions Prompt questions
• Have you taken things from other • Have you taken things from other
people that don’t belong to you? people that don’t belong to you?

Human rights which may be engaged: Human rights which may be engaged:

FREDA: Fairness, Respect, Equality, Dignity, Article 1 of Protocol 1: Protection of property – FREDA: Fairness, Respect, Equality, Dignity, Article 1 of Protocol 1: Protection of property –
Autonomy e.g. are any care plans in place to protect this right Autonomy e.g. are any care plans in place to protect this right
of other service users who live with the person? of other service users who live with the person?
Is the person treated with dignity and respect Is the person treated with dignity and respect
despite potential stealing behaviour? Do they have despite potential stealing behaviour? Do they have
the same freedom and equality as persons who do the same freedom and equality as persons who do
not display this behaviour? E.g. Are doors locked to Article 8: Right to respect for private and family not display this behaviour? E.g. Are doors locked to Article 8: Right to respect for private and family
prevent the person from leaving the property to life – By stealing, the person might affect the prevent the person from leaving the property to life – By stealing, the person might affect the
steal? Do they have a reputation of being a thief? If victim’s psychological well being. This includes steal? Do they have a reputation of being a thief? If victim’s psychological well being. This includes
so, does this reputation cause the person to be family, carers and other service users. so, does this reputation cause the person to be family, carers and other service users.
treated differently or in a degrading way? treated differently or in a degrading way?

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14) Criminal or anti social acts 14) Criminal or anti social acts
Prompt questions Prompt questions
• Have you done things which get you into • Have you done things which get you into
trouble with the police? trouble with the police?
• Have you done things which could get you • Have you done things which could get you
into trouble with the police if they found into trouble with the police if they found
out? out?

Human rights which may be engaged: Human rights which may be engaged:

FREDA: Fairness, Respect, Equality, Dignity, Autonomy FREDA: Fairness, Respect, Equality, Dignity, Autonomy
Is the person treated with dignity and respect despite the potential for any other criminal or antisocial acts? Is the person treated with dignity and respect despite the potential for any other criminal or antisocial acts?
Do they have a reputation around this risk? Does this then impede on the care they receive, or how they Do they have a reputation around this risk? Does this then impede on the care they receive, or how they
are treated by either staff members or other service users? are treated by either staff members or other service users?

Article 8: Right to respect for private and family life – By stealing, the person might affect the victim’s Article 8: Right to respect for private and family life – By stealing, the person might affect the victim’s
psychological well being. This includes family, carers and other service users. psychological well being. This includes family, carers and other service users.

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Risk Areas: Questions, Prompts Risk Areas: Questions, Prompts

and Human Rights Involved and Human Rights Involved
Section 2: Risks to Others Section 2: Risks to Others

15) Fire starting 15) Fire starting

Prompt questions Prompt questions
• Have you set fire to something and it has • Have you set fire to something and it has
put someone else in danger? put someone else in danger?

Human rights which may be engaged: Human rights which may be engaged:

FREDA: Fairness, Respect, Equality, Dignity, Article 1 of Protocol 1: Protection of property - FREDA: Fairness, Respect, Equality, Dignity, Article 1 of Protocol 1: Protection of property -
Autonomy By setting fire to somebody’s property, the person Autonomy By setting fire to somebody’s property, the person
is impeding on the victim’s right to have their is impeding on the victim’s right to have their
Is the person treated with dignity and respect property protected. Is there anything in place to Is the person treated with dignity and respect property protected. Is there anything in place to
despite the risk of arson? Are they treated as an stop this happening? despite the risk of arson? Are they treated as an stop this happening?
equal? E.g. do they have a reputation relating to equal? E.g. do they have a reputation relating to
this risk? Does this affect the care they receive, or this risk? Does this affect the care they receive, or
how they are treated by either staff members or how they are treated by either staff members or
other service users? Article 2: Right to life - If the fire is severe enough, other service users? Article 2: Right to life - If the fire is severe enough,
it could presumably cause death to the victim. This it could presumably cause death to the victim. This
will impede on their right to life. will impede on their right to life.

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16) Truthfulness 16) Truthfulness

Prompt questions Prompt questions
• Do you tell lies a lot? • Do you tell lies a lot?
• Do you lie to get your own way? • Do you lie to get your own way?
• Do you lie about your feelings? • Do you lie about your feelings?
• Do you lie to hurt people who have upset • Do you lie to hurt people who have upset
you? you?

Human rights which may be engaged: Human rights which may be engaged:

FREDA: Fairness, Respect, Equality, Dignity, Autonomy FREDA: Fairness, Respect, Equality, Dignity, Autonomy
Is the person treated with dignity and respect despite the potential for fabrication? Do they have a Is the person treated with dignity and respect despite the potential for fabrication? Do they have a
reputation around this risk? Does this then impede on the care they receive, or how they are treated by reputation around this risk? Does this then impede on the care they receive, or how they are treated by
either staff members or other service users? For example, have they got a reputation for making either staff members or other service users? For example, have they got a reputation for making
‘allegations’ of sexual abuse? Does this result in any allegations they make not to be taken seriously? ‘allegations’ of sexual abuse? Does this result in any allegations they make not to be taken seriously?
Any allegation should be treated as serious and acted upon. Any allegation should be treated as serious and acted upon.

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Risk Areas: Questions, Prompts Risk Areas: Questions, Prompts

and Human Rights Involved and Human Rights Involved
Section 2: Risks to Others Section 2: Risks to Others

17) Difficulties with 17) Difficulties with

relationships relationships
Prompt questions Prompt questions
• Do you sometimes do things other people • Do you sometimes do things other people
don’t like in order to try and make them don’t like in order to try and make them
listen or to get your needs met? listen or to get your needs met?
• Do you sometimes act in a way to scare • Do you sometimes act in a way to scare
people? people?
• Do you ever do things and say things to • Do you ever do things and say things to
people to get your own way? people to get your own way?
• Do you make demands that other people • Do you make demands that other people
don’t like? don’t like?

Human rights which may be engaged: Human rights which may be engaged:

FREDA: Fairness, Respect, Equality, Dignity, Autonomy FREDA: Fairness, Respect, Equality, Dignity, Autonomy
Is the person treated with dignity and respect despite the potential for exploitation, manipulation or Is the person treated with dignity and respect despite the potential for exploitation, manipulation or
intimidation? Do they have a reputation around this risk? Does this then impede on the care they receive, intimidation? Do they have a reputation around this risk? Does this then impede on the care they receive,
or how they are treated by either staff members or other service users? or how they are treated by either staff members or other service users?

Article 8: Right to respect for private and family life – This risk might affect the victim’s psychological or Article 8: Right to respect for private and family life – This risk might affect the victim’s psychological or
physical well being. This includes family, carers and other service users. physical well being. This includes family, carers and other service users.

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18) Any other serious risk to others. 18) Any other serious risk to others.
Please describe any other risks… Please describe any other risks…

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Risk Areas: Questions, Prompts Risk Areas: Questions, Prompts

and Human Rights Involved and Human Rights Involved
Section 3: Risks from Others Section 3: Risks from Others

Please turn to ‘Section 3: Risks from others’, in the picture booklet. Please turn to ‘Section 3: Risks from others’, in the picture booklet.
This sections looks at the risk to the service users from other people, this could include other residents, staff, This sections looks at the risk to the service users from other people, this could include other residents, staff,
people in the community and generally anyone they may come into contact with on a day to day basis. people in the community and generally anyone they may come into contact with on a day to day basis.

1) Skin colour/and or culture 1) Skin colour/and or culture

Prompt questions Prompt questions
• Do you feel that people who are a different • Do you feel that people who are a different
colour to you are not nice to you? colour to you are not nice to you?
• Do people pick on you because of the • Do people pick on you because of the
colour of your skin? colour of your skin?
• Do people hit you because of your skin • Do people hit you because of your skin
colour? colour?

Human rights which may be engaged: Human rights which may be engaged:

FREDA: Fairness, Respect, Equality, Dignity, Is the person supported to attend groups should FREDA: Fairness, Respect, Equality, Dignity, Is the person supported to attend groups should
Autonomy they wish? Do they feel pressurised to attend Autonomy they wish? Do they feel pressurised to attend
groups when they would prefer not to? Does the groups when they would prefer not to? Does the
Is the person treated as an equal and with respect? person have the opportunity to meet and socialise Is the person treated as an equal and with respect? person have the opportunity to meet and socialise
– e.g. if the person makes a complaint about how with other persons of the same ethnic group/any – e.g. if the person makes a complaint about how with other persons of the same ethnic group/any
they are being treated, is it taken seriously and other group should they wish to? they are being treated, is it taken seriously and other group should they wish to?
investigated fully? investigated fully?

Article 14: Prohibition of discrimination – Are Article 14: Prohibition of discrimination – Are
Article 3: Prohibition of torture, inhuman and there particular reasons why the person may be Article 3: Prohibition of torture, inhuman and there particular reasons why the person may be
degrading treatment–e.g. is the person treated in vulnerable to discrimination, from staff or other degrading treatment–e.g. is the person treated in vulnerable to discrimination, from staff or other
a way that might be construed as inhuman or Service Users? Is the person treated differently a way that might be construed as inhuman or Service Users? Is the person treated differently
degrading as a result of any issues relating to from others in a way that cannot be reasonably degrading as a result of any issues relating to from others in a way that cannot be reasonably
equality and diversity? Extreme abuse that is justified, because, for example, of their culture? equality and diversity? Extreme abuse that is justified, because, for example, of their culture?
discriminatory e.g. extreme racial abuse may be discriminatory e.g. extreme racial abuse may be
considered to be inhuman or degrading treatment considered to be inhuman or degrading treatment

Article 8: – Right to respect for private and Article 8: – Right to respect for private and
family life - Does the person feel able to express family life - Does the person feel able to express
themselves? Is the person given the opportunity to themselves? Is the person given the opportunity to
express their identity by making choices about their express their identity by making choices about their
clothes/hair/food/activities etc.? clothes/hair/food/activities etc.?

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2) Gender 2) Gender
Prompt questions Prompt questions
• Have you been bullied or hurt by men • Have you been bullied or hurt by men
because you are a woman. because you are a woman.
• Have you been bullied or hurt by women • Have you been bullied or hurt by women
because you are a man. because you are a man.

Human rights which may be engaged: Human rights which may be engaged:

FREDA: Fairness, Respect, Equality, Dignity, Article 14: Prohibition of discrimination – Are FREDA: Fairness, Respect, Equality, Dignity, Article 14: Prohibition of discrimination – Are
Autonomy is the person treated as an equal and there particular reasons why the person may be Autonomy is the person treated as an equal and there particular reasons why the person may be
with respect? – E.g. if the person makes a vulnerable to discrimination, from staff or other with respect? – E.g. if the person makes a vulnerable to discrimination, from staff or other
complaint regarding any emotional abuse, is it Service Users? complaint regarding any emotional abuse, is it Service Users?
taken seriously and is it investigated fully? taken seriously and is it investigated fully?
Is the person treated differently from others in a Is the person treated differently from others in a
way that cannot be reasonably justified, because, way that cannot be reasonably justified, because,
for example, of their gender? for example, of their gender?
Article 8: Right to respect for private and family Article 8: Right to respect for private and family
life - Does the person feel able to express life - Does the person feel able to express
themselves? Is the person given the opportunity to themselves? Is the person given the opportunity to
express their identity by making choices about their express their identity by making choices about their
clothes/ hair/food/activities etc.? clothes/ hair/food/activities etc.?

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Risk Areas: Questions, Prompts Risk Areas: Questions, Prompts

and Human Rights Involved and Human Rights Involved
Section 3: Risks from Others Section 3: Risks from Others

3) Religion 3) Religion
Prompt questions Prompt questions
• Do people believe you are not as good as • Do people believe you are not as good as
them because you don’t go to their place them because you don’t go to their place
of worship? of worship?
• If people don’t understand your beliefs • If people don’t understand your beliefs
does this make them angry? does this make them angry?
• Do you get picked on because of your • Do you get picked on because of your
beliefs? beliefs?
• Do people hurt you because you go to • Do people hurt you because you go to
Church/Mosque etc? Church/Mosque etc?

Human rights which may be engaged: Human rights which may be engaged:

FREDA: Fairness, Respect, Equality, Dignity, FREDA: Fairness, Respect, Equality, Dignity,
Autonomy Autonomy
Article 9: Freedom of thought, conscience and Article 9: Freedom of thought, conscience and
religion – e.g. does the person feel able to express religion – e.g. does the person feel able to express
their beliefs and practice activities regarding their beliefs and practice activities regarding
equality and diversity? Is the person supported to equality and diversity? Is the person supported to
attend meetings / events etc? If so, are clients attend meetings / events etc? If so, are clients
attending things when they don’t want to? attending things when they don’t want to?

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4) Language 4) Language
Prompt questions Prompt questions
• Do you get picked on because you • Do you get picked on because you
talk a different language? talk a different language?
• Do people hurt you because you • Do people hurt you because you
speak a different language? speak a different language?
• Do people talk in a language you • Do people talk in a language you
don’t understand in order to exclude don’t understand in order to exclude
you? you?

Human rights which may be engaged: Human rights which may be engaged:

FREDA: Fairness, Respect, Equality, Dignity, Article 3: Prohibition of torture, inhuman and FREDA: Fairness, Respect, Equality, Dignity, Article 3: Prohibition of torture, inhuman and
Autonomy degrading treatment–e.g. is the person treated in Autonomy degrading treatment–e.g. is the person treated in
a way that might be construed as inhuman or a way that might be construed as inhuman or
Is the person treated as an equal and with respect? degrading as a result of any issues relating to Is the person treated as an equal and with respect? degrading as a result of any issues relating to
– e.g. if the person makes a complaint about how equality and diversity? Extreme abuse that is – e.g. if the person makes a complaint about how equality and diversity? Extreme abuse that is
they are being treated, is it taken seriously and discriminatory they are being treated, is it taken seriously and discriminatory
investigated fully? investigated fully?

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Risk Areas: Questions, Prompts Risk Areas: Questions, Prompts

and Human Rights Involved and Human Rights Involved
Section 3: Risks from Others Section 3: Risks from Others

5) Sexuality 5) Sexuality
Prompt questions Prompt questions
• Do people who are straight • Do people who are straight
(heterosexual) think you are not as (heterosexual) think you are not as
good as them? good as them?
• Do people who are gay, lesbian or • Do people who are gay, lesbian or
bisexual think you are not as good bisexual think you are not as good
as them? as them?
• Do people pick on you or hurt you • Do people pick on you or hurt you
because of your sexuality (straight, because of your sexuality (straight,
gay, lesbian or bisexual)? gay, lesbian or bisexual)?

Human rights which may be engaged: Human rights which may be engaged:

FREDA: Fairness, Respect, Equality, Dignity, Article 14: Prohibition of discrimination – e.g. is FREDA: Fairness, Respect, Equality, Dignity, Article 14: Prohibition of discrimination – e.g. is
Autonomy the person discriminated against on the grounds Autonomy the person discriminated against on the grounds
equality and diversity issues? For example: is the equality and diversity issues? For example: is the
Is the person treated as an equal and with respect? person supported or given the opportunity to make Is the person treated as an equal and with respect? person supported or given the opportunity to make
– e.g. if the person makes a complaint about how a same-sex relationship? If the person wishes to – e.g. if the person makes a complaint about how a same-sex relationship? If the person wishes to
they are being treated, is it taken seriously and engage in sexual activity is this supported? they are being treated, is it taken seriously and engage in sexual activity is this supported?
investigated fully? Prejudices against the person with regard to their investigated fully? Prejudices against the person with regard to their
sexuality could also impede on their psychological sexuality could also impede on their psychological
well being. Strategies should be in place to prevent well being. Strategies should be in place to prevent
or reduce this prejudice. or reduce this prejudice.

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6) Disability 6) Disability
Prompt questions Prompt questions
• Do you have problems with your disability • Do you have problems with your disability
(for example because you am in a (for example because you am in a
wheelchair, wheelchair,
• Are you blind or deaf? • Are you blind or deaf?
• Do you have problems communicating • Do you have problems communicating
because of your Learning Disability? because of your Learning Disability?
• Do people pick on you? • Do people pick on you?
• Do people hurt you? • Do people hurt you?
• Do people find it hard to communicate • Do people find it hard to communicate
with you and so you don’t always get your with you and so you don’t always get your
needs met? needs met?

Human rights which may be engaged: Human rights which may be engaged:

FREDA: Fairness, Respect, Equality, Dignity, Article 3: Prohibition of torture, inhuman and FREDA: Fairness, Respect, Equality, Dignity, Article 3: Prohibition of torture, inhuman and
Autonomy degrading treatment–e.g. is the person treated in Autonomy degrading treatment–e.g. is the person treated in
a way that might be construed as torture as a result a way that might be construed as torture as a result
Is the person treated as an equal and with respect? of any issues relating to equality and diversity? Is the person treated as an equal and with respect? of any issues relating to equality and diversity?
– e.g. if the person makes a complaint about how – e.g. if the person makes a complaint about how
they are being treated, is it taken seriously and they are being treated, is it taken seriously and
investigated fully? Is the person supported to investigated fully? Is the person supported to
attend groups should they wish? Do they feel Article 10: Freedom of expression – e.g. is the attend groups should they wish? Do they feel Article 10: Freedom of expression – e.g. is the
pressurised to attend these things when they would person given the opportunity to make choices pressurised to attend these things when they would person given the opportunity to make choices
prefer not to? about their clothes / hair / food or activity etc prefer not to? about their clothes / hair / food or activity etc

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Risk Areas: Questions, Prompts Risk Areas: Questions, Prompts

and Human Rights Involved and Human Rights Involved
Section 3: Risks from Others Section 3: Risks from Others

7) Physical abuse by others 7) Physical abuse by others

Prompt questions Prompt questions
• Does anyone hurt you? • Does anyone hurt you?
• Does anyone hit/slap/punch you? • Does anyone hit/slap/punch you?
• Does anyone spit at you? • Does anyone spit at you?

Human rights which may be engaged: Human rights which may be engaged:

FREDA: fairness, respect, equality, dignity, Article 3: Prohibition of torture, inhuman and FREDA: fairness, respect, equality, dignity, Article 3: Prohibition of torture, inhuman and
autonomy degrading treatment- e.g. is there a policy of autonomy degrading treatment- e.g. is there a policy of
restraint around the person? Could this be seen as restraint around the person? Could this be seen as
Is the person treated as an equal and with physical abuse? If another service user is abusing Is the person treated as an equal and with physical abuse? If another service user is abusing
respect? e.g. if the person makes a complaint the person, is anything being done about this to respect? e.g. if the person makes a complaint the person, is anything being done about this to
about physical abuse, is it investigated fully and prevent a compromise to his / her right? Is the about physical abuse, is it investigated fully and prevent a compromise to his / her right? Is the
taken seriously? person vulnerable and likely to be a victim of taken seriously? person vulnerable and likely to be a victim of
physical abuse when out on their own? If so, are physical abuse when out on their own? If so, are
care plans and support in place to try and prevent care plans and support in place to try and prevent
Article 2: Right to life – If the person is subjected this? (e.g. having a carer with them). Article 2: Right to life – If the person is subjected this? (e.g. having a carer with them).
to extreme physical abuse by others, this could to extreme physical abuse by others, this could
result in a loss of their life. Strategies should be in result in a loss of their life. Strategies should be in
place to prevent this from happening. Article 8: Right to respect for private and family place to prevent this from happening. Article 8: Right to respect for private and family
life – Physical abuse will affect the person’s life – Physical abuse will affect the person’s
physical integrity and their psychological well physical integrity and their psychological well
being. Are strategies in place to reduce this abuse being. Are strategies in place to reduce this abuse
as much as possible? as much as possible?

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8) Sexual abuse by others. 8) Sexual abuse by others.

Prompt questions Prompt questions
• Does anyone touch you in a way you don’t like? • Does anyone touch you in a way you don’t like?
• Does anyone make you perform a sexual act when you don’t want to? • Does anyone make you perform a sexual act when you don’t want to?
• Does anyone try to take photos of you when your undressed? • Does anyone try to take photos of you when your undressed?

Human rights which may be engaged: Human rights which may be engaged:

FREDA: Is the person treated as an equal and with Article 8: Right to respect for private and family FREDA: Is the person treated as an equal and with Article 8: Right to respect for private and family
respect? e.g. if the person makes a complaint life – e.g. Is the person supported or given the respect? e.g. if the person makes a complaint life – e.g. Is the person supported or given the
about sexual abuse, is it investigated fully and opportunity to make relationships? If the client about sexual abuse, is it investigated fully and opportunity to make relationships? If the client
taken seriously? wishes to engage in sexual relationships, is this taken seriously? wishes to engage in sexual relationships, is this
supported? Has the person had help and advice supported? Has the person had help and advice
about sex and been empowered to know their about sex and been empowered to know their
Article 3: Prohibition of torture, inhuman and rights, therefore limiting the chance of sexual Article 3: Prohibition of torture, inhuman and rights, therefore limiting the chance of sexual
degrading treatment- e.g. If the person has been abuse? degrading treatment- e.g. If the person has been abuse?
sexually abused, this right has been compromised sexually abused, this right has been compromised

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Risk Areas: Questions, Prompts Risk Areas: Questions, Prompts

and Human Rights Involved and Human Rights Involved
Section 3: Risks from Others Section 3: Risks from Others

9) Financial abuse by others. 9) Financial abuse by others.

Prompt questions Prompt questions
• Do you worry about money? • Do you worry about money?
• Does someone else use your cash • Does someone else use your cash
card/cheque book? card/cheque book?
• Do you think your money is going missing? • Do you think your money is going missing?
• Does someone use their supermarket • Does someone use their supermarket
reward card when getting your shopping? reward card when getting your shopping?

Human rights which may be engaged: Human rights which may be engaged:

FREDA: fairness, respect, equality, dignity, Article 8: Right to respect for private and family FREDA: fairness, respect, equality, dignity, Article 8: Right to respect for private and family
autonomy life – e.g. who handles the person’s money? Are autonomy life – e.g. who handles the person’s money? Are
they informed about this and do they understand they informed about this and do they understand
Is the person treated as an equal and with respect? why? Does the person have access to their own Is the person treated as an equal and with respect? why? Does the person have access to their own
– e.g. if the person makes a complaint regarding money? Are they able to spend their money on – e.g. if the person makes a complaint regarding money? Are they able to spend their money on
their financial situation, is it taken seriously and is it whatever they decide? Is confidential data their financial situation, is it taken seriously and is it whatever they decide? Is confidential data
investigated fully? regarding the person’s money kept locked away investigated fully? regarding the person’s money kept locked away
and only shared on a ‘need-to-know’ basis? and only shared on a ‘need-to-know’ basis?

Article 4: Prohibition of slavery and forced Article 4: Prohibition of slavery and forced
labour – e.g. does the person undertake any kind labour – e.g. does the person undertake any kind
of work, and if they do, do they receive suitable of work, and if they do, do they receive suitable
payment for the work? (e.g. the same as any other payment for the work? (e.g. the same as any other
employee). employee).

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10) Emotional abuse by others 10) Emotional abuse by others

Prompt questions Prompt questions
• Do people make demands on you that you don’t like? • Do people make demands on you that you don’t like?
• Do people act in a way that scares you? • Do people act in a way that scares you?
• Do people listen to you? • Do people listen to you?
• Are your emotional needs met? • Are your emotional needs met?

Human rights which may be engaged: Human rights which may be engaged:

FREDA: fairness, respect, equality, dignity, Article 8: Right to respect for private and family FREDA: fairness, respect, equality, dignity, Article 8: Right to respect for private and family
autonomy -is the person treated as an equal and life – e.g. does the person feel respected in his / autonomy -is the person treated as an equal and life – e.g. does the person feel respected in his /
with respect? – E.g. if the person makes a her home? Does the person have any involvement with respect? – E.g. if the person makes a her home? Does the person have any involvement
complaint regarding any emotional abuse, is it in choosing their staff / housemates? This is complaint regarding any emotional abuse, is it in choosing their staff / housemates? This is
taken seriously and is it investigated fully? especially true if they feel they are being taken seriously and is it investigated fully? especially true if they feel they are being
emotionally abused by somebody they live with. emotionally abused by somebody they live with.

Article 3: Prohibition of torture, inhuman and Article 3: Prohibition of torture, inhuman and
degrading treatment- Extreme emotional abuse degrading treatment- Extreme emotional abuse
could be construed as torture. Strategies should be could be construed as torture. Strategies should be
in place to prevent this from happening. Staff need in place to prevent this from happening. Staff need
to be aware of potential emotional abuse as it could to be aware of potential emotional abuse as it could
be more difficult to identify, be more difficult to identify,

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Risk Areas: Questions, Prompts Risk Areas: Questions, Prompts

and Human Rights Involved and Human Rights Involved
Section 3: Risks from Others Section 3: Risks from Others

11) Looking out for my family. 11) Looking out for my family.
Prompt questions Prompt questions
• Are your family elderly? • Are your family elderly?
• Do your family have a lot going on? • Do your family have a lot going on?
• Do your family care for more than one • Do your family care for more than one
person? person?
• Does your mum, dad, sister etc care for • Does your mum, dad, sister etc care for
you by themselves? you by themselves?

Human rights which may be engaged: Human rights which may be engaged:

FREDA: fairness, respect, equality, dignity, FREDA: fairness, respect, equality, dignity,
autonomy autonomy

Article 8: Right to respect for private and family Article 8: Right to respect for private and family
life – e.g. if the person’s carer’s vulnerability is life – e.g. if the person’s carer’s vulnerability is
affecting the service users quality of life, are there affecting the service users quality of life, are there
strategies in place to help the situation? (e.g. strategies in place to help the situation? (e.g.
outside carers to give extra support). Alternatively, if outside carers to give extra support). Alternatively, if
by looking after the person the carer’s right is by looking after the person the carer’s right is
compromised, then again, are there interventions in compromised, then again, are there interventions in
place to help? place to help?

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Section 4: Risks Relating to Property Section 4: Risks Relating to Property

Please turn to 'Section 4: Risks Relating to Property', Please turn to 'Section 4: Risks Relating to Property',
in the picture booklet in the picture booklet
This section looks at potential problems around a person’s property. Some service users may damage their This section looks at potential problems around a person’s property. Some service users may damage their
own property as a way of communicating they need more help, or as a way to express how they are feeling. own property as a way of communicating they need more help, or as a way to express how they are feeling.
This becomes a problem if it is occurs regularly and belongings have to be replaced. It can also become a This becomes a problem if it is occurs regularly and belongings have to be replaced. It can also become a
problem if it is putting the service user or others at risk. problem if it is putting the service user or others at risk.

1) Damage to own property. 1) Damage to own property.

Prompt questions Prompt questions
• Do you find it difficult to express your • Do you find it difficult to express your
emotions? emotions?
• Do you throw things when you are tired, • Do you throw things when you are tired,
angry, upset or confused? angry, upset or confused?
• Do you break your things? • Do you break your things?

Human rights which may be engaged: Human rights which may be engaged:

FREDA: Fairness, Respect, Equality, Dignity, Article 1 of Protocol 1: Protection of property – If FREDA: Fairness, Respect, Equality, Dignity, Article 1 of Protocol 1: Protection of property – If
Autonomy the person damages their property, they are Autonomy the person damages their property, they are
impeding the right to have their property protected. impeding the right to have their property protected.
Is the person treated with dignity and respect Is the person treated with dignity and respect
despite the potential for arson or damage their despite the potential for arson or damage their
property? Are functional necessities replaced if they property? Are functional necessities replaced if they
have been damaged (e.g. television)? Does the Article 8: Right to respect for private and family have been damaged (e.g. television)? Does the Article 8: Right to respect for private and family
person have a reputation around this risk? Does life – e.g. If the person lives in a house with other person have a reputation around this risk? Does life – e.g. If the person lives in a house with other
this then impede on the care they receive, or how service users, then their right for a home life may be this then impede on the care they receive, or how service users, then their right for a home life may be
they are treated by either staff members or other compromised if the person damages the property they are treated by either staff members or other compromised if the person damages the property
Service Users? regularly. Service Users? regularly.

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Risk Areas: Questions, Prompts Risk Areas: Questions, Prompts

and Human Rights Involved and Human Rights Involved
Section 4: Risks Relating to Property Section 4: Risks Relating to Property

2) Damage to others people’s property 2) Damage to others people’s property

Prompt questions Prompt questions
• Do you find it difficult to express your emotions? • Do you find it difficult to express your emotions?
• Do you throw other people’s belongs when you are • Do you throw other people’s belongs when you are
tired, angry, upset or confused? tired, angry, upset or confused?
• Do you break things that are not yours? • Do you break things that are not yours?

Human rights which may be engaged: Human rights which may be engaged:

FREDA: Fairness, Respect, Equality, Dignity, FREDA: Fairness, Respect, Equality, Dignity,
Autonomy Autonomy
Article 1 of Protocol 1: Protection of property – If Article 1 of Protocol 1: Protection of property – If
the person damages somebody else’s property, the person damages somebody else’s property,
then they are violating their right to have their then they are violating their right to have their
property protected. property protected.
Article 8: Right to respect for private and family Article 8: Right to respect for private and family
life – e.g. If the person damages somebody else’s life – e.g. If the person damages somebody else’s
property, they may be compromising the owner’s property, they may be compromising the owner’s
right to a private home life. right to a private home life.

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Risk Areas: Questions, Prompts Risk Areas: Questions, Prompts

and Human Rights Involved and Human Rights Involved
Section 4: Risks Relating to Property Section 4: Risks Relating to Property

3) Fire starting 3) Fire starting

Prompt questions Prompt questions
• Do you like using matches and lighters? • Do you like using matches and lighters?
• Do you enjoy lighting fires? • Do you enjoy lighting fires?
• Have you been arrested for lighting fires? • Have you been arrested for lighting fires?

Human rights which may be engaged: Human rights which may be engaged:

FREDA: fairness, respect, equality, Dignity, Article 2: Right to Life – If the person sets fire to a FREDA: fairness, respect, equality, Dignity, Article 2: Right to Life – If the person sets fire to a
Autonomy house with somebody still in it, it might Autonomy house with somebody still in it, it might
compromise the victim’s right to life. compromise the victim’s right to life.
Is the person treated with dignity and respect Is the person treated with dignity and respect
despite the potential for arson or damage to despite the potential for arson or damage to
property? Does the person have a reputation property? Does the person have a reputation
around this risk? Does this then impede on the care Article 8: Right to respect for private and family around this risk? Does this then impede on the care Article 8: Right to respect for private and family
they receive, or how they are treated by either staff life – e.g. If the person damages somebody else’s they receive, or how they are treated by either staff life – e.g. If the person damages somebody else’s
members or other Service Users? property, they may be compromising the owner’s members or other Service Users? property, they may be compromising the owner’s
right to a private home life. right to a private home life.

Article 1 of Protocol 1: Protection of property – Article 1 of Protocol 1: Protection of property –

Setting fire to somebody’s property is violating their Setting fire to somebody’s property is violating their
right to have their property protected. right to have their property protected.

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3.4 Sharing the Summary 3.4 Sharing the Summary

Using the “What are we going to do now?” sheet located at the back of the record form, the assessor Using the “What are we going to do now?” sheet located at the back of the record form, the assessor
summarises the recognised areas of risk and the human rights implications. summarises the recognised areas of risk and the human rights implications.

The ‘Keeping Me Safe and Well’ Assessment is the first stage of assessing somebody’s risk. Risks scoring The ‘Keeping Me Safe and Well’ Assessment is the first stage of assessing somebody’s risk. Risks scoring
four or higher indicate the need for a management plan (IRAMP / HR JRAMP) to be completed. Following four or higher indicate the need for a management plan (IRAMP / HR JRAMP) to be completed. Following
this, the assessor should then identify strategies and plans to address them. This sheet can be completed this, the assessor should then identify strategies and plans to address them. This sheet can be completed
either at the time of the assessment or at a later date, however the service user should ALWAYS receive a either at the time of the assessment or at a later date, however the service user should ALWAYS receive a
copy of this back page. copy of this back page.

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Improving Mental Health Improving Mental Health

Rebuild Clinical Business Unit Rebuild Clinical Business Unit

Olive Mount Mansion Olive Mount Mansion
Old Mill Lane Old Mill Lane
Liverpool, L15 8LW Liverpool, L15 8LW
Appendix 2: Appendix 2:

Human Rights in Risk Management Strategies Guidance Human Rights in Risk Management Strategies Guidance

Human rights are inherent in many of the risks posed by or to Service Users. Different rights are also Human rights are inherent in many of the risks posed by or to Service Users. Different rights are also
raised when various strategies are employed to manage these risks. raised when various strategies are employed to manage these risks.

When developing strategies, useful questions to ask include: When developing strategies, useful questions to ask include:
o Which rights are raised? o Which rights are raised?
o What type of right is it? (i.e. absolute, non-absolute or Article 5: Right to liberty) o What type of right is it? (i.e. absolute, non-absolute or Article 5: Right to liberty)
o Whose rights are they? o Whose rights are they?
o Do I have a duty to protect the rights? o Do I have a duty to protect the rights?
o How do I make sure I’m not breaching them? o How do I make sure I’m not breaching them?

If the right is non-absolute, for all strategies employed, you must ensure that: If the right is non-absolute, for all strategies employed, you must ensure that:
o There is a legitimate aim (e.g. To protect other people’s rights) o There is a legitimate aim (e.g. To protect other people’s rights)
o The strategy is necessary (e.g. Is it really needed to achieve that aim?) o The strategy is necessary (e.g. Is it really needed to achieve that aim?)
o The strategy is lawful (e.g. Is it in line with the Mental Capacity Act, Mental Health Act?) o The strategy is lawful (e.g. Is it in line with the Mental Capacity Act, Mental Health Act?)
o The strategy is proportionate (i.e. The least restrictive alternative?) o The strategy is proportionate (i.e. The least restrictive alternative?)

Some key considerations include: Some key considerations include:

o Is the strategy appropriate and not excessive to the risk posed? o Is the strategy appropriate and not excessive to the risk posed?
o Is the interference with the Service Users rights kept to a minimum? o Is the interference with the Service Users rights kept to a minimum?
o Is the least restrictive strategy being used? o Is the least restrictive strategy being used?
o What will be left of the Service User’s rights if you employ the strategy? o What will be left of the Service User’s rights if you employ the strategy?
o Is there an alternative, less drastic strategy? o Is there an alternative, less drastic strategy?

The diversity of and creativity involved in developing strategies means that it is not possible to provide The diversity of and creativity involved in developing strategies means that it is not possible to provide
an exhaustive list of their potential human rights implications. These guidelines are intended as an an exhaustive list of their potential human rights implications. These guidelines are intended as an
overview of the rights that may be raised by strategies employed to manage risks identified in the overview of the rights that may be raised by strategies employed to manage risks identified in the
‘Keeping Me Safe and Well Screen.’ ‘Keeping Me Safe and Well Screen.’

The rights that are most often relevant to healthcare in general, and risk management in particular, are The rights that are most often relevant to healthcare in general, and risk management in particular, are
likely to be: likely to be:
• Article 3: The right not to be tortured or treated in an inhuman or degrading way Article 3 applies in • Article 3: The right not to be tortured or treated in an inhuman or degrading way Article 3 applies in
‘extreme’ cases. It may be useful to think of a ‘spectrum’ between Article 3 and Article 8. For ‘extreme’ cases. It may be useful to think of a ‘spectrum’ between Article 3 and Article 8. For
example, restraining somebody to a chair for hours each day may constitute inhuman treatment, example, restraining somebody to a chair for hours each day may constitute inhuman treatment,
but the use of physical restraint to manage specific behaviours would be more likely to raise Article but the use of physical restraint to manage specific behaviours would be more likely to raise Article
8. 8.
• Article 8: The The right to respect for private and family life, home and correspondence • Article 8: The The right to respect for private and family life, home and correspondence
• Article 14: The right not to be discriminated against in relation to any of the rights contained in the • Article 14: The right not to be discriminated against in relation to any of the rights contained in the
European Convention; A strategy cannot restrict a Service User’s enjoyment of their rights based on European Convention; A strategy cannot restrict a Service User’s enjoyment of their rights based on
their learning disability, gender, sexuality, religion or any other aspect of their diversity. All their learning disability, gender, sexuality, religion or any other aspect of their diversity. All
strategies have the potential to raise Article 14, and you should ensure that you account for equality strategies have the potential to raise Article 14, and you should ensure that you account for equality
and diversity issues when developing your strategies. and diversity issues when developing your strategies.

However, a number of other human rights may be relevant and each strategy should be considered However, a number of other human rights may be relevant and each strategy should be considered
individually. individually.

Article 5: The right to liberty; there are very strict guidelines as to when a Service User’s right to liberty Article 5: The right to liberty; there are very strict guidelines as to when a Service User’s right to liberty
can be restricted. To be a lawful restriction, the Service User would need to under a section of the can be restricted. To be a lawful restriction, the Service User would need to under a section of the
Mental Health Act. Mental Health Act.

Article 7: The right to punishment without law; Article 7 is strictly limited to punishment linked to Article 7: The right to punishment without law; Article 7 is strictly limited to punishment linked to
criminal law and so does not refer to strategies (e.g. removal of an afternoon activity following an criminal law and so does not refer to strategies (e.g. removal of an afternoon activity following an
incident) which act as a form of punishment. Any strategy which may be construed as a punishment is incident) which act as a form of punishment. Any strategy which may be construed as a punishment is
likely to have human rights implications. Often these may be under Article 8 (The right to respect for likely to have human rights implications. Often these may be under Article 8 (The right to respect for
private and family life). private and family life).

Management Strategies likely to have Human Rights Implications Management Strategies likely to have Human Rights Implications
Any risk management strategy (whether pro or reactive) has the potential to restrict a Service User’s Any risk management strategy (whether pro or reactive) has the potential to restrict a Service User’s
rights. In general, proactive strategies are more likely to be human rights compliant. Proactive strategies rights. In general, proactive strategies are more likely to be human rights compliant. Proactive strategies
should be integral to and the main focus of any management plan. Where it is not possible (for reasons should be integral to and the main focus of any management plan. Where it is not possible (for reasons
of the person’s safety) the least restrictive reactive strategies should be used. These guidelines are of the person’s safety) the least restrictive reactive strategies should be used. These guidelines are
intended to assist your decision making process when developing strategies rather than being a intended to assist your decision making process when developing strategies rather than being a
definitive or ‘literal’ checklist. It is important to keep a record of this process. definitive or ‘literal’ checklist. It is important to keep a record of this process.

Pro Re Nate (PRN) medication Pro Re Nate (PRN) medication

Article 3: The right not to be tortured or treated in an inhuman or degrading way The use of PRN Article 3: The right not to be tortured or treated in an inhuman or degrading way The use of PRN
medication to keep somebody sedated would not be acceptable practice and may constitute inhuman medication to keep somebody sedated would not be acceptable practice and may constitute inhuman
and degrading treatment. Rapid tranquilisation may only be used in extreme circumstances and it is and degrading treatment. Rapid tranquilisation may only be used in extreme circumstances and it is
essential that Trust guidelines are followed. essential that Trust guidelines are followed.
• Have direct support staff been trained in the use of PRN? • Have direct support staff been trained in the use of PRN?

Article 8: The right to respect for private and family life, home and correspondence Article 8: The right to respect for private and family life, home and correspondence
• Does the Service User know what PRN medication is used for? • Does the Service User know what PRN medication is used for?
• Have they been given accessible information about the particular medication being administered? • Have they been given accessible information about the particular medication being administered?
• Does the Service User have any input into decisions relating to PRN medication? • Does the Service User have any input into decisions relating to PRN medication?
• Is the Service User aware of any side-effects of PRN medication? • Is the Service User aware of any side-effects of PRN medication?
• Is the PRN medication administered in the least invasive way? • Is the PRN medication administered in the least invasive way?
• Has the Service User consented to the use of PRN? If not, is the strategy a proportionate and • Has the Service User consented to the use of PRN? If not, is the strategy a proportionate and
balanced decision? balanced decision?

FREDA FREDA
• Is the person treated with dignity and respect when receiving PRN medication? • Is the person treated with dignity and respect when receiving PRN medication?
• Is there a PRN protocol and is this followed? • Is there a PRN protocol and is this followed?

Physical and Mechanical restraint Physical and Mechanical restraint

Article 2: The Right to life Article 2: The Right to life
In extreme cases, the use of physical restraint has resulted in death. This has been due to the use of In extreme cases, the use of physical restraint has resulted in death. This has been due to the use of
excessive force or unsuitable restraint technique being employed. You should ensure that the Service excessive force or unsuitable restraint technique being employed. You should ensure that the Service
User has regular physical examinations to determine whether restraint is appropriate. User has regular physical examinations to determine whether restraint is appropriate.
Article 3: The right not to be tortured or treated in an inhuman or degrading way Article 3: The right not to be tortured or treated in an inhuman or degrading way
If restraint is very severe and used with excessive force (i.e. not proportionate to the risk); it could If restraint is very severe and used with excessive force (i.e. not proportionate to the risk); it could
potentially be considered inhuman or degrading treatment. If this is suspected, action should cease potentially be considered inhuman or degrading treatment. If this is suspected, action should cease
immediately as Article 3 is an absolute right that should not be compromised. immediately as Article 3 is an absolute right that should not be compromised.
• Are the restraints approved by a recognised/accredited body e.g. Mersey Care Managing Violence • Are the restraints approved by a recognised/accredited body e.g. Mersey Care Managing Violence
and Aggression (MVA) or British Institute of Learning Disabilities? and Aggression (MVA) or British Institute of Learning Disabilities?
• Do the techniques emphasise use of de-escalation prior to use of physical intervention? • Do the techniques emphasise use of de-escalation prior to use of physical intervention?
• Do techniques use the minimum force necessary to ensure the safety of the person and/or others? • Do techniques use the minimum force necessary to ensure the safety of the person and/or others?
E.g. tying somebody to a chair to prevent them moving would be inhuman and degrading E.g. tying somebody to a chair to prevent them moving would be inhuman and degrading
treatment. treatment.
• Is any mechanical restraint (e.g. splints) used appropriately and not for prolonged periods unless • Is any mechanical restraint (e.g. splints) used appropriately and not for prolonged periods unless
absolutely necessary (would removal of the restraint result in immediate, extreme harm to the absolutely necessary (would removal of the restraint result in immediate, extreme harm to the
Service User and/or others)? Service User and/or others)?

Article 8: The right to respect for private and family life, home and correspondence Article 8: The right to respect for private and family life, home and correspondence
• Is the use of physical restraint regularly reviewed to make sure it is still necessary and the least • Is the use of physical restraint regularly reviewed to make sure it is still necessary and the least
restrictive option? restrictive option?
• Does the Service User have an Advanced Statement which includes information about preferred • Does the Service User have an Advanced Statement which includes information about preferred
restraints, effective verbal de-escalation techniques? restraints, effective verbal de-escalation techniques?

FREDA FREDA
• Is the Service User treated with dignity and respect before, during and after the physical • Is the Service User treated with dignity and respect before, during and after the physical
intervention? intervention?
• Does the Service User understand the reasons for the physical restraint and are they debriefed • Does the Service User understand the reasons for the physical restraint and are they debriefed
following this? following this?
• Does the person have a say in how they are restrained or who restrains them? (e.g. gender, • Does the person have a say in how they are restrained or who restrains them? (e.g. gender,
relationship to the person) relationship to the person)

1-6) Self-harm/injury (see also section on sexual abuse) 1-6) Self-harm/injury (see also section on sexual abuse)
(For the purpose of this booklet, this does not refer to parasuicidal behaviours) (For the purpose of this booklet, this does not refer to parasuicidal behaviours)

Article 2: The Right to life Article 2: The Right to life

• Any strategy e.g. harm reduction, that supports the person to continue self-harming is likely to • Any strategy e.g. harm reduction, that supports the person to continue self-harming is likely to
involve their right to life. However, a harm reduction approach may jeopardise a person’s right to involve their right to life. However, a harm reduction approach may jeopardise a person’s right to
life less than ‘unsupported’ self-injury. life less than ‘unsupported’ self-injury.

Article 8: The right to respect for private and family life, home and correspondence Article 8: The right to respect for private and family life, home and correspondence
• Where family contact is identified as a trigger to self harm and restrictions are placed on this, the • Where family contact is identified as a trigger to self harm and restrictions are placed on this, the
person’s right to a family life should be considered. person’s right to a family life should be considered.
• Is the Service User’s room or clothing searched for items with which they may self-injure? • Is the Service User’s room or clothing searched for items with which they may self-injure?
• Is the Service User able to access appropriate and non-judgemental medical treatment (if needed) • Is the Service User able to access appropriate and non-judgemental medical treatment (if needed)
following self-harm or self injury? Or, is the Service User able to care for their injuries effectively? following self-harm or self injury? Or, is the Service User able to care for their injuries effectively?
• Are proactive, person-centred strategies in place to reduce the likelihood/severity of self harm/self • Are proactive, person-centred strategies in place to reduce the likelihood/severity of self harm/self
injury? injury?
• Have these strategies considered the person’s reasons and motivations to self harm? • Have these strategies considered the person’s reasons and motivations to self harm?
• Have the staff team considered what role self harm/injury fulfils? • Have the staff team considered what role self harm/injury fulfils?
• Is the Service User’s right to make informed decisions and choices respected? • Is the Service User’s right to make informed decisions and choices respected?
• Does the Service User have a say in the strategies that are used e.g. Dialectical Behaviour Therapy • Does the Service User have a say in the strategies that are used e.g. Dialectical Behaviour Therapy
(DBT) techniques of marking skin with a red pen, flicking elastic bands against your wrist? (DBT) techniques of marking skin with a red pen, flicking elastic bands against your wrist?
• Does the person have the opportunity to talk to somebody following the self harm/injury? • Does the person have the opportunity to talk to somebody following the self harm/injury?

FREDA FREDA
• Do staff/carers respect the Service User’s autonomy by supporting them to use their proactive • Do staff/carers respect the Service User’s autonomy by supporting them to use their proactive
strategies? e.g. DBT. strategies? e.g. DBT.
• Does the Service User have any say in which staff members intervene when they are self-harming? • Does the Service User have any say in which staff members intervene when they are self-harming?

1-10) Strategies for domestic hazard 1-10) Strategies for domestic hazard
Article 8: The right to respect for private and family life, home and correspondence Article 8: The right to respect for private and family life, home and correspondence
• Does the strategy prevent a Service User from making hot drink/snacks for themselves? If so are • Does the strategy prevent a Service User from making hot drink/snacks for themselves? If so are
they regularly offered these by staff? they regularly offered these by staff?
• Does the strategy restrict the person’s access to the kitchen or cupboards within the kitchen? (In • Does the strategy restrict the person’s access to the kitchen or cupboards within the kitchen? (In
extreme cases, this could raise Article 3) extreme cases, this could raise Article 3)
• Can the Service User receive snacks/drinks when they ask for them? • Can the Service User receive snacks/drinks when they ask for them?
• Are safety gates in place? • Are safety gates in place?
• If safety gates are used do they restrict the person’s access to bathroom/toilet etc.? • If safety gates are used do they restrict the person’s access to bathroom/toilet etc.?
• Are certain things locked away to prevent the Service User from using them? • Are certain things locked away to prevent the Service User from using them?
• In shared accommodation, do any strategies impede the quality of life of other Service Users who • In shared accommodation, do any strategies impede the quality of life of other Service Users who
are not at risk of domestic hazard? are not at risk of domestic hazard?

FREDA FREDA
• Does any intervention consider fairness, dignity and respect? • Does any intervention consider fairness, dignity and respect?
• Are interventions within the home (e.g. safety gates) age appropriate? • Are interventions within the home (e.g. safety gates) age appropriate?

Article 1 of protocol 1: The right to peaceful enjoyment of property Article 1 of protocol 1: The right to peaceful enjoyment of property
• Do any restrictions in place limit the Service User’s access to their property or rooms that contain • Do any restrictions in place limit the Service User’s access to their property or rooms that contain
their property? Is this a necessary, proportionate restriction? their property? Is this a necessary, proportionate restriction?

1-11) Leaving package of care without support 1-11) Leaving package of care without support
Article 5: Right to liberty and security Article 5: Right to liberty and security
• Are doors to the person’s home locked, restrictors/alarms placed on windows or doors or is the • Are doors to the person’s home locked, restrictors/alarms placed on windows or doors or is the
Service User supervised for lengthy periods of the day? If so, unless the person is detained under a Service User supervised for lengthy periods of the day? If so, unless the person is detained under a
relevant section of the Mental Health Act their detention is likely to be unlawful. relevant section of the Mental Health Act their detention is likely to be unlawful.
• Any restriction placed on liberty and security must be considered in light of the potential for harm • Any restriction placed on liberty and security must be considered in light of the potential for harm
to the Service User, staff and the community (including property) if the strategy was not in place. If to the Service User, staff and the community (including property) if the strategy was not in place. If
the restriction protects other, competing rights of the Service User (e.g. the right to life) or the the restriction protects other, competing rights of the Service User (e.g. the right to life) or the
rights of others (e.g. The right not to be tortured or treated in an inhuman or degrading way) it rights of others (e.g. The right not to be tortured or treated in an inhuman or degrading way) it
must be a proportionate response and the balanced decision evidenced. must be a proportionate response and the balanced decision evidenced.
• Is the person able to request to leave the property? • Is the person able to request to leave the property?

Article 8: The right to respect for private and family life, home and correspondence Article 8: The right to respect for private and family life, home and correspondence
• Is the Service User aware of their rights relating to leaving the property? • Is the Service User aware of their rights relating to leaving the property?
• Is the Service User aware of their rights under the Mental Health Act? • Is the Service User aware of their rights under the Mental Health Act?
• Consider the impact any restriction can have on psychological integrity. • Consider the impact any restriction can have on psychological integrity.
• Are the reasons for any restrictions explained to the Service User? • Are the reasons for any restrictions explained to the Service User?
FREDA FREDA
• Is the Service User’s autonomy respected? • Is the Service User’s autonomy respected?

Supervision Supervision
Article 8: The right to respect for private and family life, home and correspondence Article 8: The right to respect for private and family life, home and correspondence
• If the Service User requires intensive support, is their independence preserved as far as possible? • If the Service User requires intensive support, is their independence preserved as far as possible?
This may be by using the minimum number of staff, or having periods in the day with reduced This may be by using the minimum number of staff, or having periods in the day with reduced
ratios/time for the person to be alone. ratios/time for the person to be alone.
• If the Service User shares their home with staff or other residents, is the home respected as their • If the Service User shares their home with staff or other residents, is the home respected as their
own? own?
• Are there any restrictions on visits to or visits from family/friends? • Are there any restrictions on visits to or visits from family/friends?
• Are all visits supervised or is this decided on an individual basis? • Are all visits supervised or is this decided on an individual basis?
• Is there a restriction on the ability for the Service User to develop personal and sexual relationships? • Is there a restriction on the ability for the Service User to develop personal and sexual relationships?

FREDA FREDA
• Is the Service User treated with dignity and respect when being supported? • Is the Service User treated with dignity and respect when being supported?

1-12) Deterioration in mental health 1-12) Deterioration in mental health

Article 5: Right to Liberty and security Article 5: Right to Liberty and security
• Is the Service User sectioned under the Mental Health Act? • Is the Service User sectioned under the Mental Health Act?

Article 8: The right to respect for private and family life, home and correspondence Article 8: The right to respect for private and family life, home and correspondence
• Does the person have any input into how their mental health problems are managed? • Does the person have any input into how their mental health problems are managed?
• Has the Service User made an Advanced Statement? Is this used? • Has the Service User made an Advanced Statement? Is this used?
• Is the Service User aware of people they can talk to if they have any concerns relating to their • Is the Service User aware of people they can talk to if they have any concerns relating to their
mental health? mental health?
• Does the Service User have access to medical and psychological treatments if their mental health • Does the Service User have access to medical and psychological treatments if their mental health
deteriorates? deteriorates?
• Are proactive strategies in place? E.g. Symptom maintenance, awareness of early warning signs, • Are proactive strategies in place? E.g. Symptom maintenance, awareness of early warning signs,
Staying Well Plan? Staying Well Plan?
• Does the Service User have accessible information on any diagnosed mental health problem? • Does the Service User have accessible information on any diagnosed mental health problem?
If the Service User takes medication for their mental health problem: If the Service User takes medication for their mental health problem:
• Has the Service User consented to take medication? • Has the Service User consented to take medication?
• How is medication administered (orally, depot injection etc.)? • How is medication administered (orally, depot injection etc.)?
• Is the Service User involved in decisions regarding their medication? • Is the Service User involved in decisions regarding their medication?
• Does the Service User know how to raise any concerns relating to their medication? • Does the Service User know how to raise any concerns relating to their medication?
• Does the Service User have accessible information about the reasons for being on medication and • Does the Service User have accessible information about the reasons for being on medication and
their possible side effects? their possible side effects?
• Is the medication regularly reviewed? • Is the medication regularly reviewed?

FREDA FREDA
• Is the Service User treated with dignity and respect with regard to their mental health problems? • Is the Service User treated with dignity and respect with regard to their mental health problems?
This includes the attitudes of and treatment by the staff team, family and other Service Users. If This includes the attitudes of and treatment by the staff team, family and other Service Users. If
they take medication, is the Service User able to do so in private? they take medication, is the Service User able to do so in private?

1-13) Alcohol and substance abuse 1-13) Alcohol and substance abuse
Article 2: Right to Life Article 2: Right to Life
• Can mainstream services be accessed by the Service User (e.g. alcohol services)? If not, this could • Can mainstream services be accessed by the Service User (e.g. alcohol services)? If not, this could
potentially raise their right to life potentially raise their right to life
Article 5: Right to liberty and security Article 5: Right to liberty and security
• Are there restrictions placed on the Service User leaving their home (e.g. restrictors, locked doors)? • Are there restrictions placed on the Service User leaving their home (e.g. restrictors, locked doors)?
• Has the Service User been issued a treatment order? • Has the Service User been issued a treatment order?

Article 8: The right to respect for private and family life, home and correspondence Article 8: The right to respect for private and family life, home and correspondence
• Has the Service User consented to any intervention? • Has the Service User consented to any intervention?
• Is the Service User offered psycho-education to promote their understanding of the effects of • Is the Service User offered psycho-education to promote their understanding of the effects of
alcohol/substance misuse? alcohol/substance misuse?
• Is the Service User’s access to money restricted? • Is the Service User’s access to money restricted?
• Is the Service User supported to maintain nutrition and personal hygiene? Lack of support could • Is the Service User supported to maintain nutrition and personal hygiene? Lack of support could
potentially lead to inhuman or degrading treatment. potentially lead to inhuman or degrading treatment.
• Does the strategy place any restriction on access to family/friends or children • Does the strategy place any restriction on access to family/friends or children
FREDA FREDA
It the Service User’s autonomy for making decisions about their drinking habits (for example) respected? It the Service User’s autonomy for making decisions about their drinking habits (for example) respected?

Psychological therapies Psychological therapies

Although not a ‘risk management’ strategy per se, many Service Users may have ongoing or short-term Although not a ‘risk management’ strategy per se, many Service Users may have ongoing or short-term
psychological therapy for a variety of reasons. This can include indirect psychological interventions with psychological therapy for a variety of reasons. This can include indirect psychological interventions with
family and staff teams. family and staff teams.

Article 8: The right to respect for private and family life, home and correspondence Article 8: The right to respect for private and family life, home and correspondence
• Has the Service User provided informed consent for direct and indirect interventions? • Has the Service User provided informed consent for direct and indirect interventions?
• Is the Service User aware of confidentiality and implications of any disclosures they make? • Is the Service User aware of confidentiality and implications of any disclosures they make?
• Is any information about the Service User shared on a need to know basis? • Is any information about the Service User shared on a need to know basis?
• Is psychological therapy being used to locate the problem in the person and not in the system of • Is psychological therapy being used to locate the problem in the person and not in the system of
support? E.g. Is anger management being used to ‘treat’ someone when they are angry about their support? E.g. Is anger management being used to ‘treat’ someone when they are angry about their
rights being denied? rights being denied?
• Is information shared on a ‘need to know’ basis? • Is information shared on a ‘need to know’ basis?

Restrictions on access to the community Restrictions on access to the community

Restrictions on access to the community may be based on protecting the community or possibly, specific Restrictions on access to the community may be based on protecting the community or possibly, specific
groups within the community (including adult males, adult females or a specific ethnic minority group). groups within the community (including adult males, adult females or a specific ethnic minority group).
This may be pertinent where a Service User poses a risk of verbal aggression/intimidation or physical This may be pertinent where a Service User poses a risk of verbal aggression/intimidation or physical
violence. violence.

Any restriction should: Any restriction should:

• Be applied only to specific areas, places or times that would trigger the risk behaviour • Be applied only to specific areas, places or times that would trigger the risk behaviour
• Be regularly reviewed – is a ‘permanent’ restriction justified? • Be regularly reviewed – is a ‘permanent’ restriction justified?
• Be mindful of the benefits if positive risk taking etc. • Be mindful of the benefits if positive risk taking etc.

Article 5: Right to liberty and security Article 5: Right to liberty and security
• Does the strategy impose restrictions on the Service User leaving their home (e.g. restrictors on • Does the strategy impose restrictions on the Service User leaving their home (e.g. restrictors on
doors/windows)? doors/windows)?
• Is the person sectioned under the Mental Health Act? • Is the person sectioned under the Mental Health Act?
• Does any other legislation, community order and/or bail conditions etc impose any lawful • Does any other legislation, community order and/or bail conditions etc impose any lawful
restrictions? restrictions?

Article 8: The right to respect for private and family life, home and correspondence Article 8: The right to respect for private and family life, home and correspondence
• Is the person aware of the reasons for any restrictions? • Is the person aware of the reasons for any restrictions?
• Does the restriction prevent the Service User from being able to have meaningful participation in the • Does the restriction prevent the Service User from being able to have meaningful participation in the
community? Is this proportionate? community? Is this proportionate?
• Is there a restriction on the ability for the Service User to develop personal and sexual relationships? • Is there a restriction on the ability for the Service User to develop personal and sexual relationships?

2-4) Sexual offending 2-4) Sexual offending

Article 5: Right to liberty and security Article 5: Right to liberty and security
• Are doors locked to prevent the Service User from going out and potentially sexually offending? • Are doors locked to prevent the Service User from going out and potentially sexually offending?
• Is the person sectioned under the Mental Health Act? • Is the person sectioned under the Mental Health Act?
• Does any other legislation, community order and/or bail conditions etc impose lawful restrictions? • Does any other legislation, community order and/or bail conditions etc impose lawful restrictions?

Article 8: Respect for family and private life, home and correspondence Article 8: Respect for family and private life, home and correspondence
• Is the Service User prevented from going to certain areas within the community? • Is the Service User prevented from going to certain areas within the community?
• Is the Service User restricted from going to any place/area within the community because they • Is the Service User restricted from going to any place/area within the community because they
would be at risk from others? would be at risk from others?
• Are any restrictions of the Service User’s movements within the community part of a court • Are any restrictions of the Service User’s movements within the community part of a court
judgement/ruling? judgement/ruling?
• Does any strategy mean that the Service User’s choices about where they live have to be refused? • Does any strategy mean that the Service User’s choices about where they live have to be refused?
Is this explained and understood by the Service User? Is this explained and understood by the Service User?
• Does the strategy restrict visits to or from family members and friends? • Does the strategy restrict visits to or from family members and friends?
• Is information relating to sexual offences shared on a ‘need to know’ basis? • Is information relating to sexual offences shared on a ‘need to know’ basis?

FREDA FREDA
If the Service User is suspected of/known to have committed a sexual offence, are they treated with If the Service User is suspected of/known to have committed a sexual offence, are they treated with
dignity, fairness and respect? Do staff and services treat them equally? dignity, fairness and respect? Do staff and services treat them equally?

2-5) Stealing 2-5) Stealing

Article 3: Right to be free from torture or inhuman and degrading treatment Article 3: Right to be free from torture or inhuman and degrading treatment
• Is the Service User ever searched if they are suspected of stealing? This would raise Article 8, but • Is the Service User ever searched if they are suspected of stealing? This would raise Article 8, but
standard practice of always searching the person with no reasonable grounds could constitute standard practice of always searching the person with no reasonable grounds could constitute
degrading treatment. degrading treatment.

Article 5: Right to liberty and security Article 5: Right to liberty and security
• Are there any restrictions placed on the Service User leaving the property to prevent stealing? • Are there any restrictions placed on the Service User leaving the property to prevent stealing?

Article 8: Right to respect for family and private life, home and correspondence Article 8: Right to respect for family and private life, home and correspondence
• Are there restrictions placed on accessing certain rooms within the Service User’s home? • Are there restrictions placed on accessing certain rooms within the Service User’s home?
• Consider protecting the rights of the staff team/family/public (see risk guidance) • Consider protecting the rights of the staff team/family/public (see risk guidance)
• Are the Service User’s room or belongings ever searched if they are suspected of stealing? • Are the Service User’s room or belongings ever searched if they are suspected of stealing?
FREDA FREDA
• Is the Service User treated with dignity and respect despite suspected or potential stealing • Is the Service User treated with dignity and respect despite suspected or potential stealing
behaviour? behaviour?
• Does the Service User have the same freedom and equality as other Service Users who do not • Does the Service User have the same freedom and equality as other Service Users who do not
display this risk? display this risk?

2- 6) Arson 2- 6) Arson
Article 3: Right to be free from torture or inhuman and degrading treatment Article 3: Right to be free from torture or inhuman and degrading treatment
• Is the Service User ever searched for fire-setting materials? If this is done on a daily basis e.g. when • Is the Service User ever searched for fire-setting materials? If this is done on a daily basis e.g. when
the Service User returns home after being in the community, this could constitute degrading the Service User returns home after being in the community, this could constitute degrading
treatment. treatment.

Article 8: Respect for private and family life, home and correspondence Article 8: Respect for private and family life, home and correspondence
• Is the Service User’s access to the community restricted? (see relevant section) • Is the Service User’s access to the community restricted? (see relevant section)
• Are there restrictions on the Service User’s finances? (see relevant section) • Are there restrictions on the Service User’s finances? (see relevant section)

Safeguarding Children Safeguarding Children

Consult ‘Keeping Me Safe and Well Screen’ guidelines for the rights of children that the strategy must Consult ‘Keeping Me Safe and Well Screen’ guidelines for the rights of children that the strategy must
aim to protect. aim to protect.

2-10 Managing any risk posed to children 2-10 Managing any risk posed to children
Article 5: Right to liberty and security Article 5: Right to liberty and security
• If the strategy imposes a restriction on the Service User leaving their home at any time; it could • If the strategy imposes a restriction on the Service User leaving their home at any time; it could
interfere with their right to liberty and security. interfere with their right to liberty and security.

Article 8: The right to respect for private and family life, home and correspondence Article 8: The right to respect for private and family life, home and correspondence
• Is the Service User restricted from visiting any place/areas within the community where they could • Is the Service User restricted from visiting any place/areas within the community where they could
pose a risk to children (e.g. parks, areas close to schools, swimming pools)? pose a risk to children (e.g. parks, areas close to schools, swimming pools)?
• Is the Service User restricted from going to any place/area within the community because they • Is the Service User restricted from going to any place/area within the community because they
would be at risk there? would be at risk there?
• Are any restrictions of the Service User’s movements within the community part of a court • Are any restrictions of the Service User’s movements within the community part of a court
judgement? judgement?
• Does any strategy mean that the Service User’s choices about where they live have to be refused? • Does any strategy mean that the Service User’s choices about where they live have to be refused?
Is this explained and understood by the Service User? Is this explained and understood by the Service User?

2 – 11) Strategies to support Service Users with dependants 2 – 11) Strategies to support Service Users with dependants
Article 8: The right to respect for private and family life, home and correspondence Article 8: The right to respect for private and family life, home and correspondence
• Are proactive strategies in place to support the Service User to develop parenting skills and to help • Are proactive strategies in place to support the Service User to develop parenting skills and to help
them to have a safe and productive family life with their child? them to have a safe and productive family life with their child?
• If the Service User does not live with the child: • If the Service User does not live with the child:
o Does the strategy restrict the Service User’s access to their children? o Does the strategy restrict the Service User’s access to their children?
o Does the Service User have to be supervised when spending time with their children? o Does the Service User have to be supervised when spending time with their children?
• N.B. The child also has the right to have a meaningful relationship with their parent. • N.B. The child also has the right to have a meaningful relationship with their parent.

FREDA FREDA
• Is the Service User treated fairly and equally when being supported to develop their family life? • Is the Service User treated fairly and equally when being supported to develop their family life?

3 – 3-4) Strategies to protect the Service User from physical, sexual, emotional and financial 3 – 3-4) Strategies to protect the Service User from physical, sexual, emotional and financial
abuse by others abuse by others
See the ‘Keeping Me Safe and Well Screen’ guidelines for the rights of the Service User that need to be See the ‘Keeping Me Safe and Well Screen’ guidelines for the rights of the Service User that need to be
protected. These areas are likely to be quite complex and will entail a thorough, balanced decision protected. These areas are likely to be quite complex and will entail a thorough, balanced decision
making process. making process.

N.B. The strategy could severely restrict the rights of family members, carers and friends. However this N.B. The strategy could severely restrict the rights of family members, carers and friends. However this
restriction may be rights compliant if it has the genuine aim to protect the Service User from ongoing restriction may be rights compliant if it has the genuine aim to protect the Service User from ongoing
torture or degrading treatment (e.g. if they were a survivor of physical abuse). torture or degrading treatment (e.g. if they were a survivor of physical abuse).

Article 8: The right to respect for private and family life, home and correspondence Article 8: The right to respect for private and family life, home and correspondence
• Are any restrictions placed on contact with family members or friends? • Are any restrictions placed on contact with family members or friends?
• Is the Service User involved in the development of strategies to protect them from abuse? • Is the Service User involved in the development of strategies to protect them from abuse?
• Does the Service User have access to psychological therapies and counselling? • Does the Service User have access to psychological therapies and counselling?
• Are the reasons for any restrictions explained to the Service User? • Are the reasons for any restrictions explained to the Service User?
• Does the Service User have capacity? • Does the Service User have capacity?
• Have you fulfilled your duty to protect the Service User from ongoing abuse? • Have you fulfilled your duty to protect the Service User from ongoing abuse?

Article 1 of Protocol: The right to peaceful enjoyment of possessions Article 1 of Protocol: The right to peaceful enjoyment of possessions
• Are there management strategies surrounding the Service Users finances to protect them from • Are there management strategies surrounding the Service Users finances to protect them from
abuse? (see below) abuse? (see below)

Managing a Service User’s money Managing a Service User’s money

Article 1 of Protocol: The right to peaceful enjoyment of possessions Article 1 of Protocol: The right to peaceful enjoyment of possessions
• If the Service User’s money is managed, do they understand the reasons for this? • If the Service User’s money is managed, do they understand the reasons for this?
• Does the person have a say in how their money is managed? • Does the person have a say in how their money is managed?

Article 8: The right to respect for private and family life, home and correspondence Article 8: The right to respect for private and family life, home and correspondence
• Does the management of the Service User’s money prevent access to activities that they would • Does the management of the Service User’s money prevent access to activities that they would
otherwise enjoy? otherwise enjoy?
• Does the Service User have their own bank account even where they are assisted to manage their • Does the Service User have their own bank account even where they are assisted to manage their
own money? own money?
• Are restrictions on finances aimed to manage risks (e.g. alcohol/substance misuse)? • Are restrictions on finances aimed to manage risks (e.g. alcohol/substance misuse)?
Appendix 3 Appendix 3

Human Rights Decision Making Form Human Rights Decision Making Form

This form is to assist your decision making process when developing risk management This form is to assist your decision making process when developing risk management
strategies. Any risk management decisions should be discussed within the MDT. strategies. Any risk management decisions should be discussed within the MDT.

1. WHAT RIGHTS ARE INVOLVED IN THE RISK BEHAVIOUR? 1. WHAT RIGHTS ARE INVOLVED IN THE RISK BEHAVIOUR?
(See ‘Keeping Me Safe and Well’ screen guidelines) (See ‘Keeping Me Safe and Well’ screen guidelines)
It will be useful to keep these in mind to make balanced decisions and when considering proportionality. It will be useful to keep these in mind to make balanced decisions and when considering proportionality.

2. WHOSE RIGHTS ARE INVOLVED IN THE RISK? (e.g. Service User, Staff, community, property) 2. WHOSE RIGHTS ARE INVOLVED IN THE RISK? (e.g. Service User, Staff, community, property)

3. WHAT ARE YOUR STRATEGIES FOR RESPONDING TO THE RISK? 3. WHAT ARE YOUR STRATEGIES FOR RESPONDING TO THE RISK?

PROACTIVE REACTIVE PROACTIVE REACTIVE

4. WHO WILL BE AFFECTED BY YOUR STRATEGIES? 4. WHO WILL BE AFFECTED BY YOUR STRATEGIES?
(E.g. Service User, Staff, community, property) (E.g. Service User, Staff, community, property)

5. WILL THE STRATEGIES ENGAGE ANYONE’S RIGHTS? 5. WILL THE STRATEGIES ENGAGE ANYONE’S RIGHTS?
(See human rights strategies guidance for suggestions) (See human rights strategies guidance for suggestions)
IF NO: your strategies are likely to be human rights compliant and you do not need to continue with this IF NO: your strategies are likely to be human rights compliant and you do not need to continue with this
flowchart. flowchart.
However: However:
o You should reassess the situation regularly - things may change!
EXIT o You should reassess the situation regularly - things may change!
EXIT
o You should consult the MDT to reach this agreement o You should consult the MDT to reach this agreement
o You should ensure that you are still acting within the remit of the Mental Health Act/Mental o You should ensure that you are still acting within the remit of the Mental Health Act/Mental
Capacity Act/Deprivation Of Liberty safeguards Capacity Act/Deprivation Of Liberty safeguards

IF YES: Which rights does the strategy engage, and how? IF YES: Which rights does the strategy engage, and how?
Whose rights are they? Whose rights are they?

6. WILL THE STRATEGY RESTRICT ANYONE’S RIGHTS? 6. WILL THE STRATEGY RESTRICT ANYONE’S RIGHTS?

If no: your strategies are likely to be human rights compliant and you do not need to continue with this If no: your strategies are likely to be human rights compliant and you do not need to continue with this
flowchart. flowchart.
However: However:
o Be aware that your strategy may affect whether particular groups or people can enjoy their o Be aware that your strategy may affect whether particular groups or people can enjoy their
rights. rights.
o You should reassess the situation regularly - things may change! o You should reassess the situation regularly - things may change!
o You should consult the MDT to reach this agreement o You should consult the MDT to reach this agreement
EXIT EXIT
If yes: If yes:
a) Are any of the rights absolute? a) Are any of the rights absolute?
If yes, then the strategy may not be human rights compliant. If you are concerned about this you should: If yes, then the strategy may not be human rights compliant. If you are concerned about this you should:
o Discuss your concerns with the MDT o Discuss your concerns with the MDT
o Change the strategy so that it does not restrict the right o Change the strategy so that it does not restrict the right
o Consider seeking legal advice
EXIT o Consider seeking legal advice
EXIT

b) Is Article 5: The right to liberty raised? b) Is Article 5: The right to liberty raised?
If yes, then the strategy may not be human rights compliant. There are specific circumstances in which If yes, then the strategy may not be human rights compliant. There are specific circumstances in which
Article 5 can be limited: Article 5 can be limited:
o Legal detention under the MHA (with regular reviews) o Legal detention under the MHA (with regular reviews)
o Informal detention of Service Users who lack capacity to decide if they would like to be admitted o Informal detention of Service Users who lack capacity to decide if they would like to be admitted
to hospital to hospital
o Any restriction on Article 5 must be legal and proportionate o Any restriction on Article 5 must be legal and proportionate
EXIT EXIT
c) If the right is NOT absolute then . . . c) If the right is NOT absolute then . . .

i) Is the restriction of the right lawful? Do the MHA, MCA or DOL guidelines apply? i) Is the restriction of the right lawful? Do the MHA, MCA or DOL guidelines apply?
Write down any relevant legislation. Write down any relevant legislation.

ii) Do you have a legitimate aim that is in accordance with the Human Rights Act (e.g. the protection of ii) Do you have a legitimate aim that is in accordance with the Human Rights Act (e.g. the protection of

other people)? other people)?

iii) Is the strategy necessary to achieve this aim? iii) Is the strategy necessary to achieve this aim?

iv) Is the strategy proportionate? iv) Is the strategy proportionate?

v) Are there any competing rights? Is your decision balanced? v) Are there any competing rights? Is your decision balanced?

If yes to all of these, the strategy is likely to be human rights compliant, however: If yes to all of these, the strategy is likely to be human rights compliant, however:
o You should reassess the situation regularly - things may change! o You should reassess the situation regularly - things may change!
o You should consult the MDT to reach this agreement o You should consult the MDT to reach this agreement
o You may still need legal advice EXIT o You may still need legal advice EXIT

If no to (or you are unsure about any of these), then your strategy may not be human rights compliant. If If no to (or you are unsure about any of these), then your strategy may not be human rights compliant. If
a strategy is ‘unsafe’ there is potential for it to be an Article 3 (Freedom from torture or inhuman or a strategy is ‘unsafe’ there is potential for it to be an Article 3 (Freedom from torture or inhuman or
degrading treatment) issue. degrading treatment) issue.
7. MINI CHECKLIST 7. MINI CHECKLIST
Some key considerations for all strategies include: Some key considerations for all strategies include:
o Whose rights are they? o Whose rights are they?
o How do I make sure I’m not breaching them? o How do I make sure I’m not breaching them?
o Is the strategy appropriate and not excessive to the risk posed? o Is the strategy appropriate and not excessive to the risk posed?
o Is the interference with Service Users rights kept to a minimum? o Is the interference with Service Users rights kept to a minimum?
o Is the least restrictive strategy being used? o Is the least restrictive strategy being used?
o What will be left of the Service Users rights if you employ the strategy? o What will be left of the Service Users rights if you employ the strategy?
o Is there an alternative, less drastic strategy? o Is there an alternative, less drastic strategy?
o Has the Service User or Service User consultant been involved in the development of the o Has the Service User or Service User consultant been involved in the development of the
strategy? strategy?
o Has the MDT been involved in the decision making process? o Has the MDT been involved in the decision making process?

If your answer is yes to all of these questions, your strategy is likely to be human rights compliant. If your answer is yes to all of these questions, your strategy is likely to be human rights compliant.

If your answer is no to any of the questions, then the strategy may not be human rights compliant. If your answer is no to any of the questions, then the strategy may not be human rights compliant.
Consider all of the rights involved and aim to make a balanced decision. Consider all of the rights involved and aim to make a balanced decision.

EXIT EXIT

8. WHAT NEXT? 8. WHAT NEXT?

If you are concerned that the strategy is not human rights compliant or with any of the decisions you If you are concerned that the strategy is not human rights compliant or with any of the decisions you
have made, what action will you take? You could: have made, what action will you take? You could:
o Change the strategy so that it does not restrict the right o Change the strategy so that it does not restrict the right
o Raise your concerns with the MDT EXIT o Raise your concerns with the MDT EXIT
o Seek legal advice o Seek legal advice
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Improving Mental Health Improving Mental Health

Rebuild Clinical Business Unit Rebuild Clinical Business Unit

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