Risk Assessment

Only a small number of people with mental illness are violent or dangerous. However, when assessing a person with mental illness think of your safety before a situation arises:

• Find out if a patient has a history of violence or police involvement. Past behaviour is a predictor of future behaviour.
• Sit in the seat nearest to the door so it is possible to leave the room quickly.
• Situations that are particularly risky might be in those with alcohol/drug intoxication or withdrawal, psychosis, mania, or dementia/delirium.
• Read the warning signs that someone is becoming aggressive such as facial expression, agitation, and hostility. Act accordingly.
• Trust your instincts!
• If you feel unsafe, you could suggest taking a break so that you can decide what to do and call for help.
• Follow the advice in the chapter on Managing an Aggressive or Agitated Patient.

If you are seeing somebody in their own home, let people know where you are going and what time you will be back.

Risk can be grouped into four main categories:

1. Suicide/Self-harm
2. Self-neglect
3. Harm to others
4. Harm or exploitation by others

It is very important to find out what the immediate risk is to a patient in order to take action and ensure safety. The following risk screening questions are a critical part of the assessment:

Have you had thoughts about hurting yourself or ending your life?

This is a difficult thing to ask but it always needs to be done. It may stop someone from committing suicide. Asking this question saves lives. If the person answers yes, you need to ask for further detail. See Suicide risk assessment and also Part 7 of this book for tips on asking about this.

How much have you been eating and drinking over the last few days?

People with a serious mental illness may not be eating or drinking enough, or their carers may not be giving them enough food or water.

Have you had any thoughts of hurting someone else?

This is another difficult thing to ask but it also needs to be done particularly if the person is aggressive or is experiencing psychotic symptoms. If the person answers yes, you need to ask for further detail such as if the person has thoughts of harming a specific person, a plan, access to a weapon etc.

Is anyone hurting you?

People with mental illness are vulnerable to harm from others. Ask if anyone is hurting them and look for signs that would mean this was true for example: frightened behaviour, cuts, bruises or weight loss.

Consider the four types of risk:

1. Suicide/Self-harm
2. Self-neglect
3. Harm to others (deliberate harm or neglect e.g. of children)
4. Harm or exploitation by others

Take into account the following:

• The answers to the risk screening questions that you have asked
• Current mental state
• Any previous high-risk behaviours
• Evidence of self-neglect
• Evidence of alcohol or drug misuse
• Access to dangerous items
• Any children (or other dependents) who could be at risk
• What support that the person has at home

Classify each of the 4 types of risk as HIGH / MEDIUM / LOW / MORE INFORMATION NEEDED.

If you think a risk is high, note down why and/or what the specific risk is. Make sure that your assessment “fits the facts” e.g. if you recorded that the person had beaten his mother yesterday, then it would not make sense if you recorded the risk to others as low; it is clearly high!

Note down any other risks e.g. risk of absconding, or noncompliance with medication.

Refer to separate section for management of those actively suicidal, for those self-harming, or for managing the agitated or aggressive patient.

For high risk patients, consider if admission to a mental hospital is necessary and, if so, whether using the Mental Health Act (see section) is necessary.