Trust Corporate Policy
Policy for the management of patients and visitors who are
abusive, aggressive or threatening
Author(s)
Version
Nicola Havutcu
Risk & Compliance Consultant
3.1
Version Date
November 2012
Implementation/approval Date
November 2012
Review Date
November 2015
Review Body
Health & Safety Committee
Policy Reference Number
20\tw\o\va\
Table of Contents
VERSION CONTROL .......................................................................................................................... 2
1.0
Summary ................................................................................................................................... 3
2.0
Objectives ................................................................................................................................. 3
3.0
Introduction ............................................................................................................................... 3
4.0
Scope of Policy ......................................................................................................................... 4
5.0
Definitions ................................................................................................................................ 4
6.0
Roles and Responsibilities ........................................................................................................ 5
7.0
Duty of care ............................................................................................................................... 5
8.0
Practice recommendations ........................................................................................................ 6
9.0
Trust Pro-security Strategies ..................................................................................................... 9
10.0
Review and Monitoring ........................................................................................................ 10
11.0
References / Bibliography .................................................................................................... 10
Appendix 1: Flowchart 1 Risk Assessment for Abusive Patient with Underlying Cause in acute
hospital setting ................................................................................................................................... 11
Appendix 2: Flowchart Risk Assessment for Abusive Patient With No Underlying Cause in acute
hospital setting ................................................................................................................................... 12
Page 1 of 22
Appendix 3: Debrief following an abusive, aggressive or threatening incident ................................... 13
Appendix 4: Verbal warning .............................................................................................................. 14
Appendix 5: Behaviour Agreement .................................................................................................... 15
Appendix 6: First Written Warning (‘yellow card’ - to be printed on yellow paper) .............................. 16
Appendix 7: Final Written Warning (‘red card’ – to be printed on red paper)...................................... 17
Appendix 8: Local sanctions and involving the police ........................................................................ 18
Appendix 9: Equalities Impact Assessment ....................................................................................... 19
Appendix 10: Policy Submission Form .............................................................................................. 21
VERSION CONTROL
Version
3.0
3.1
Date
June
2010
Apr
2011
Author
Reason
Cliff
Hammond
Nicola
Havutcu
Corporate requirement
Full review of policy integrating City &
Hackney Community Services
Management of Violence and
Aggression Policy, Ref: RM007 October
2008, ensuring compliance with NHS
Security Management Services
Guidance and NHSLA.
Ratification
Required
Yes
Yes
Page 2 of 22
1.0
Summary
1.1
Homerton Hospital NHS Foundation Trust takes the safety and security of its staff, patients and
visitors very seriously.
Statement of commitment:
Our staff have the right to carry out their duties; and our patients and visitors have the
right to be cared for, without fear of attack or abuse.
We will always press for the strongest possible penalties against those who attack,
threaten or abuse our staff. The Trust will also seek to give full support to staff
members in the taking forward of any action as a result of physical or non-physical
assault,
1.2
This procedure outlines the steps to be taken should a patient or member of the public be
abusive, aggressive or threaten staff in any way. Flow diagrams are used to illustrate and
support the text and guide and support staff in the event of such a situation.
1.3
It must be remembered that visiting hospital or a hospital stay can be a frightening and anxiety
provoking experience for patients and their families. This fear and anxiety can often manifest
as aggression towards staff. Whilst staff must not put themselves at risk, an understanding of
this is important. The use of effective communication can often defuse potentially aggressive
or violent situations. All staff should therefore act in accordance with the Homerton Code of
Behaviour and take steps to avoid aggravating a situation which may result in violence or
aggression.
2.0
Objectives
2.1
2.3
2.4
To provide guidance to staff in dealing with violent, threatening or abusive behaviour from
patients or visitors.
To develop a pro-security culture of deterring, preventing, detecting, investigating and
executing sanctions.
To clearly set out the steps to be taken in the event of an incident.
To set out the Trust expectations in terms of:
4.3.1 Reporting of incidents.
4.3.2 Access to training.
4.3.3 Access to support.
4.3.4 Management response.
3.0
Introduction
3.1
Work related violence and aggression is a recognised occupational hazard for staff working in
the NHS. NHS staff and professionals are at greater risk of physical assault or verbal abuse
than many other professionals. (Department of Health (DH) Statistics June 2006).
In 2003 the National Audit Office produced a report called ‘A Safer Place to Work – protecting
NHS hospital and ambulance staff from violence and aggression’. From this the Department of
Health Zero Tolerance Campaign was launched and has led to the current structure of the
development of local policies and procedures and central reporting systems.
2.2
3.2
Page 3 of 22
3.3
3.4
The Trust has a duty of care under the Care Quality Commission outcomes.
This procedure was developed in consideration of the guidance from the DH and the NHS
Counter Fraud and Security Management Service (CFSMS).
4.0
Scope of Policy
4.1
4.2
All hospital based staff including contracted Medirest & Security.
Community based staff should to refer to the Lone Worker Policy.
5.0
Definitions from NHS Business Services Authority Security Management Division 2006:
5.1
Non-physical assault:
5.1.1 The use of inappropriate words or behaviour causing distress and / or constituting
harassment.
5.1.2 It is difficult to provide a comprehensive list of the types of incident that are covered;
however some examples are provided:
 Offensive language, verbal and swearing.
 Racist comments.
 Loud and intrusive conversation.
 Unwanted or abusive remarks.
 Negative, malicious or stereotypical comments.
 Invasion of personal space.
 Brandishing objects or weapons.
 Near misses (i.e. unsuccessful physical assaults.
 Offensive gestures.
 Threats or risk of serious injury to staff.
 Intimidation.
 Stalking.
 Alcohol or drug fuelled abuse.
 Incitement of others and / or disruptive behaviour.
 Unreasonable behaviour and non-cooperation such as repeated disregard of
hospital visiting hours.
 Any of the above linked to destruction of or damage to property.
5.2
Physical assault:
5.2.1 The intentional application of force to the person of another without lawful justification
resulting in injury or discomfort.
5.2.2 It is difficult to provide a comprehensive list of the types of incident that are covered;
however some examples are provided:
 Spitting on / at staff.
 Pushing.
 Shoving.
 Poking or jabbing.
 Scratching or pinching.
 Throwing objects, substances or liquids onto a person.
 Punching and kicking.
 Hitting and slapping.
 Sexual assault.
 Incidents where reckless behaviour results in physical harm to others.
 Incidents where attempts are made to cause physical harm to others and fail.
Page 4 of 22
5.3
Effects of assault: the effects of non-physical and physical assault are wide ranging and it
should be acknowledged that as well as the more obvious impacts of a physical assault such
as a visible bruise or injury, there may often be non-evident, longer lasting impacts such as
emotional and psychological distress or trauma. It is not necessary for there to be any physical
injury as a result of the assault for further action to be taken.
6.0
Roles and Responsibilities
6.1
Chief Executive
To ensure effective security arrangements are in place to protect and support Trust staff and
its property and assets.
6.2
Non-Exec Director
Promote security management measures.
6.3
Board Level Director
To take responsibility for development and delivery of effective security management
measures.
6.4
Local Security Management Specialist (LSMS)
To ensure a system is in place to review all incidents of violence or aggression and to review
the content of this policy to ensure its contents are up to date. Where this is not the case the
policy is to be updated and returned to Board for approval
6.5
Security Threat & Assessment Team (STAT)
To undertake rapid response to all calls for assistance whilst not placing themselves at risk of
violence or aggression. All STAT team members to be aware of the steps to be taken,
flowcharts and actions through training.
6.6
Managers
All managers to be responsible for ensuring processes and actions are implemented.
6.7
All staff
To ensure they take responsibility for their own personal safety by risk assessing situations
where they feel vulnerable. To take measures that do not expose themselves or others to
unnecessary danger. All staff to be aware of the steps to be taken, flowcharts and actions
through training.
6.8
Incident Review Group
To review all incidents of violence and aggression ensuring that staff are aware the support
available and that the correct management and investigation was undertaken
6.9
Security Staff
To undertake regular site patrols, monitoring of CCTV and offer assistance to the STAT team
as requested during instance where violence or aggression is displayed.
6.10
STAT Team
The STAT team consists of experienced nurses & security staff trained in dealing with violence
and aggression. Their early intervention can prevent a situation from deteriorating. The team
are there to support staff in dealing with difficult situations, not to take over.
7.0
Duty of care
Page 5 of 22
7.1
7.2
7.3
7.4
The Trust has a duty of care to all its patients, including those who may be a threat to
themselves or others.
There are serious implications for healthcare staff and managers in considering taking action
which would deny patients life-sustaining treatment.
It is important that the possibility of violent and aggressive behaviour being in any way linked to
a patient’s clinical condition, medication or treatment is fully explored. For example; lack of
oxygen to the brain causes neurological problems which can result in confusion or unusual
behaviour.
Deterrents, warnings or contracts of behaviour will be neither appropriate nor effective for
those whose behaviour is caused by their clinical condition and who lack the capacity to control
their behaviour.
7.5
It is understandable for patients to become angry, upset or otherwise emotional when faced
with a particular diagnosis or medical intervention / decision.
7.6
Equally relatives and friends may also become emotional.
If not dealt with appropriately this can exacerbate a situation.
8.0
Practice recommendations
8.1
Risk Assessment
It is recognised that feeling threatened or at risk is a subjective and personal perspective and it
is up to that individual member of staff to risk assess the situation and identify whether and
when they need assistance (see below).
Training beforehand and debriefing after the event will help staff to identify their personal
abilities and development needs. Staff are not expected to put themselves at risk. If from
the outset or at any time during the incident, the patient or visitor behaves, or threatens to
behave, in a violent or aggressive manner, assistance from the STAT Team (for hospital staff)
or Police (Community staff) should be summonsed as detailed below.
When the STAT team or Police arrives the staff should not leave the scene unless the team
instruct them to do so.
8.1.1
Community staff
Managers should informally risk assess potential interactions with patients to determine
whether there is a risk of violence and aggression based upon their knowledge of the patient
and any previous incidents and the lessons learnt from them. This will determine whether
additional controls should be put in place, such as additional physical security or additional
staff. Lone workers should also refer to Lone Working Policy
8.1.1
A patient being abusive, aggressive or threatening and has a probable underlying clinical
cause:
The following key questions are to be asked:
a.
b.
c.
d.
Has the patient been clinically assessed? If not then this needs to be done as soon as
possible.
Do you feel able to calm the patient?
Is there anyone close by who can assist you?
Do you feel able, with that assistance to calm the patient?
Page 6 of 22
If the answer is ‘No’ to questions a, b or c the member of staff should move away, call for
assistance and call the Police on 999.
The patient’s medical team should be summoned to review and consider appropriate
interventions to manage current and future behavioural problems.
An incident form will be completed and a full account documented in the patients record.
Once the immediate situation has been managed a debrief will held (Appendix 3).
8.1.2 A patient being abusive, aggressive or threatening and there is no underlying clinical cause.
The following key questions are to be asked:
a.
b.
c.
Do you feel able to calm the patient?
Is there anyone close by who can assist you?
Do you feel able, with that assistance to calm the patient?
If the answer is ‘No’ to questions a, b or c the member of staff should move away, call for
assistance and call the Police.
The patient’s medical team should be summoned to review and consider appropriate
interventions or sanctions to manage current and future behavioural problems
A member of the medical and senior nursing team will consider the requirement of
sanctions.
An incident form will be completed and a full account documented in the patients record.
Once the immediate situation has been managed a debrief will held (Appendix 3).
8.2.1
Hospital staff
A patient being abusive, aggressive or threatening and has a probable underlying clinical
cause:
Use Flowchart 1 (Appendix 1) as a step by step guide through the process.
The following key questions are to be asked:
a. Has the patient been clinically assessed? If not then this needs to be done as soon as
possible.
b. Do you feel able to calm the patient?
c. Is there anyone close by who can assist you?
d. Do you feel able, with that assistance to calm the patient?
If the answer is ‘No’ to questions a, b or c the member of staff should move away, call
for assistance and call the STAT team.
The patient’s medical team should be summoned to review and consider appropriate
interventions to manage current and future behavioural problems.
An incident form will be completed and a full account documented in the patients
record.
Once the immediate situation has been managed a debrief will held (Appendix 3).
8.2.2 A patient being abusive, aggressive or threatening and there is no underlying clinical cause.
Use Flowchart 2 (Appendix 2) as a step by step guide through the process.
The following key questions are to be asked:
Page 7 of 22
a. Do you feel able to calm the patient?
b. Is there anyone close by who can assist you?
c. Do you feel able, with that assistance to calm the patient?
If the answer is ‘No’ to questions a, b or c the member of staff should move away, call for
assistance and call the STAT team.
The patient’s medical team should be summoned to review and consider appropriate
interventions or sanctions to manage current and future behavioural problems
A member of the medical and senior nursing team (consultant lead nurse / matron / CSM)
will consider the requirement of sanctions.
An incident form will be completed and a full account documented in the patients record.
Once the immediate situation has been managed a debrief will held (Appendix 3).
8.3
Sanctions:
8.3.1 A range of sanctions are available to be used. They can only reasonably be issued to
patients who are able to take responsibility for, and have the mental capacity to control
their behaviour.
8.3.2 Sanctions do not necessarily have to be issued in order but a discussion between a
clinician and manager (Band 7 and above) with advice and support from clinical site
management team and security services must be held to decide the most appropriate.
These staff then must jointly sign the corresponding documented entry in the patient’s
record.
8.3.3 Verbal warning (Appendix 4). This is the first step to be taken after de-escalation or
resolution of the incident. It is to be issued by a senior member of staff (matron, CSM,
lead nurse, general manager) to reflect the significance. An assessment of the best
time to do so should be made and rests with that manager to ensure the situation is not
reignited.
8.3.4 Behavioural agreement (Appendix 5). This is a signed, jointly agreed contract of
behaviour and is used as a second stage. Clear expectations of required behaviour are
made and documented and the patient signs the agreement.
8.3.5 First Written Warning – ‘yellow card’ (Appendix 6): This is the first formal notification to
the patient that clearly states our expectations and further actions that may be taken in
the event of further inappropriate behaviour. This letter may be given whilst the patient
is in attendance or sent to the home address. An assessment of the best time to do so
should be made and rests with that manager to ensure the situation is not reignited.
8.3.6 Final Written Warning – ‘red card’ (Appendix 7): This is the final formal warning that
would be sent before seeking exclusion and is sent by the Chief Executive. This letter
may be given whilst the patient is in attendance or sent to the home address. An
assessment of the best time to do so should be made and rests with that manager to
ensure the situation is not reignited.
8.3.7 Local sanctions (Appendix 8): following discussion and review of the situation it may be
decided that specific local sanctions would be the best course of action. For example if
someone has a seriously ill relative it might be arranged that they have escorted visits.
Such decision must be made between the clinician, senior and middle manager for that
particular area with advice from security to ensure that there is a balance between
addressing the person’s needs as well as staff safety and security.
8.3.8 Involving the Police: Security staff act as the liaison between the Trust and the Police
service and will at all times assist staff in determining when and whether the Police
should be involved as well as the practical arrangements of contacting them.
Page 8 of 22
9.0
Trust Pro-security Strategies
9.1
Homerton Hospital NHS Foundation Trust takes the safety and security of its staff, patients and
visitors very seriously. The following corporate steps have been taken to underpin and support
this:
9.2
Measuring and monitoring
9.2.1
9.2.2
9.3
Skills and knowledge
9.3.1
9.4
9.4.2
9.4.3
Primary prevention – action taken before violence occurs. This is through staff training
in conflict resolution and de-escalation techniques.
Secondary prevention – action taken to prevent violence when it is perceived as
imminent and to minimise harm. This is through swift and consistent response to
incidents such as use of the flowcharts.
Tertiary prevention – action taken to prevent or reduce the potential for violence, such
as through debriefing, supporting staff to press charges, sanctions.
Deterrence
9.5.1
9.5.2
.
9.6
The Trust is committed to providing training on Conflict Resolution for all front line staff
and this will be delivered as part of the Trust’s Training Needs Analysis. Trust staff
have a responsibility to themselves and their colleague to attend this training in order to
ensure they have the best skills possible to recognise and resolve conflict from
occurring in the first instance
Prevention
9.4.1
9.5
All staff are expected to follow the required reporting process for abusive, violent or
threatening incidents. This entails completion of an electronic incident form on the
DATIX system, and documentation in the patient’s notes.
For physical assault a specific form is required obtainable from either security or the
CSM’s. This data is sent to the NHS Counter Fraud and Security Management Service.
An adapted version of the Trust Code of Behaviour will be clearly displayed at key
points within the hospital. This will indicate expected standards of behaviour from
patients and the public.
The Trust will support staff who have been victims of abuse, aggression or assault to
press charges and will always press for the strongest possible penalties.
Staff support
9.6.1 All staff involved in or affected by a violent or abusive incident will be seen as soon as
possible afterwards by either their line manager (or nominated other in the absence of).
The manager will ensure the following:
 That a debrief session has been held or is arranged, see appendix 3. This
document to be uploaded to Datix as an attachment
 A discussion takes place to ensure the member of staff feels safe and supported.
 That any training or support needs identified are arranged.
Page 9 of 22
9.6.2
All staff involved in or affected by a violent or abusive incident will be seen as soon as
possible afterwards by the Site Services Manager or his deputy to ensure the following:
 A discussion takes place to consider that staff member’s personal safety and sense
of security.
 The staff confidential counselling & EHMS services are offered and available to
assist staff in dealing with any concerns or anxieties they might have after an
incident. In this matter the Site Services Manager will alert both departments of
possible contact
 Assistance and support as required should criminal charges be sought.
9.6.3 The Trust takes the support of staff seriously and if there is any concern raised a formal
referral must be made immediately to the Employee Health Management Service.
10.0
Review and Monitoring
This Policy should be kept under review in the light of changing circumstances and requirements. As
a minimum it should be reviewed routinely every three years. If there are significant changes this
should returned to the ratifying body for approval. The processes for monitoring compliance with this
procedure are outlined in the table below:
Measurable
Policy Objective
Monitoring /
Audit
Frequency of
monitoring
Responsibility for
performing the
monitoring
Monitoring reported to
which
groups/committees, inc
responsibility for
reviewing action plans
Incidents of
Violence and
Aggression are
managed
appropriately
Review of all
incidents of
violence and
aggression
Weekly
Incident Reporting
Group
Patient Safety Committee
11.0
References / Bibliography
Violence Towards NHS Staff From The Public (2006) NHS Counter Fraud and Security
Management Service.
Protecting NHS Staff from Violence (2006) – leaflet. NHS Counter Fraud and Security
Management Service.
Prevention and Management of Violence Where Withdrawal of Treatment is not an Option.
(2006) NHS Counter Fraud and Security Management Service.
A Safer Place to Work. Report from the Comptroller and Auditor General (2003) HM Stationary
Office.
Procedure for the Management and Care of Patients and Visitors who are Violent or Abusive.
(2001) Homerton Hospital NHS Foundation Trust.
Page 10 of 22
Appendix 1: Flowchart 1 Risk Assessment for Abusive Patient with Underlying Cause in acute hospital setting
A patient is being abusive, aggressive or threatening and
has a probable underlying clinical cause.
Do you feel able to calm
the patient?
Yes
Yes
No
Has the patient been
clinically assessed?
No
Is there anyone close by
who can assist you?
No
Do you feel able to calm
the patient?
No
Yes
Is the medical team
available to assess at
this moment?
Yes
Constantly
review
Do you feel, with this
assistance that you are able to
calm the patient?
Yes
No
Once calmed complete
incident form and document in
patient notes.
DEBRIEF
No
Yes
MOVE AWAY and / or
CALL FOR
ASSISTANCE
CALL STAT TEAM ON
EXT 3333
No
Do you feel, with this
assistance that you are able to
calm the patient?
Yes
Constantly
review
Page 11 of 22
Appendix 2: Flowchart Risk Assessment for Abusive Patient With No Underlying Cause in acute hospital setting
A patient is being abusive, aggressive or threatening and
there is no underlying clinical cause.
VERBAL WARNING
Do you feel able to calm the
patient?
Yes
BEHAVIOUR
AGREEMENT
No
Is there anyone close by who
can assist you?
MOVE AWAY and / or
CALL FOR
ASSISTANCE
CALL STAT TEAM ON
EXT 3333
MINIMUM
of two staff
to consider
and decide
whether
sanction
appropriate
See relevant
appendices:
FIRST WRITTEN
WARNING
(YELLOW CARD)
IN ALL CASES:
1. Complete
incident form.
2. Document in
patients notes.
Yes
No
FINAL WRITTEN
WARNING
(RED CARD)
3. Two staff to
sign entry in
patients notes.
4. Debrief
Do you feel, with this
assistance that you are able to
calm the patient?
LOCAL SANCTION
(e.g. escorted
attendance)
Constantly
review
Yes
No
POLICE
Page 12 of 22
Appendix 3: Debrief following an abusive, aggressive or threatening incident
(This completed form to be uploaded to Datix as an attachment by the manager.
Incident date:
Clinical area:
Involving:
Key questions to ask:
1. Did we ‘see this coming?’
2. Was there anything we could have done to prevent it?
3. What did we do well in managing the situation?
4. What could we have done better?
5. Was the sanction (if any) appropriate?
6. What will we do if he / she returns?
7. Checklist:
a. Documentation: incident form, statement, record in patients notes.
b. Training needs?
c. Team support needs?
d. Individual support needs?
8. Other thoughts / comments
Page 13 of 22
Appendix 4: Verbal warning
1. To be ‘issued’ by a senior nurse or manager (senior nurse / matron / clinical site manager /
general manager) accompanied by a colleague.
2. Suggested key phrases:

Sir (Madam / Mr X / Ms X) it has been reported to me that you have behaved
inappropriately and specifically (add e.g. used abusive language, threatening behaviour)
and I am as such formally issuing you with a verbal warning as per our Trust Policy.

I accept that this is a difficult time for you, and I acknowledge that you have now
calmed down but I need to reiterate to you that our staff have the right to work in an
environment that is safe and non threatening.

I hope that there will be no further episodes and as such that we can close this.
However, should that not be the case and you again behave in an unacceptable way
then further measures will be taken.
3. Whilst this is a verbal warning it is important that it is still documented in the patient’s record so
that staff are aware in the future that one has been issued. Thus should there be further
episodes it will be apparent whether or not there is a history of such behaviour.
4. A file note of this action is also to be retained by the manager attached to the copy of the
incident form.
Page 14 of 22
Appendix 5: Behaviour Agreement
(One copy to be retained in patient notes and one by the manager with the relevant incident form).
Agreement between Homerton Hospital NHS Foundation Trust and:
Pt name:…………………………………….
DOB:………………………………..
Hospital number:……………………………
Consultant:………………………...
Date of agreement:………………………….




Homerton Staff will do everything possible to ensure the highest standards of care and support
provided to you.
Details of any proposed treatment plan will be discussed and agreed with you.
Any questions you have will be answered and any concerns explained before the onset of any
treatment.
The doctor responsible for your care is:……………………………………………
In return you must co-operate with the agreed treatment plan and comply with the following conditions
during your admission:


Add specifics
Add specifics

Failure to comply with these conditions in whole or in part will make it difficult to continue to
provide the treatment programme as agreed. Under these circumstances your care plan will be
reviewed by your doctor, who may, in the interest of staff safety or welfare elect to provide
emergency treatment only.

In the event that such action becomes necessary Homerton will take steps to exclude you from
attending the hospital, except for urgent emergency treatment.
---------------------------------------------------------------------------------------------------------------------Details of my treatment programme and the condition on which this programme will be provided have
been fully explained to me. I agree to comply with these conditions.
I understand that if I do not meet the conditions set out above my treatment programme may be
modified or may be discontinued.
Signed…………………………………………
Date:………………………………
---------------------------------------------------------------------------------------------------------------------Witnesses:
Name:…………………………………….
(Consultant or Registrar)
Name:………………………………
(Senior nurse or midwife)
Designation:……………………………..
Designation:……………………….
Signed:…………………………………..
Signed:……………………………..
Date:…………………………………….
Date:………………………………..
Page 15 of 22
Appendix 6: First Written Warning (‘yellow card’ - to be printed on yellow paper)
(One copy to be retained in patient notes and one by the manager with the relevant incident form)
Patients full name
Address
Hospital number
Date:
Dear…………………..
I am writing to you concerning an incident that occurred on…………….at…………….
It is alleged that you (used threatening behaviour / language etc – insert as reported). Behaviour such
as this is unacceptable and will not be tolerated. Homerton Hospital NHS Foundation Trust is firmly of
the view that all those who work in order to provide services to the NHS have the right to do so without
fear of violence or abuse.
If you continue to act in an antisocial manner consideration will be given to one or more of the
following actions:




The matter may be reported to the Police with a view to this health body supporting a criminal
prosecution by the Crown Prosecution Service.
The matter may be reported to the NHS Security Management Service’s Legal Protection Unit with
a view to this health body supporting criminal or civil proceedings or other sanctions. Any legal
costs will be sought from you.
Consideration may be given to obtaining civil injunctions or an anti-social behaviour order. Any
legal costs will be sought from you.
Alternative arrangements may be made for you to receive your treatment elsewhere and any
hospital transport service currently provided to you may be withdrawn.
I very much hope that none of these sanctions will be necessary and that we may work together with
you in providing you the care that you need.
If you consider that your alleged behaviour has been misrepresented in any way or that this warning
letter is unwarranted please write to our Legal Department who will review this decision in the light of
your account of the incident.
A copy of this letter will be placed on your file for 12 months and a copy has been sent to your General
Practitioner.
Yours sincerely
Page 16 of 22
Appendix 7: Final Written Warning (‘red card’ – to be printed on red paper)
(One copy to be retained in patient notes and one by the manager with the relevant incident form)
Patients full name
Address
Hospital number
Date:
Dear…………………..
I am writing to you concerning an incident that occurred on…………….at…………….
It is alleged that you (used threatening behaviour / language etc – insert as reported). Behaviour such
as this is unacceptable and will not be tolerated. Homerton Hospital NHS Foundation Trust is firmly of
the view that all those who work in order to provide services to the NHS have the right to do so without
fear of violence or abuse.
I note that this is not the first time you have behaved in such a manner and you received a warning
letter on (date)………………….outlining expected standards of behaviour.
Homerton is very committed to supporting staff against threatening behaviour and will support staff in
bringing about criminal prosecutions wherever possible.
I must inform you that should there be just one further report of unacceptable behaviour I will take
steps to exclude you from Trust premises. In that event I will make alternative arrangements to ensure
you are able to receive medical treatment where necessary. However I will also inform your GP, the
Primary Care Trust and the Health Authority of our concerns and any care provided may be subject to
conditions set by the alternative hospital or health centre.
A copy of this letter will be placed on your file for 12 months and a copy has been sent to your General
Practitioner.
Yours sincerely
Chief Executive
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Appendix 8: Local sanctions and involving the police
Local Sanctions
This option may come through discussion with the patient / visitor and consideration of the specific
circumstances. For example if a member of family is seriously ill escorted visits may be arranged so
that staff feel safe and supported.
If a person has been red carded / excluded from the Trust but is admitted for emergency treatment
under our duty to care a discussion will take place between clinicians and security staff for the best
way to manage any potential situations – and ensure staff feel safe and able to undertake their work
without fear.
Involving the Police
Any member of the public has a right to call the Police if they feel they need their assistance – and
Trust staff have that right too.
However, the Trust STAT team provide immediate assistance and support and will act as the liaison
should Police services need to be involved. This
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Appendix 9: Equalities Impact Assessment
This checklist should be completed for all new Corporate Policies and procedures to understand their
potential impact on equalities and assure equality in service delivery and employment.
Directorate:
Policy for the management of patients & visitors who
are abusive, aggressive or threatening
Cliff Hammond-Reid
Deputy Director of Environment
Environment
Date
22nd June 2010
Policy/Service
Name:
Author:
Role:
Equalities Impact Assessment
Question
Yes
No
Comment
1. How does the attached
policy/service fit into the trusts
overall aims?
The policy reflects on the duty of the Trust to
risk assess the safety of it staff and to provide a
safe environment
2. How will the policy/service be
implemented?
Following approval the policy will be published
to the intranet as well as being publicised to
managers via the Trusts LSMS
3. What outcomes are intended by
implementing the policy/delivering
the service?
A safe work environment
4. How will the above outcomes be
measured?
As part of the Trusts annual security
management assessment, reduction in reports
of violence & aggression & staff awareness of
policy
5. Who are they key stakeholders in
respect of this policy/service and
how have they been involved?
6. Does this policy/service impact
on other policies or services and
is that impact understood?
7. Does this policy/service impact
on other agencies and is that
impact understood?
8. Is there any data on the policy or
service that will help inform the
EqIA?
9. Are there are information gaps,
and how will they be
addressed/what additional
information is required?
All Trust staff. Draft policy sent for comment
X
X
X
X
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Equalities Impact Assessment
Question
Yes
No
10. Does the policy or service
development have an adverse
impact on any particular group?
X
11. Could the way the policy is
carried out have an adverse
impact on equality of opportunity
or good relations between
different groups?
X
12. Where an adverse impact has
been identified can changes be
made to minimise it?
Comment
None identified
13. Is the policy directly or indirectly
discriminatory, and can the latter
be justified?
X
14. Is the policy intended to increase
equality of opportunity by
permitting Positive Action or
Reasonable Adjustment? If so is
this lawful?
X
EQUALITIES IMPACT ASSESSMENT
FOR POLICIES AND PROCEDURES
2.
If any of the questions are answered ‘yes’, then the proposed policy is likely to be relevant to
the Trust’s responsibilities under the equalities duties. Please provide the ratifying committee
with information on why ‘yes’ answers were given and whether or not this is justifiable for
clinical reasons. The author should consult with the Director of HR & Environment to develop
a more detailed assessment of the Policy’s impact and, where appropriate, design monitoring
and reporting systems if there is any uncertainty.
3.
A copy of the completed form should be submitted to the ratifying committee when submitting
the document for ratification. The Committee will inform you if they perceive the Impact to be
sufficient that a more detailed assessment is required. In this instance, the result of this impact
assessment and any further work should be summarised in the body of the Policy and support
will be given to ensure that the policy promotes equality.
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Appendix 10: Policy Submission Form
To be completed and attached to any policy or procedure submitted to the Trust Policy Group
1
1.1
Details of policy
Title of Policy:
1.2
Lead Executive Director
1.3
Author/Title
1.4
Lead Sub Committee
1.5
Reason for Policy
1.6
Who does policy affect?
1.7
Are national guidelines/codes of
practice incorporated?
Has an Equality Impact
Assessment been carried out?
Information Collation
Where was Policy information
obtained from?
1.8
2
2.1
Policy for the management of patients &
visitors who are abusive, aggressive or
threatening
Andrew Panniker
Cliff Hammond-Reed, Deputy Director of
Environment
Health and Safety
Process to be adopted by staff in the
management of patients or visitors who
become violent or aggressive
All staff
Yes
Yes
NHS Counter Fraud and Security
Management Service, Report from the
Comptroller and Auditor General & previous
Trust policy
3
3.1
Policy Management
Is there a requirement for a new or
revised management structure if
the policy is implemented?
3.2
If YES attach a copy to this form
N/A
3.3
If NO explain why
Process already in place and no requirement
to change based upon policy review
4
4.1
Consultation Process
Was there internal/external
consultation?
4.2
List groups/Persons involved
4.3
Have internal/external comments
been duly considered?
No
Yes
Board Directors & Deputies, LSMS, CSMs,
Senior Nurses, General Managers, Lead
Nurses, JSCC
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