Rights at risk staff manual final version
Rights at Risk
Shared Rights,
Risk and
Recovery
Assessment and
Plan
STAFF MANUAL
Rights at risk staff manual amendments V1 7.2.15
Authors
Christy Laganis (Trainee Clinical Psychologist, University of Liverpool/Mersey Care NHS Trust)
Claire Dowling (Assistant Psychologist, Mersey Care NHS Trust)
Bethan Roberts (Trainee Clinical Psychologist, University of Lancaster)
Sophie Howes (Senior Human Rights Officer, British Institute of Human Rights)
Dr Sarah Butchard (Clinical Psychologist, Mersey Care NHS Trust)
Dr Beth Greenhill (Senior Clinical Tutor/ Clinical Psychologist, University of Liverpool/Mersey Care
NHS Trust)
Acknowledgements
The authors would like to thank Professor Richard Whittington, Professor John Read, Dr Caroline
Logan, Dr James Riley, Dr Sarah Hamner and Vikki Harrison for their helpful comments and feedback
during the development of this resource. We would also like to thank the staff and service users
from Mersey Care NHS Trust who have been involved in developing and piloting this resource.
We would like to acknowledge the input into this element of the project made by Lyndsey Holt,
Khowla Jomar, Emma Forde and James Dudley who were part of the overall project team and all
those who took part in the steering groups. We would also like to thank Richard Whitehead for the
support shown by him to the authors throughout the project.
We would like to know your views on how this resource can be improved and further developed. To
give feedback, or to get involved in further piloting work or adaptation please contact Beth Greenhill
at [email protected]
© <2015> Equality and Human Rights Commission. All rights reserved. This material may be copied
for use within Higher Education Institutions on the understanding that the authors and the
University of Liverpool are acknowledged as the developer of the material on all copies, that this
copyright statement is retained and that the intellectual property rights of the authors and of the
Equality and Human Rights Commission are acknowledged.
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Contents
Contents ................................................................................................................................. 2
Introduction ........................................................................................................................... 5
References ............................................................................................................................. 6
Who is this guide for? ............................................................................................................ 7
How to use this guide ............................................................................................................ 7
Rights.......................................................................................................................................... 8
Why take a human rights based approach? .......................................................................... 8
Human rights and the law: The Human Rights Act ................................................................ 9
International and European human rights law .................................................................. 9
The Human Rights Act........................................................................................................ 9
Key rights in the Human Rights Act in health and social care ............................................... 9
Article 2: The right to life ................................................................................................... 9
Article 3: The right to be free from torture and inhuman or degrading treatment ........ 10
Article 5: The right to liberty ............................................................................................ 10
Article 8: The right to family life, private life, home and correspondence. .................... 10
Article 14: The right not to be discriminated against in relation to any of the rights
contained in the European Convention. .......................................................................... 10
The FREDA principles ........................................................................................................... 10
A human rights based approach .......................................................................................... 11
The Mental Health Act and the Mental Capacity Act .......................................................... 11
Mental Health Act .......................................................................................................... 12
The Mental Capacity Act ................................................................................................. 12
Human rights and Positive Behaviour Support .................................................................... 13
References ........................................................................................................................... 15
Risk ........................................................................................................................................... 17
Risk in mental health services .............................................................................................. 17
Existing approaches to risk assessment: Static and dynamic risk ....................................... 17
Best practice in managing risk ............................................................................................. 18
Box 1: The 16 Best Practice in Managing Risk Principles ........ Error! Bookmark not defined.
Positive Risk Management ................................................................................................... 19
Box 2: What is positive risk management? .......................................................................... 19
Risk sharing partnerships ..................................................................................................... 20
Risk formulation ................................................................................................................... 20
Protective factors and coping strategies ............................................................................. 21
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Care programme approach to risk assessment ................................................................... 21
References ........................................................................................................................... 23
How to complete the Rights at risk: Shared rights, risk and recovery plan ............................ 24
Why have we done it the way we have? ............................................................................. 24
Positive Risk Management ...................................................... Error! Bookmark not defined.
Ownership of Risk ................................................................... Error! Bookmark not defined.
Relationships ........................................................................... Error! Bookmark not defined.
Criminality and Mental Health ................................................ Error! Bookmark not defined.
Providing a rationale for the questions we ask ...................... Error! Bookmark not defined.
Literacy in the General Population ......................................... Error! Bookmark not defined.
Guidance notes .................................................................................................................... 25
Facilitating Service User Involvement.................................................................................. 25
Where to obtain the information from?.......................................................................... 26
Assessing risk: Likelihood and Severity ............................................................................ 28
2.3 Completing the risk assessment ................................................................................ 30
2.4 Recording and worked example ................................................................................ 31
Risks Areas: Questions, prompts and human rights involved ................................................. 33
Section 1: Advanced Statement ............................................................................................... 33
Section 2: Risks to self .............................................................................................................. 34
Please turn to ‘Section 2: Risks to self’ in the shared information booklet .................... 34
1) Physical health ................................................................................................................. 34
2) Taking medication............................................................................................................ 36
3) Mental Health .................................................................................................................. 38
4) Self-neglect (not looking after myself) ............................................................................ 40
5) Self-harm (Hurting or harming myself)............................................................................ 42
6) Suicide .............................................................................................................................. 44
7) Engagement (Not wanting help from services) ............................................................... 47
Rationale: ......................................................................................................................... 47
8) Alcohol/Substance misuse ............................................................................................... 49
9) Transport
(private) ..................................................................................................... 51
10) Safety at home ............................................................................................................... 52
Section 3: Risks to others ......................................................................................................... 54
1) People you Care for: Dependants and Children .............................................................. 54
2) Verbal aggression/ Intimidation ...................................................................................... 56
3) Physical violence (no weapons) ....................................................................................... 58
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4) Physical Violence (weapons)............................................... Error! Bookmark not defined.
5) Sexually inappropriate behaviour.................................................................................... 60
6) Criminal or Antisocial acts ............................................................................................... 61
7) Arson (Starting Fires) ....................................................................................................... 63
8) Difficulties with relationships ............................................. Error! Bookmark not defined.
Section 4: Risk from others ...................................................................................................... 65
1) Discrimination ............................................................................................................... 65
2) Physical abuse by others ............................................................................................... 67
3) Sexual abuse by others .................................................................................................... 69
4) Financial abuse by others ............................................................................................. 71
5) Emotional abuse by others ........................................................................................... 72
Section 5) Protective factors and coping strategies ................................................................ 73
1) Protective factors .......................................................................................................... 73
2) Coping Strategies .......................................................................................................... 74
Section 6: Human rights based formulation: ........................................................................... 77
Section 7: Shared rights, risk and recovery plan...................................................................... 80
Appendix A ............................................................................................................................... 81
Box 1: The 16 Best Practice in Managing Risk Principles ..................................................... 81
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Introduction
A family of progressive approaches, inspired by service user movements, is leading a
paradigm shift in mental health services. Recovery, rights, person-centred planning, Positive
Behaviour Support and service user involvement are changing services for the better.
However, the influence of these ideas is often missing from risk assessment and
management.
Service users often feel their perspectives are excluded from risk assessment and
management (1, 2) and that risk processes are an obstacle to recovery (3). Although human
rights principles inform the Care Quality Commission’s (4) evaluation of mental health
services, and positive risk management advocates have created risk alliances between
service users and staff (5, 6), there is little to practically guide the clinician who wants to
adopt an empowering, relational and collaborative approach to risk.
‘Rights at risk’ is a practical toolkit for developing risk sharing alliances using a human rights
based approach to risk. ‘Rights at risk’ maximises service user participation in the risk
assessment and management process. ‘Rights at risk’ aims to balance the human rights of
service users, their carers, and members of their communities; so risk can be managed more
positively. Using a human rights based approach allows ‘Rights at risk’ to integrate complex
legal and policy drivers, including the Mental Health Act, the Mental Capacity Act and recent
government recommendations on using Positive Behaviour Support to reduce restraint and
restrictive practice (7).
The approach to risk outlined here has been adopted for a number of years in learning
disability services through the ‘Keeping Me Safe and Well Risk Assessment’ (8). We are now
applying our learning to mental health services. Bringing human rights to life in risk
assessment is a work in progress, but one in which we hope this risk sharing plan and guide
will be a significant milestone.
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Quick Summary:
• Rights rarely feature in planning and assessment around risk.
• A rights based approach balances the human rights of service
users, their
carers, and members of their communities; so risk can be managed more
positively.
•
The approach to risk outlined here has been adopted for a number of years in
learning disability services.
•
This risk sharing plan and guide aims to help keep rights at the forefront of
thinking about risk.
References
1. Sheldon, K. (2011). Service User’s Experiences of Risk and Risk Management. In R.
Whittington, & C. Logan, (Eds.) Self-harm and violence: Towards best practice in
managing risk in mental health services (p. 11-34). London: Wiley.
2. Langan, J. & Lindow, V. (2004). Living with risk: Mental health service user involvement in
risk assessment and management. Bristol: Policy Press.
3. Boardman, J. & Roberts, G. (2009). Risk, Safety and Recovery. ImRoc briefing paper.
Retrieved from: http://www.centreformentalhealth.org.uk/pdfs/ImROC-Briefing-RiskSafety-and-Recovery.pdf. [Accessed 4 Jan 2015].
4. Care Quality Commission. (2014). Human rights approach for our regulation of health
and social care services. Retrieved from:
http://www.cqc.org.uk/sites/default/files/20140925_our_human_rights_approach_final
.pdf. [Accessed 4 Jan 2015].
5. 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: Department of Health.
6. Whittington, R. & Logan, C. (2011). Self-Harm and Violence: Towards Best Practice in
Managing Risk in Mental Health Services. London: Wiley.
7. Department of Health. (2014). Positive and proactive care: Reducing the need for
restrictive interventions. London: The Stationary Office.
8. Lee, A., Kaur K., Cookson, A. & Greenhill, B. (2008). The Keeping Me Safe and Well Screen
(KMSAW), 2nd edn. Equality & Human Rights Commission. Available from
https://www.ewin.nhs.uk/resources/item/477/keeping-me-safe-and-well-kmsawscreen . [Accessed 27 February 2015].
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Who is this guide for?
This guide is for use by appropriately qualified mental health professionals who want to
create risk sharing alliances with service users. Appropriately qualified in this instance refers
to any healthcare professional registered with the Health and Care Professions Council,
Nursing and Midwifery Council, or General Medical Council and tasked with assessing
clinical risk as part of their professional role.
The use of this guide is not limited to any particular setting, for example inpatient or
community.
How to use this guide
This staff manual provides professionals with background information about why human
rights based approaches are integral to exploring risk issues. It then provides guidance on
how to conduct a risk assessment jointly with a service user. The manual consists of three
main sections. The first section, ‘Rights’, outlines the human rights background to the staff
manual. The second section ‘Risk’, explains key concepts and best practice in risk
assessment and management. The third section, the practical guidance, describes how to
complete the ‘Rights at risk’ shared rights, risk and recovery plan before detailing questions,
prompts and human rights involved in each of the risk areas.
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Rights
In this section we explain the basic ideas of a human rights based approach. We argue
that a human rights approach to risk has a number of advantages. We describe the Human
Rights Act (HRA) and the underlying principles and values it expresses. We also explain
how the Human Rights Act fits with key legislation in mental health services such as the
Mental Health Act and the Mental Capacity Act. Finally, we consider how human rights
approaches can be seen as integral to Positive Behaviour Support.
Why take a human rights based approach?
There are many good reasons to adopt a human rights based approach to risk.
Human rights based approaches can provide a robust and unifying framework for the
disparate strands of policy and law which are relevant to risk assessment (1). In the UK, new
legislation, including mental health law, must be compatible with the European Convention
on Human Rights, unless a declaration of incompatibility is made. This is because of the
Human Rights Act. Many of the policies in mental health services are informed by the
human rights principles enshrined in the Human Rights Act. The statutory weight of human
rights can strengthen person-centered approaches to risk, which are often the first casualty
of competing agendas such as risk management or time and financial pressures (2).
The legal duties on and regulation of the National Health Service (NHS) also suggest human
rights should be included in risk processes. Under section 6 of the Human Rights Act, it is
unlawful for a public authority, like the NHS, to act incompatibly with an ECHR right (unless
required to do so by primary legislation). Under section 7, anyone whose rights have been
violated can bring proceedings against the public authority.
Public authorities not only have to refrain from breaching human rights (‘negative’
obligations) but also, in certain well-defined circumstances, have to take preventative steps
to secure people’s human rights, even if the threat is from a private party and not the
authority itself (‘positive’ obligations). This is because of the Human Rights Act. The health
care regulator, the Care Quality Commission (CQC), views respecting diversity, promoting
equality and ensuring human rights as a key means of securing quality services for service
users and has developed a human rights approach to the regulation of care services (3).
There is also an economic case for human rights based approaches. Human rights
approaches emphasise a preventative, proactive, approach which is usually cheaper than
more restrictive and invasive practice. For example, responding to a service user’s
‘behaviours which challenge’ at home in their local community with a positive behaviour
support approach involving family and carers is far less expensive than removing the person
to an ‘out of area’ placement, such as Winterbourne View, which can cost in the region of
£180,000 per year (4).
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Human rights and the law:
Human rights in the UK can be defined in law at three levels; internationally, at European
level, and within UK law.
International and European human rights law
Although other international human rights law is relevant to UK health care practices, for
example the UN Convention on The Rights of Person with Disabilities, the most accessible
and relevant for the UK context is the ECHR (5). The ECHR also has the greatest legal force,
because of the Human Rights Act.
The Human Rights Act
The Human Rights Act (1998) incorporated into UK law most of the rights detailed in the
ECHR and, as such, is the main legal source of human rights protection in the UK.
Table 1: Articles of the European Convention on Human Rights (ECHR)
The rights of the ECHR included in the Human Rights Act (1998) are:
Article 2: The right to life
Article 3: The right not to be tortured or treated in an inhuman or degrading way
Article 4: The right to be free from slavery or forced labour
Article 5: The right to liberty
Article 6: The right to a fair trial
Article 7: The right to no punishment without law
Article 8: The right to respect for private and family life, home and correspondence
Article 9: The right to freedom of thought, conscience and religion
Article 10: The right to freedom of expression
Article 11: The right to freedom of assembly and association
Article 12: The right to marry and found a family
Article 14: The right not to be discriminated against in relation to any of the rights
contained in the ECHR.
Article 1 Protocol 1: The right to peaceful enjoyment of possessions
Article 2 Protocol 1: The right to education
Article 3 Protocol 1: The right to free elections
Protocol 6: Abolition of the death penalty
Key rights listed in the Human Rights Act relevant to health and social care
The human rights articles which are most often engaged in health and social care are
discussed below.
Article 2: The right to life
Article 2 protects the right to life. It places both a negative duty on the state not to take life
and a positive duty, in some circumstances, to actively protect life. An example of the
positive duty to protect life might be where you aware of a person under your care who has
expressed suicidal thoughts or behaviours, or somebody who is experiencing life
threatening neglect or abuse. Article 2 also includes a duty to carry out an effective and
independent investigation into a death in which the state is implicated.
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Article 3: The right to be free from torture and inhuman or degrading treatment
Treatment must cause serious harm to a person to be classed as inhuman or degrading.
There is a negative duty on the state not to treat someone like this, and a positive duty to
take action where this right might be at risk. There is also a duty to carry out an
investigation into allegations that this right has been breached. Abuse, neglect, or poor
treatment in a health and social care setting may place this right at risk.
Article 5: The right to liberty
Article 5 protects the right to liberty. This is not a right to be free to do whatever you want;
it protects you against extreme restrictions being placed on your movement. This right can
only be restricted in very specific circumstances as set out in Article 5, for example to keep
someone safe, or to protect the rights of others. Any restrictions to someone’s right to
liberty must comply with the safeguards, listed in Article 5. These safeguards form the basis
of the Mental Health Act and the Mental Capacity Act.
Article 8: The right to family life, private life, home and correspondence
Family life: The right to develop ‘ordinary’ family relationships and the right to on-going
contact when the family is split up.
Private life: The right to psychological and physical integrity. This means having control
over your own body and life. Consent and dignity are an important part of this right,
including the right to participate in important decisions about care and treatment.
Home: Respect for the home you already have, whether this is the house you own or
another place you call home (e.g. a care home or hospital ward).
Correspondence: Uninterrupted, uncensored communication with others.
Article 8 (2) - Article 8 is a 'qualified' right. This means that the state can interfere in the
right to respect for private and family life, home and correspondence, but only in certain
circumstances. The interference must be for one of the legitimate reasons set out in Article
8 itself, there must be a law that allows the restriction, and the action must be necessary –
that is, responding to a pressing social need - and proportionate to achieving this aim.
Article 14: The right not to be discriminated against in relation to any of the rights
contained in the ECHR
This is not a stand-alone right not to be discriminated against. It is a right not to be
discriminated against in relation to any of the other rights in the ECHR, unless the
discrimination can be objectively and reasonably justified. This prohibition on discrimination
is not restricted to specific grounds; the list is open-ended and so Article 14 can be used to
challenge discrimination on a wide range of grounds.
For example, somebody in hospital who is prevented from seeing their family because of
mental health problems may argue that their right to family life is not being protected
because they are being discriminated against as a person with a mental health problem.
The FREDA principles
The human rights listed in the Human Rights Act can be understood through the FREDA
principles (5). The FREDA principles are not in and of themselves law, but are the values
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which run through all human rights and are at the heart of high quality health and social
care. The CQC use the FREDA principles as an accessible way of making rights meaningful
(3). Box 1 outlines the FREDA Principles.
Box 1: FREDA principles
Value
Fairness
Respect
Equality
Dignity
Autonomy
Examples of human rights that reflect each of these values
 Right to fair trial
 Fairness is also protected by the 'procedural obligations'
under the right to respect for family and private life,
home and correspondence
 Right to respect for family and private life, home and
correspondence
 Right not to be discriminated against in the enjoyment
of other human rights
 Right not to be tortured or treated in an inhuman or
degrading way
 Right to respect for family and private life, home and
correspondence
 Right to respect for private life
A human rights based approach
‘Human Rights in Healthcare’ (5) outlines a human rights based approach to service delivery.
The human rights based approach is particularly useful for considering changes to or
assessments of service delivery as it provides service standards and a guide to good
processes. The principles underlying a human rights based approach have been called the
‘PANEL’ principles (6). Table two below outlines the PANEL principles, as defined by the
British Institute of Human Rights (6). We have used the PANEL principles to guide the
approach we take to risk assessment in the staff manual.
Table 2: The PANEL Principles for applying a human rights based approach.
Principle
Participation
Accountability
Non-discrimination
Empowerment
Legality
Definition
Enabling meaningful participation of all key people and stakeholders
Ensuring clear accountability, identifying who has legal duties and
practical responsibility for a human rights approach
Discrimination avoided, attention paid to groups made vulnerable
Empowerment of staff and service users with knowledge, skills and
commitment to realising human rights
Expressly applying human rights laws, particularly the Human Rights
Act
The Mental Health Act and the Mental Capacity Act
The Mental Capacity Act (2005) and Mental Health Act (1983, amended 2007) are strongly
informed by the Human Rights Act.
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Mental Health Act
The revised code of practice for the Mental Health Act (7) draws on the ECHR rights listed in
the Human Rights Act for its guiding principles. The guiding principles (table three below)
are highly congruent with the values of the Human Rights Act. The revised code of practice
contains adapted statutory guidance including a chapter on human rights, equality and
health inequalities. The Mental Health Act outlines the duty to comply with the Human
Rights Act and to ensure the human rights of all service users are safeguarded.
Table 3: Description of Guiding Principles of the Mental Health Act
Principle of the Mental Health
Description
Act
Least restrictive option and Where it is possible to treat a service user safely and
maximising independence
lawfully without detaining them under the Act, the service
user should not be detained. Wherever possible, a service
user’s independence should be encouraged and supported
with a focus on promoting recovery wherever possible.
Empowerment and
Service users should be fully involved in decisions about
involvement
care, support and treatment. The views of families, carers
and others, if appropriate, should be fully considered when
taking decisions. Where decisions are taken which are
contradictory to views expressed, professionals should
explain the reasons for this.
Respect and dignity
Service users, their families and carers should be treated
with respect and dignity and listened to by professionals.
Purpose and effectiveness
Decisions about care and treatment should be appropriate
to the service user, with clear therapeutic aims, promote
recovery and should be performed to current national
guidelines and/or current, available best practice
guidelines.
Efficiency and equity
Providers, commissioners and other relevant organisations
should work together to ensure that the quality of
commissioning and provision of mental healthcare services
are of high quality and are given equal priority to physical
health and social care services. All relevant services should
work together to facilitate timely, safe and supportive
discharge from detention.
The Mental Capacity Act
The Mental Capacity Act (2005) provides a framework for decision-making involving people
who have not got the mental capacity to make their own decisions. The Mental Capacity Act
is designed to be fully compliant with the Human Rights Act. The Mental Capacity Act takes
a similar approach to the Mental Health Act (1983) in outlining five guiding principles (table
four) to guide clinicians (8).
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Table 4: Guiding Principles of the Mental Capacity Act
Principle of the Mental Capacity Act
A presumption of capacity
Description
Every adult (aged over 16) 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 in respect of each
specific decision.
Individuals must be supported to make A person must be given all practicable help
their own decisions:
before any anyone treats them as not being
able to make their own decisions.
Unwise decisions
Just because an individual makes a decision
others may consider to be unwise, they
should not be treated as lacking capacity to
make that decision
Best interests
An act done or decision made under the Act
for or on behalf of a person who lacks
capacity must be done in that person’s best
interests
Least restrictive option
A person doing anything for or on behalf of a
person who lacks capacity should consider
options that are less restrictive of their basic
rights and freedoms while meeting the
identified need.
(Sourced from NHS England, 2014)
Deprivation of Liberty Safeguards (DoLS)
Following the findings of the ‘Bournewood judgement’ (9,10), the Mental Capacity Act was
amended in 2009 to include the DoLS. In the ‘Bournewood judgement’ a man was judged to
have been unlawfully deprived of his liberty in breach of article 5 of the ECHR when he had
been informally admitted to a psychiatric hospital without being able to give consent. These
amendments created procedures to ensure the Mental Capacity Act is observed when
adults are being, or are potentially being, deprived of their liberty in care homes or
hospitals. Again, the DoLs resonate strongly with the rights protected by the Human Rights
Act.
Human rights and Positive Behaviour Support
Positive Behaviour Support is an approach which “blends values about the rights of
people…with a practical science about how learning and behaviour change occur” (11, p.
97). As such it fits well with a human rights based approach (12).
Positive Behaviour Support is a technique for supporting and managing a person’s behaviour
in the long-term (13). Positive Behaviour Support focuses on understanding why people may
express their feelings through difficult or ‘challenging’ behaviour. It tries to understand and
address the underlying issues for a person to prevent their behaviours that challenge us.
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Positive Behaviour Support uses positive, person-centred methods to reinforce and teach
the person new behaviours and to improve the person’s quality of life. Box 4 outlines the
principles of Positive Behaviour Support.
The PANEL framework is used in the ‘Positive and Proactive’ guidance on how to use
Positive behaviour support to help reduce restrictive practice (14). ‘Positive and Proactive’
states that management plans should be a collaboratively developed between service-users,
their carers and services. They should also acknowledge service user’s strengths and embed
a positive risk management approach within the culture of services.
Box 4: The principles of Positive Behaviour Support (13)
Positive Behaviour Support is about:
• A person-centred and value led approach.
• Behaviour as having meaning.
• The understanding of behaviour in leading to change.
• Predicting behaviour in reducing its likelihood.
• Focusing on the elimination of problems by helping to establish new behaviours or
skills; or by re-establishing those which have been lost or distorted.
• Improvements to quality of life
Box 5 below is a re-production of how the PANEL principles apply to Positive Behaviour
Support as explained in ‘Positive and Proactive’.
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Box 5: Application of the PANEL principles to Positive Behaviour Support
References
1. Greenhill, B. & Whitehead, R. (2011). Promoting Service User Inclusion in Risk
Assessment and Management: A Pilot Project Developing a human rights based
approach. British Journal of Learning Disabilities, 39 (4), 277–83.
2. Mansell, J. & Beadle-Brown, J. (2005). Historical Overview and a critical appraisal of
Person-Centred Planning. In: Cambridge P, Carnaby S. (Eds). Person Centred Planning
and Care Management for People with Learning Disabilities. London: Jessica Kingsley.
3. Care Quality Commission. (2014). Human rights approach for our regulation of health
and social care services. Retrieved from:
[http://www.cqc.org.uk/sites/default/files/20140925_our_human_rights_approach_fina
l.pdf]. [Accessed 6 Jan 2015].
4. Department of Health. (2012). Transforming care: A national response to Winterbourne
View hospital. Department of health review: Final report. London: The Stationary Office.
Retrieved from
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/21321
5/final-report.pdf. [Accessed 28 February 2015].
5. Equality and human rights group. (2008). Human rights in healthcare: A framework for
local action (2nd Edition). London: Department of Health. Retrieved from:
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od_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_088972
.pdf. . [Accessed 6 Jan 2015].
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6. British Institute of Human Rights. (2013). The difference it makes: Putting human rights
at the heart of health and social care. Retrieved from: www.bihr.org.uk. [Accessed 25
January 2014].
7. Department of Health. (2015). Mental Health Act 1983: Code of practice. London:
Department of Health. Retrieved from
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/39691
8/Code_of_Practice.pdf. [Accessed 1 May 2015].
8. NHS England. (2014). Mental Capacity Act 2005: A guide for clinical commissioning
groups and other commissioners of healthcare services on commissioning for
compliance. London: NHS England. [Retrieved from http://www.england.nhs.uk/wpcontent/uploads/2014/09/guide-for-clinical-commissioning.pdf.
9. R (L) v Bournewood Community and Mental Health NHS Trust (1998) UKHL 24
10. HL v UK 45508/99 (2004) ECHR 471
11. Horner, R.H. (2000). Positive behaviour supports. Focus on Autism and Other
Developmental Disabilities, 15 (2): 97–105.
12. Bailey, S., Ridley, J., Greenhill, B. (2010) Challenging behaviour: A human rights based
approach. Advances in Mental Health and Intellectual Disabilities, 4 (2), p. 20-26.
13. Allen, D., James, W., Evans, J., Hawkins, S. & Jenkins, R. (2005). ‘Positive Behaviour
Support: Definition, current status and future directions’, Tizard Learning Disability
Review, 10 (2), 4–11.
14. Department of Health. (2014). Positive and Proactive Care: Reducing the need for
restrictive interventions. London: The Stationary Office.
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Risk
In this section, we explore the role of risk assessment and management in mental health
services. We discuss existing approaches towards risk assessment and consider the
influence of static and dynamic risk factors. We explain how positive risk management is
part of developing risk sharing alliances. We outline the key features of positive risk
management, the importance of protective factors, coping strategies and discuss risk
formulation. Finally, we place risk assessment in the context of the Care Programme
Approach.
Risk in mental health services
Mental health difficulties and risk have a complex relationship. Stigma and stereotypes can
create a focus on how mental health issues ‘cause’ people to pose risks to themselves or
others. However, people with mental health difficulties may often be more vulnerable to
harm from, rather than to, others (1). In recognition of this complexity, a core function of
mental health services has been to minimise harm to service-users and others and more
recently, to promote recovery. Consequently, risk assessment and risk management have
been routinely embedded in the practice of mental health services.
Mental health practitioners and their employers face the uncertainties associated with risk
assessment and management on a daily basis; the ‘duty of care’ and ‘dignity of risk’ must be
carefully balanced. Managing this tension can create anxiety and stress. For some
practitioners, this may translate into risk avoidance and a defensive risk practice which
focuses on protecting the practitioner and the organisation. Service users have considered
defensive risk management to be a consequence of the blame culture within the NHS (1).
Staff reported that helpful factors in positive risk management included developing a good
relationship with the service-user and acknowledging their strengths with consideration of
the context in which risks arise (1). Overly restrictive practice may violate the service user’s
human rights, limit their opportunities for recovery and creates negative experiences of
mental health services.
Existing approaches to risk assessment: Static and dynamic risk
Risk assessments are used to make predictions about a person’s behaviour about ‘risk’
factors, usually based on historical incidents of risk behaviour (2). Many risk assessments
focus on unchangeable, statistical risk factors, known as ‘static risks’ (3). Static risks include
gender, religious beliefs, sexuality and historical incidents of risk. These risk factors will not
change depending on other mediating variables; for example, fluctuations in mental health
(4). Static risk assessments can reinforce explicit and implicit attitudes towards individuals
with mental health problems or towards particular minority groups. This has obvious human
rights implications. For example, exploring a young Black and Minority Ethnic (BME) male
service user’s risk of violence without considering any situational factors (i.e. environment)
may reinforce the beliefs about young BME men as a group (4). Risk assessments which
focus only on static risk predictors can create the illusion that the risk is chronic and
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irreversible (4). Overemphasising risk factors can lead professionals to hold negative beliefs
about the person and result in stigmatisation (4).
Although it is important to be aware of static risk factors, the narrow focus of many risk
assessments can underestimate the importance of protective factors, coping strategies and
mediating and moderating effects in managing risk (5). Collaboratively exploring protective
factors can enable practitioners and service users to manage risk in a way that is least
restrictive and proportionate to the risk posed, in keeping with a human rights based
approach. For example, a good relationship with a close friend could decrease the likelihood
of a person hurting themselves or others. A balanced consideration of risk factors and
mediating protective factors can benefit both the individual and the professional (6).
A dynamic approach involves acknowledging the interactive process between the
professional, the service user and their interpretations of the world around them. Dynamic
risk factors are factors which change over time, for example use of alcohol or drugs (7).
Dynamic risk factors can be aspects of the individual or factors relating to their environment
or social context. For example, if a person does not want to engage with mental health
services they may build trust in professionals over time, this means this risk will change and
become easier to manage. Some dynamic risk factors may be a stable feature of somebody’s
life which change slowly over time i.e. use of alcohol. A collaborative approach to risk
assessment helps practitioners consider dynamic risk factors and develop awareness of how
best to support service users during risky situations.
Best practice in managing risk
‘Best practice in managing risk’ (8) advocates risk sharing partnerships, and promotes many
of the same values which inform the Human Rights Act. Risk assessment and management
are viewed as the joint responsibility of health professionals, the service-user, their carers
and any other agencies involved. Best practice is believed to be founded upon a
collaborative, therapeutic relationship which respects the views of service users and those
involved in the service user’s care. The guidance recognises that risk factors are dynamic
and relational; an interaction between individuals, situations and environments. Risk
formulation is believed to explain the contexts in which risks become triggered and can
subsequently inform risk management. The guidance advocates risk management plans
based on positive risk management principles and which recognise the service user’s
strengths and protective factors.
Appendix A contains a reproduction of the sixteen best practice principles outlined in the
guidance.
Each of the domains outlined in ‘Best practice in managing risk’ will now be discussed in
turn; positive risk management, risk sharing partnerships, risk formulation, protective
factors and coping strategies.
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Positive Risk Management
Positive risk management “emphasises the positive aspects of what can be achieved
through risk management rather than simply the avoidance of undesirable consequences”
(9, p. 206) and fits well with the philosophy of human rights based approaches. Risks are
encountered on a daily basis in all of our lives. It is therefore unreasonable and undesirable
to expect mental health practitioners to eliminate all risks posed to service users and so care
plans will inevitably carry a degree of risk. Providing that clinical judgement is informed by
relevant guidelines, based on the best information available at the time, is clearly
documented and communicated, this will be deemed the best decision at the time
regardless of outcome (8). Box 2 reproduces the principles of positive risk management (8).
Box 2: What is positive risk management?
Positive risk management includes:








working with the service user to identify what is likely to work;
paying attention to the views of carers and others around the service user when
deciding a plan of action;
weighing up the potential benefits and harms of choosing one action over
another;
being willing to take a decision that involves an element of risk because the
potential positive benefits outweigh the risk;
being clear to all involved about the potential benefits and the potential risks;
developing plans and actions that support the positive potentials and priorities
stated by the service user, and minimise the risks to the service user or others;
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; and
using available resources and support to achieve a balance between a focus on
achieving the desired outcomes and minimising the potential harmful outcome.
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Risk sharing partnerships
The principles of positive risk management, the recovery movement, and of a human rights
based approach suggest risk sharing partnerships or alliances in which risk is not ‘done to’ a
person but is explored collaboratively. Therefore, the therapeutic relationship is often at the
heart of effective risk assessment and management. In risk alliances, service users and their
carers are empowered to accept responsibility for their risks, well-being and recovery, as far
as possible. In the spirit of this approach it is important that all parties are open and honest
about the risks which are posed to and by the service-user. A collaborative approach may
involve negotiating disagreements, but this can provide additional clinical information
rather than being seen as problematic if it is openly discussed and clearly recorded. If
disagreement does arise, advocacy services can play an important role. Full engagement is
not always possible and the timing engagement within the process can be key. Collaboration
with the service user should always be considered but if not possible alternatives may be
considered, such as collaborating with family members, advocates or chosen support staff
until it is possible to involve the service user more explicitly.
Risk formulation
Risk formulation “is a way of making sense of the person’s behaviour and of drawing
together all the information in a manageable format” (11, p. 225). Risk formulation bridges
the gap from risk assessment to developing a risk management plan, guided by an
understanding of the service user and the context of risk. Consequently, risk formulation is a
vital process in risk management and contributes to developing person-centred
management plans which have the best chance at minimising risk and contributing towards
achieving positive outcomes. Risk formulation provides a framework showing how and why
identified risks may present again in the future. It also provides hypotheses about which
management strategies may prevent this from occurring. Collaboration with the service user
and their support networks is also vital throughout this process. As such, risk formulation
adheres to the principles of accountability; empowerment and participation which are part
of the human rights based approach (see chapter 2). Box 3 outlines the factors which should
be considered in developing a formulation.
Box 3: Factors to be considered in risk formulations
Risk formulations should consider:




Predisposing factors: These are historical factors which contribute to the
service user’s risk.
Precipitating factors: These are immediate factors or events which have
contributed to the present risk.
Perpetuating factors: These are factors which maintain the risk.
Protective factors: These are factors which contribute to a reduction in risk
or prevent escalation in risks.
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Protective factors and coping strategies
Protective factors are those which alleviate or prevent an escalation in risk and should be
included within a risk formulation. Recognising the service user’s protective factors,
strengths and current coping strategies facilitates a balanced approach towards risk
assessment and management. Focussing on protective factors and coping strategies fits
with a human rights based approach through communicating hope and empowering service
users to recover (7). This focus also contributes to establishing a shared risk alliance with the
service user through outlining how they are mitigating identified risks and contributing to
the risk management strategy, thus promoting responsibility and ownership of risk (9).
Care programme approach to risk assessment
The Care Programme Approach (CPA; 11) offers secondary mental health services a
framework to co-ordinate service user’s care. CPA views risk assessment and management
as part of a holistic assessment to meet the complex needs of service users. CPA includes
supporting the service user to: maintain diverse roles, meet their individual needs to work
towards recovery and wellbeing, ensure that care is personalised and that service-user and
carer involvement is facilitated via a trusting therapeutic relationship (11). The refocused
CPA makes clearer links with risk management, emphasising that risk assessment, crisis,
contingency and risk management are integral to the CPA process and refers to the best
practice guidance set out by the Department of Health (2007) to underpin clinical practice
(8). The principles of positive risk management, risk sharing partnerships, risk formulation,
protective factors and coping strategies are not separate to the CPA but are integral to the
objectives of the CPA, and therefore reflect the values of the human rights based approach
(see chapter 2).
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Quick Summary:
•
Risk assessment and management is a core responsibility in mental health
services.
•
Risk assessments traditionally focus on statistical risk factors known as
‘static risks’ which do not change.
•
Whilst it is important to be aware of static risk factors, focussing too much
on these ignores scope to change and dynamic risk factors.
•
•
Dynamic risk factors are factors which can change over time.
•
Collaborative consideration of both static and dynamic risk factors can
inform management plans to minimise risk whilst also working towards
service users aspirations for recovery.
•
‘Best practice in managing risk’ guidelines emphasise the importance of
risk sharing partnerships and understanding the context in which risk
occurs
•
‘Best practice in managing risk’ guidelines state risk management plans
should use positive risk management principles and recognise service
users’ strengths.
•
Developing risk sharing partnerships during the risk assessment and
management process can empower service users and carers to accept
responsibility of their risks, wellbeing and recovery.
•
Risk formulation aids understanding of a person’s risks and can offer an
explanation why they may occur again. This can help guide a personcentred risk management plan to minimise risks and promote positive
outcomes.
•
Positive risk management aims to balance the risks involved in choosing
one management strategy over another in order to ensure that risks are
minimised but are also aligned with service user’s goals and recovery.
•
Service user’s protective factors and coping strategies should be
considered in the risk assessment and management process because it
offers useful insight into what service users can contribute to the risk
management plan.
•
The care programme approach (CPA) is adopted nationally and views risk
assessment and management as part of a holistic assessment.
•
Positive risk management, risk sharing partnerships, risk formulation, and
protective factors and coping strategies are an integral process of the CPA.
Collaboratively exploring dynamic risk factors with service users will
facilitate consideration of factors which make risk more or less likely.
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References
1. Langan, J., & Lindow, V. (2004). Living with risk: Mental health service user involvement
in risk assessment and management. Bristol: Policy Press.
2. McDermott, B., Edens, J., Quanbeck, C., Busse, D., Scott, C. (2008). Examining the role of
static and dynamic risk factors in the prediction of inpatient violence: Variable and
person focused analyses. Law and Human Behaviour, 32 (4), 325-38.
3. Thornton, D. (2002). Constructing and Testing a Framework for Dynamic Risk
Assessment. Sexual Abuse, 14 (2), 139-53.
4. Rogers, R. (2000). The Uncritical Acceptance of Risk Assessment in Forensic Practice. Law
and Human Behaviour, 24 (5), 595- 605.
5. Heilbrun, K., Philipson, J., Berman, L. & Warren, J. (1999). Risk communication: Clinicians'
reported approaches and perceived values. Journal of the American Academy of
Psychiatry and the Law, 27 (3), 397–406.
6. Lauritsen, J., Sampson, R. & Laub, J. (1991). Link between offending and victimization
among adolescents. Criminology, 29 (2), 265-291.
7. Sullivan, G., Wells, K.B., Morgenstern, H., Leake, B. (1995). Identifying modifiable risk
factors for rehospitalisation: A case-control study of seriously mentally ill persons in
Mississippi. American Journal of Psychiatry, 152 (12), 1749-56.
8. 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: Department of Health.
9. Clifford, P. (2011). Evidence and principles for positive risk management. In: R.
Whittington & C., Logan. (Eds.). Self-Harm and Violence: Towards Best Practice in
Managing Risk in Mental Health Services, 205–14. London: Wiley.
10. Whitehead, R., Carney, G., & Greenhill, B. (2011). Encouraging positive risk
management: Supporting decisions by people with learning disabilities using a human
rights-based approach. In: R. Whittington & C., Logan. (Eds.). Self-Harm and Violence:
Towards Best Practice in Managing Risk in Mental Health Services, p. 215– 36. London:
Wiley.
11. Department of Health. (2008). Refocusing the care programme approach: Policy and
positive practice guidance. London: Department of Health.
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How to complete the Rights at risk: Shared rights, risk
and recovery plan
In this section, we present a summary of the common features of the approaches
described so far. We also provide guidance on the process of completing the shared rights,
risk and recovery plan including risk assessment, a human rights based formulation and on
constructing a risk management plan.
Integrating Rights and Risk
This manual has explored a number of policies and laws which are relevant to risk
assessment and management. Many shared principles and concepts link recovery, the
Mental Health Act, the Mental Capacity Act, positive risk management, Positive Behaviour
Support and human rights. Appendix B contains a detailed mapping of those principles and
concepts. These can be distilled into few central principles;








Including service users in the risk assessment and management processes
Advocating least restrictive and proportionate practice
Valuing service user’s coping strategies, strengths and other resources
Maximising capacity and autonomous decision making
Considering diversity and the impact of stigma
Making risk assessment accessible
Being explicit about human rights
Balancing the human rights of the service user, their carers, their staff and their
community.
Appendix C provides information about the development of the shared rights, risk and
recovery plan.
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Guidance notes
This step-by-step staff risk assessment manual is accompanied by a shared information
booklet for use with the service user. You can find the form for recording your risk
assessment at the end of the shared information booklet. This form includes a:


Record form
Human rights formulation
For each item in the risk assessment manual there is a corresponding section in the
recording form. Assessors should not be constrained by the space available or feel they have
to fill it all. However, there should not be any blank spaces in the final assessment
document. Assessments and plans should be written in plain English, using the language of
the service user where possible and appropriate.
Facilitating Service User Involvement
How much involvement should the service user have?
A human rights based approach to risk means ensuring service users are as involved as they
can possibly be in their own risk assessment process. Whether the service user participates
fully or contributes to a small aspect of their risk assessment, some involvement will almost
always be possible. However, we recognise that when someone with a mental health need
first accesses our service, they might not be able to take part in every aspect of their risk
assessment process. Their ability to engage might be affected in different ways.
Who should complete the risk assessment?
Speaking to the service user to find out who they would like to be involved in their risk
assessment is essential. They may want to complete the screen with their health worker.
They may also want, or indeed choose not to have, input from family members, advocacy
services or chosen support staff.
Is a person able to become actively involved?
A number of elements may be helpful in considering how best to involve the service user in
their ‘Rights at risk’ assessment. These may include thinking about the person’s:
• Psychological state (e.g. is depression, anxiety or active psychosis preventing the person
from engaging with the assessment?)
• Attention span (e.g. how long can the person concentrate for?)
• Engagement (e.g. will the person engage with the assessment?)
• Insight (e.g. if the person has problems with physical violence, do they realise they could
be causing risk to themselves or others?)
• Remorse (e.g. if the person has hurt somebody, do they say sorry and mean it?)
• Suggestibility (e.g. is the person able to say ‘no’ and expect this to be heard or do they feel
as though they have to agree and say ‘yes’?)
Timing can be key when considering at what level the service user can participate in
the ’Rights at risk’ assessment and requires good clinical judgement about what the service
user can tolerate. Where full participation is not possible, the practitioner would be
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expected to work through the ‘Rights at risk’ assessment on the service user’s behalf with
the help of family members, the person’s advocate or chosen support staff. A ‘service user
consultant’, or ‘expert by experience’, could become involved if the person is unable to
participate.
The continuum below (figure one) shows the journey a service user may go on in relation to
their ‘Rights at risk’ assessment. The ‘gold standard’ is for the service user to lead and be
fully involved with the whole process. Although this is the aim, the level of inclusion may
move back and forth along the continuum depending on the presentation of the service
user at any given time and their level of involvement should be regularly reviewed.
Figure 1: Inclusion continuum
Information gathering
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 particular critical events.
Assessors should also reference where they obtained the information, including the date
that applies to each particular source (e.g. “CPA report, October 2013”). The reliability and
comprehensiveness of the information obtained should be considered. Where caution
needs to be exercised in interpreting data this should be clearly stated.
The following, although not an exhaustive list, may provide a useful checklist of sources of
information:

Interviewing the service user

Family members/ partners

Carers/ friends

Previous/ current care staff
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



Psychiatric reports/ clinical records
Probation services
Police services
Court reports and depositions
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Assessing risk: Likelihood and Severity
When assessing risk, consideration of the likelihood of risk occurring and also the severity of
the consequences should be made.
Likelihood
When considering likelihood, only take into account the next 6 months. You should look at
events over the last 6 months to make an estimate of likelihood over the next 6 months.
The scoring for likelihood is as follows:
1. Unlikely
It is unlikely that the risk will happen in the next 6 months.
2. Up to 50% chance
There is up to 50% chance that the risk will occur in the next 6 months.
3. More than 50% chance
There is more than a 50% chance of the risk occurring in the next 6 months.
Severity
When considering severity the scoring is as follows:1. Minor


The risks that the client or others are exposed to are no greater than for the general
population.
Where any harm that results (physical or psychological), it would not require
professional support (e.g. medical, clinical, on-call etc.).
2. Serious



Physical injury to the client or others which would require medical attention (e.g. GP)
Psychological trauma which impinges on the clients or others quality of life and
sense of well-being, and would require professional support.
Behaviour which may lead to breakdown of current place of residence/ placement.
3. Major



Physical injury to the client or others which would require their admission to hospital
(including death).
Psychological trauma to the client or others which would require their admission to
hospital.
Behaviour which would result in criminal prosecution and imprisonment or
sectioning under the Mental Health Act.
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Service users are also asked to rate what they believe the risk is. The scoring system for
service users is:
 “This does not concern me”
 “This concerns me somewhat”
 “This is a big concern for me”.
Scoring
The total score is obtained by multiplying the likelihood score by the severity score, e.g. 2 x
2 = 4. The scores correspond to service user’s rating as follows:
A score of 1 or 2 equates to “This does not concern me”
A score of 3 or 4 equates to “This concerns me somewhat”
A score of 6 and 9 equates to “This is a big concern for me”.
Example: For somebody who has offended with children in the past, but who is now in a
closely supervised package of support, the likelihood of the risk happening might be low (a
score of 1), but the severity of the risk if it were to occur would be major (a score of 3).
Therefore, the combined risk would be 3, or “This concerns me somewhat”.
When is a risk management plan needed?
If a service user scores more than 4 on a risk area, a more detailed risk management plan
may be needed for the identified risk. Your clinical discretion and knowledge may
sometimes inform a decision to develop a management plan where lower levels of risk have
been identified. You may choose to complete a human rights based formulation to
understand the context of the risk and to help produce the shared rights, risk and recovery
plan. Both of these can be found at the back of the shared information booklet.
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Completing the risk assessment
Explaining risk, rights and the scoring system
Please turn to the “Explaining risk, rights and the scoring system” section in the shared
information booklet.
Talk through each of the sections using the shared information booklet:
What is a risk?
What is this plan about?
What are human rights?
What is the scoring system?
What will staff look for?
This will give the service user the opportunity to ask any questions and to fully understand
what the assessment is about.
Identifying Human Rights issues
The human rights which may be relevant to each area of risk are listed under each risk
section. The human rights are listed in order of relevance. Not every right mentioned will
necessarily be relevant but, if listed, should be considered for the person you are working
with and the situation they are describing. The human rights issues have been identified by
taking into account case law, relevant literature and have been reviewed by the British
Institute of Human Rights and the Equality and Human Rights Commission.
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Recording and worked example
Each question in the risk assessment asks you to work with the person to rate their risk
using the scoring system. The manual lists the human rights that could be affected for each
area of risk. Both you and the service user are then asked to consider if any of the human
rights listed have been engaged. If a significant risk is recognised the assessor must record
which human rights may be engaged (see figure two).
Figure two 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.
Figure 2: Example of question on record sheet
Self-harm
Please include details of identified risk
“Jack has hurt himself by cutting his
arm with a razor blade on numerous
occasions over the last 6 months
when he has been upset. This has
resulted in Jack going to A&E on
numerous occasions”
Likelihood
Please score here on the likelihood it will
happen again 1 - 3
3
Severity
Please score here on the severity of
consequences
3
Total
Please multiply the likelihood score by the
severity score
9
Service user rating
Please indicate level of risk by circling the
relevant score
“This does not concern me”
“This concerns me somewhat”
“This is a big concern for me”.
Human rights implication(s
Please indicate which human rights are at
risk of being infringed using the Article
number(s). (Human rights articles are listed
below each question).
“2, 3, 8”
In this example Jack’s self-harm has posed a significant risk for him within the last six
months. He scored 3 for the likelihood that he would have to attend A&E again and a score
of 3 for the severity of consequences.
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Multiplying the likelihood and severity together gave Jack a total score of 9 for self-harm.
Using the human rights which were already listed in the document, both the assessor and
Jack were able to identify that the following human rights may be engaged: Right to life
(Article 2), freedom from inhuman or degrading treatment (Article 3) and right to respect
for private and family life (Article 8).
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Risks Areas: Questions, prompts and human rights
involved
Section 1: Advanced Statement
Rationale:
Advanced statements are documents written when you are feeling well, to help other people to
respect your wishes when you are in crisis. You can let people know how, by whom and in what way
you would like to be supported. You can say if there are medications you prefer to take, for example,
because they have fewer side effects. You can also tell people things you do not want to happen or
people you do not want to be involved. Advanced statements are not necessarily legally binding but
the people involved in your care should normally follow them.
Prompt questions:




Advanced
statement
ICON
Do you have an advanced statement?
Would you like to have an advanced statement?
What are the important things in your advanced statement
which could help to keep you safe and well?
How could your advanced statement help us think about your coping strategies or the
things which help you to feel and stay safe?
Human rights which may be engaged:
Article 8: Right to respect for family and private life: Working in a collaborative way to help
implement a person’s advance statement is likely to help protect and respect service user’s
human rights, in particular their right to respect for private and family life. This way of
working treats service users with respect and dignity and values their autonomy through
asking about their choices and working with them to make these choices a reality where
possible.
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Section 2: Risks to self
Please turn to ‘Section 2: Risks to self’ in the shared information booklet
This section focuses on the risks to the service user.
1) Physical health
Rationale:
Routinely asking about a Service User’s physical health issues can help to provide them with a
holistic package of care and can meet national agendas set up to improve the physical health of
service users with mental health difficulties. People with severe mental health difficulties are more
likely to experience physical health problems and may live for twenty years less than people without
the same difficulties (1). Commissioning for Quality and Innovation (CQUIN) is a payment framework
which aims to improve outcomes in healthcare. CQUIN targets require consideration of physical
health difficulties e.g. likelihood of cardiovascular disease by exploration of known risk factors.
Physical health issues can also affect psychological wellbeing.
Prompt questions:










Do you any health problems?
Do you have diabetes or epilepsy?
Do you have a GP and how frequently do you attend?
When was your last physical health check?
Do you have physical health problems or pain?
Are you on any medication for your physical health?
Do you smoke? Would you like to stop?
Do you exercise regularly?
Do you have a healthy diet?
Do you have a history of health issues?
PHYSICAL
HEALTH ICON
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Human rights
engaged:
which
may
be
Article 8: Right to respect for private and
family life – An untreated physical health
problem could have an impact on the person’s
physical and psychological well-being.
Is the person supported to make informed
choices around medical treatment (e.g.
attending the doctors)? Being able to
participate in decisions that affect your health
and wellbeing is an important part of Article
8.


Does the person have access to
appropriate health care services?
Are reasonable adjustments made for
their mental health difficulties in
accessing health care?
health medication if it is not in their
possession e.g. if somebody needs their
inhaler or insulin, are there enough staff
to ensure the person has access to it as
needed? If not, in some situations this
could risk the right to life.
FREDA principles:
You may also wish to consider the FREDA
principles: Fairness, Respect, Equality,
Dignity, and Autonomy.
Is the person being treated with fairness,
respect, equality, dignity, and autonomy in
relation to their physical health?
Article 14: Freedom from discrimination in
relation to other human rights – eg, has the
person been denied informed choices in
treatment for physical health on the grounds
of their mental health difficulties or disability?
Article 3: Right to be free from inhuman or
degrading treatment- e.g. Are facilities
available to avoid treating people with
physical health needs (eg wheelchair users) in
a degrading way? In serious cases of
degrading treatment, this could be a breach of
Article 3. If the person is detained under MCA
(DOLs) or MHA, are they getting the medical
treatment that they need? If a failure to
provide treatment to someone deprived of
their liberty leads to serious harm, this could
be a breach of Article 3.
Article 2: Right to life
Is the person supported to access medical
checks and clinics? In extreme cases, lack
of support with healthcare could lead to a
fatality.

Does the person have access to their
physical health medication? If necessary,
are enough staff available to ensure that
the person is able to access their physical
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Rights at risk staff manual amendments V1 7.2.15
2) Taking medication
Rationale:
Medication can sometimes help people stay well. Sometimes not taking medication can contribute
to a relapse. Equally taking medication can cause side effects, which may not only affect wellbeing
but may also contribute to non-concordance.
Prompt questions:







How do you feel about any medication you take?
Do you always take your medication?
Do you forget to take your medication?
Do you take more medication than you need to?
Do you experience any side effects from your medication?
Do you feel that taking your medication is helping you?
Has this been an issue in the past?
Taking
medication
icon
______________________________________________
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Rights at risk staff manual amendments V1 7.2.15
Human rights
engaged:
which
may
be
Article 8: Right to respect for private and
family life – Is information about the person’s
medication shared only on a ‘need-to-know’
basis? Does the person have any input into
decisions about their medication? (Do they
have capacity?) Is the person responsible for
administering their own medication? Is the
person given respect and privacy while taking
their medication? Are they given information
about their medication and any side effects?
Is medication used as a form of restraint for
the person?
Article 2: Right to life – e.g. Does the person
have access to any regular medication (e.g. is
diabetes or epilepsy medication taken at the
correct time with the correct doses etc.). In
extreme cases, lack of support with
medication could lead to a fatality. Are the
relevant agencies taking steps to provide any
support that is necessary?
FREDA principles:
You may also wish to consider the FREDA
principles: Fairness, Respect, Equality,
Dignity, and Autonomy.
Is the person being treated with fairness,
respect, equality, dignity, and autonomy in
relation to their medication? e.g. are they
able to take it in private?
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Rights at risk staff manual amendments V1 7.2.15
3) Mental Health and Wellbeing
Rationale:
Poor mental health is the largest cause of disability in the UK (1). It can affect every aspect of a
person’s life including their physical health, relationships, work and education. It is also a known risk
factor for suicide (2). The government’s mental health strategy, ‘No Health without Mental Health’
(3), states that mental health is equally as important as physical health and those with mental health
difficulties should be supported to get the care they need to improve their quality of life.
Prompt questions:









How would you describe your mood?
Mental health
Have you felt low or anxious recently?
icon
Have you been feeling irritated or angry?
Have you heard voices or seen things which other people
cannot recently?
Have you felt suspicious of others recently?
Have you had any difficulty sleeping?
Have you been isolating yourself from others?
Have people been discriminating against you because of your mental health?
Have you experienced difficulties with your mental health in the past?
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Rights at risk staff manual amendments V1 7.2.15
Human rights
engaged:
which
may
be
problems? This includes treatment by staff,
family and others.
Article 5: Right to liberty and security- e.g. is
the person able to leave when they want? If
they are not free to leave, this is a deprivation
of liberty and can only be done lawfully under
the MHA or MCA, If the person is sectioned
under the MHA, have the right procedures
been followed and have they been given
information about why they are sectioned,
and are regular reviews being carried out by
the Mental Health Tribunal? If the person
lacks mental capacity and is not free to leave
the hospital or care home where they live, is
there a DOLs in place?
Article 8: Right to respect for private and
family life – This risk has clear implications for
the person’s psychological wellbeing. Is the
person using ‘behaviours which challenge’ to
communicate their distress? If they do, is any
physical restraint used in response,
proportionate, necessary and part of a
Positive Behaviour Support plan?
Article 3: Right to be free from inhuman or
degrading treatment - If the person is
detained under MCA (DOLs) or MHA, are they
getting the medical treatment that they
need? If a failure to provide treatment to
someone deprived of their liberty leads to
serious harm, this could be a breach of Article
3.
Article 14: Protection against discrimination
in relation to other human rights – e.g. does
the person lack informed choice on
appropriate healthcare services because of
their mental health difficulties?
FREDA principles:
You may also wish to consider the FREDA
principles: Fairness, Respect, Equality,
Dignity, and Autonomy.
Is the person being treated with respect and
dignity in relation to their mental health
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Rights at risk staff manual amendments V1 7.2.15
4) Self-neglect (not looking after myself)
Rationale:
Self-neglect can be due to mental health difficulties, brain injury or dementia. Factors which can
contribute to self-neglect occurring include: physical abilities, poor motivation or attention and low
energy levels. In extreme cases, self-neglect can be life threating and can cause dehydration,
malnutrition and can make medical conditions worse. It is therefore important to assess self-neglect
to reduce the likelihood of these risks.
Prompt questions:






Do you look after yourself properly?
Do you eat and drink regularly or do you eat more or less than
you should?
Do you wash/shower and change your clothes regularly?
Do you do things around the house like cleaning and shopping?
Do you look after your money?
Has this been an issue in the past?
Self-neglect
icon
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Rights at risk staff manual amendments V1 7.2.15
Human rights
engaged:
which
may
be
Article 8: Right to respect for private and
family life – e.g. is the person able to make or
get a drink or food when they want? Does the
person have access to money? Are they able
to spend their money on whatever they
decide?
Article 3: Right to be free from inhuman or
degrading treatment – is the self-neglect
severe enough to place the person at risk of
harming themselves, or of being in a state
which is seriously degrading? Are appropriate
steps in place to ensure this does not happen?
Article 2: Right to life – If self-neglect
becomes extreme; this could potentially lead
to loss of life. Are appropriate steps in place
to ensure this does not happen?
FREDA principles:
You may also wish to consider the FREDA
principles: Fairness, Respect, Equality,
Dignity, and Autonomy.
Is the person being treated with equality and
dignity regardless of their presentation? Is the
person given respect and privacy (by both
staff and other service users) whilst
undertaking personal care? If the person
refuses to do personal care, is this right
respected? Is the person encouraged to eat if
they refuse food?
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5) Self-harm (Hurting or harming myself)
Rationale:
Self-harming behaviour varies from person to person but it can involve: cutting, burning, hitting or
scratching, breaking bones, hair pulling, swallowing toxic substances or objects or risky behaviour. It
is often a sign of emotional distress or mental health difficulties. Self-harm is often used to
communicate and cope with distressing emotions. There is often no intent to die by suicide but
people who self-harm are at an increased risk of dying by suicide (4). It is important to consider the
extent of the person’s distress and their coping skills, as well as the extent of the risk, including
accidental suicide.
Prompt questions:









Do you hurt yourself to cope with difficult feelings?
Do you use objects to cut yourself?
Self-harm icon
Do you ever burn yourself on purpose?
Do you swallow objects/substances to harm yourself?
Do you ever swallow substances to harm yourself?
Do you ever hit/punch yourself to hurt yourself?
How do you feel when you cut or hurt yourself? At the time? Afterwards?
Do you have ways of coping with difficult feelings?
Has this been an issue in the past?
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Rights at risk staff manual amendments V1 7.2.15
Human rights
engaged:
which
may
be
Article 8: Right to respect for private and
family life – e.g. is all information about the
person’s behaviour kept confidential? If not, is
it only shared on a ‘need-to-know’ basis? Is
there a collaborative support plan which aims
to understand the function of the person’s
self-harm and address any underlying
psychological distress? Have harm
minimisation approaches been considered?
Does the support plan, where possible,
promote the person’s choices in caring for
wounds and choice of staff intervening
(including staff gender)?
Article 3: Right to be free from inhuman or
degrading treatment – is the person at risk of
causing serious harm to themselves? Are
there appropriate interventions to prevent
this?
Article 2: Right to life – e.g. are appropriate
interventions in place to avoid serious injury
to the person that places their life at risk?
Does the person have access to suitable
healthcare services to get help?
FREDA principles:
You may also wish to consider the FREDA
principles: Fairness, Respect, Equality,
Dignity, and Autonomy.
Is the person being treated with dignity and
respect in the event of self-harm? e.g. are
they given the opportunity to speak to
somebody after they have cut or hurt
themselves? If the person needs medical
treatment (e.g. Accident and Emergency), are
they
treated
respectfully
by
staff?
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Rights at risk staff manual amendments V1 7.2.15
6) Suicide
Rationale:
A key national objective is a reduction in the suicide rate of people in the care of mental health
services, including inpatients and other high risk groups such as: young and middle-aged men,
people with a history of self-harm, people in contact with the criminal justice system and specific
occupational groups (e.g. doctors, nurses, veterinary workers, farmers and agricultural workers) (5).
It is important that those at increased risk of suicide are adequately supported to be kept safe from
preventable harm and to ensure intervention is timely when somebody is in distress or in crisis.
Prompt questions:










Has anybody in your family ever taken their own life?
Have you ever tried to take your own life in the past?
If you have tried to take your own life in the past, was
it
planned?
Do you ever think about taking your own life?
How often/how long do you experience these thoughts?
Do you have any plans to take your own life?
Have you thought about how you would take your own life?
Have you written a suicide note?
Do you feel like things can get better?
How do you feel about having these thoughts?
Suicide icon
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Rights at risk staff manual amendments V1 7.2.15
Human rights
engaged:
which
may
be
Article 8: Right to respect for private and
family life – e.g. is all information about the
person’s behaviour kept confidential? If not, is
it just shared on a ‘need-to-know’ basis? Is the
intervention proportionate to the risk?
Article 2: Right to life – e.g. have appropriate
interventions been put in place to avoid the
person taking their own life (with appropriate
observations, access to therapy / services to
help with their feelings).
Article 3: Right to be free from inhuman or
degrading treatment - Is the person at risk of
causing serious harm to themselves if they
attempt, unsuccessfully, to take their own
life? Are appropriate interventions in place to
avoid this happening?
FREDA principles:
You may also wish to consider the FREDA
principles: Fairness, Respect, Equality,
Dignity, and Autonomy.
Is the person taken seriously and treated with
dignity in the event of attempted suicide?
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Rights at risk staff manual amendments V1 7.2.15
7) Interpersonal difficulties
Rationale
Sometimes people find it difficult to develop and maintain relationships, especially if their
trust has been broken or they have experienced trauma in the past. Sometimes people have
learnt and get stuck in the same patterns of relating to the people around them, even when
these ways of relating cause problems. Difficulties with relationships can cause stress and
can contribute to mental health difficulties. Equally, when people are distressed their
relationships can be affected. Depending on a person’s life experiences, they may have
different ways of relating to people, some of which may be difficult for us to understand.
This domain will enable you to explore this sensitive topic with the service user to hopefully
develop a joint awareness of this risk.
Prompt questions:
 Do you feel very stuck in the same patterns in lots of
different relationships in your life?
 Do you sometimes do things other people don’t like in
order to try and make them listen or to get your needs
met?
 Do other people say you challenge boundaries?
 Do you sometimes act in a way to scare people?
 Do you make demands that other people don’t like?
Difficulties with
relationships
icon
Human rights which may be engaged:
Article 8: Right to respect for private and family life – This risk might affect the service
user’s psychological or physical wellbeing. It may also impact on family, carers and other
service users.
FREDA principles:
You may also wish to consider the FREDA principles: Fairness, Respect, Equality, Dignity,
and Autonomy.
Is the person treated with dignity and respect despite difficulties in relationships? Do they
have a reputation around this risk? Does this then impact on the care they receive, or how
they are treated by either staff members or other service users?
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Rights at risk staff manual amendments V1 7.2.15
8) Engagement (Not wanting help from services)
Rationale:
Those who are the most difficult to engage with mental health services are often the most
vulnerable and can be at the greatest risk. Lack of engagement may be due to a number of different
reasons including previous negative experience of services and suspiciousness of statutory services
because of upbringing. It is important to consider engagement with services as this can mitigate or
increase risk and needs to be taken into consideration in treatment plans. Discussions about this can
potentially support engagement to overcome barriers.
Prompt questions:




Engagement
Do you ever miss appointments with staff
icon
from mental health services? What makes you miss
appointments?
Do you ever leave home for long periods of time without
telling people where you are going and when you will be
back?
Do you want support from services? If not, it might help if we can talk about the reasons
for this?
If you been admitted from hospital previously, have you ever run away or walked out?
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Rights at risk staff manual amendments V1 7.2.15
Human rights
engaged:
which
may
be
Article 8: Right to family and private life- If
the person doesn’t want support from
services is this right respected by the service
providers? If the person seems to lack the
capacity to decline support from services, has
the MCA guidance been followed in making an
assessment of this?
Article 5: Right to liberty and security - If the
person is a voluntary inpatient, are they
aware of their right to leave when they want?
If they are not free to leave, this could be an
unlawful deprivation of liberty. If the person is
sectioned, have the right procedures been
followed? Have they been given information
about why they have been sectioned and has
their case been reviewed by the Mental
Health Tribunal? Is the care plan
proportionate to the risks and the least
restrictive course of action? Have proactive
strategies been developed as part of a
Positive Behaviour Support plan? If the
person lacks the capacity to consent to their
detention is there a DoLs in place?
FREDA principles:
You may also wish to consider the FREDA
principles: Fairness, Respect, Equality,
Dignity, and Autonomy.
Is the person being treated with fairness,
respect, equality, dignity and autonomy in
relation to the level of support they receive
i.e. too much or too little?
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Rights at risk staff manual amendments V1 7.2.15
9) Alcohol/Substance misuse
Rationale:
Approximately half of those who have mental health difficulties also misuse alcohol or drugs (6). This
may be to cope with difficult feelings but alcohol or substance misuse can also contribute to a
deterioration of mental health. It may also impact on a person’s wellbeing, physical health,
relationships with others and employment. Dual diagnosis is also associated with increased risk of
suicide and suicide attempts (7). Misusing alcohol or substances can also contribute to anti-social
behaviour, including violence. It is important to assess the extent to which this is a problem to
consider how or if it mitigates other risks to self or others.
Prompt questions:








Do people worry that you drink a lot of alcohol or use
Alcohol/
drugs?
substance
Do you use alcohol or drugs to cope?
misuse icon
Do you take legal highs?
How much? How often?
Do you experience withdrawal symptoms if you do not drink/ take drugs?
In the past, have you used alcohol or drugs to cope?
Do you engage in any risky behaviour when you are under the influence of
alcohol/drugs?
Do you experience any other problems related to your alcohol/substance use?
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Rights at risk staff manual amendments V1 7.2.15
Human rights
engaged:
which
may
be
Article 8: Right to respect for private and
family life –Is the person supported in making
informed choices regarding his or her
drinking?
Article 3: Right to be free from inhuman or
degrading treatment – is the person’s misuse
of alcohol or substances making them at risk
of causing serious harm to themselves ? Could
this harm be avoided through appropriate
intervention?
Article 2: Right to life – e.g. are there services
available for the person to help with serious
alcohol problems (e.g. specialist alcohol
services)? Does the person have access to
suitable healthcare to get help? In extreme
cases lack of access to suitable healthcare
may lead to a fatality.
FREDA principles:
You may also wish to consider the FREDA
principles: Fairness, Respect, Equality,
Dignity, and Autonomy.
Is the person being treated with respect and
dignity in relation to alcohol/substance use?
Are they receiving adequate support with this
issue?
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Rights at risk staff manual amendments V1 7.2.15
10) Transport (private)
Rationale:
When people experience mental health difficulties it can affect their ability to drive. This can
be due to either the mental health symptoms or side effects of the medication a person is
taking. The Driver Vehicle and Standards Agency (DVLA; 8) has regulations about driving
when a person has been diagnosed with a mental health problem. You may want to prompt
the person to contact the DVLA to discuss their difficulties. If a person is unable to drive due
to their mental health problem, they may be eligible for a free pass to use public transport.
Prompt questions:
 Do you currently have a driving licence?
 Do you own a vehicle?
 Do you regularly drive your vehicle?
Transport Icon
 Are you taking any medication which might make it difficult
for you to drive?
 Have you informed the Driver Vehicle and Standards Agency
(DVLA)
of your diagnosis?
 Do you have access to any other means of transport i.e. public transport?
 Has this been an issue in the past?
Human rights which may be engaged:
Article 8: Right to respect for private and family life - Is the person’s lack of access to
transport likely to impact on their physical and psychological wellbeing? For example, by
preventing them from accessing health services, or preventing them from engaging in social
activities?
Are there reasons why the person needs to have access to a particular type of transport –
for example, are they a wheelchair user? If so, could denying access potentially impact upon
their psychological wellbeing? If the person is not able to drive for legal reasons, has the
person been supported to think about other options available to them i.e. public transport?
FREDA principles:
You may also wish to consider the FREDA principles: Fairness, Respect, Equality, Dignity, and
Autonomy.
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Rights at risk staff manual amendments V1 7.2.15
11) Safety at home
Rationale:
People have a right to feel safe and secure in all aspects of life, including their health and
wellbeing, to enjoy safety but not feel over-protected, and to be free from exploitation and
abuse at home. When people are experiencing mental health problems, they may not feel
able to keep themselves safe. This domain explores whether the person feels able to
maintain their safety in their own home.
Prompt questions:
 Do you live at home alone?
 Do you have any support at home either from
family, friends or support staff?
 Do you feel like you can keep yourself safe at
Safety at home
home?
icon
 Do you know what to do if you don’t feel safe at
home?
 Do people worry that you have items at home you
may harm yourself or others with? For example, sharp knives or weapons.
 Has this been an issue in the past?
Human rights which may be engaged:
Article 8: Right to respect for private and family life – Either the risk itself or the strategies
in place could have implications for the person’s psychological wellbeing. Is enough being
done to reduce any restriction as much as possible? Is any intervention proportionate to the
person’s difficulties? In shared accommodation, does any restriction impact on the quality
of life of other service users who do not have a problem with keeping themselves safe?
Article 3: Right to be free from inhuman or degrading treatment – is the person at risk of
causing serious harm to themselves? If so how can this be minimised? e.g. if the person is
restricted from using knives, could they be supervised to use them? Is there a Positive
Behaviour Support plan?
Article 2: Right to life – e.g. if the person is in danger of seriously harming or killing
themselves, are procedures in place to prevent this happening? (e.g. are sharp knives locked
away?)
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Rights at risk staff manual amendments V1 7.2.15
FREDA principles:
You may also wish to consider the FREDA principles: Fairness, Respect, Equality, Dignity, and
Autonomy.
Is the person treated with fairness, dignity and respect in relation to their issues around
managing their safety at home?
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Rights at risk staff manual amendments V1 7.2.15
Section 3: Risks to others
Please turn to ‘Section 3: Risks to others’ in the shared information booklet. This section
focuses on the risks to other people in the service user’s life. This section is important
because public authorities such as the NHS have a positive obligation to take steps to
prevent risks to other people arising as a result of their decisions about a service user in
their care.
1) People you care for: Dependants and children
Rationale:
Many people using mental health services will have some kind of caring responsibilities, either as
parents or as carers for older people. Caring for someone else can mean that a person experiences
high levels of stress. Forty per cent of carers may experience depression or psychological problems
(9). Parents with mental health difficulties may struggle to manage their parenting role or need
support. Children may become carers for their parents. Roughly 175,000 young carers are caring for
a parent or another family member with mental health difficulties in the UK (10).
Prompt questions:








Are you a carer? Do you look after anyone?
CARER ICON
Is this a child, an older person or someone with a disability?
Do people worry that you do things to put them in danger?
Do you sometimes find it hard to cope?
Do you find it hard to keep them clean?
If you lose your temper, do you ever take it out on the person you care for?
If the person you care for is a child: Do you find it hard to get your child to school?
Do people worry that children might not be safe with you? Do you like to play with
children, but hear other people say that you shouldn’t? Do people say you can’t look
after children properly?
Has this been a risk in the past?
Human rights which may be engaged:
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Rights at risk staff manual amendments V1 7.2.15
Rights of service user
Article 8: Right to respect for private and family life – Is the person’s family life respected? Do
services take a ‘whole family’ approach to supporting them as a carer? Is the person supported or
given the opportunity to have a family life with their child? If the child does not live with the person,
do they have visiting rights to see the child? Are steps in place to support the person to have a safe
and productive family life with the child? Is the person supported to participate in important
decisions affecting their family life?
Article 14: Protection against discrimination in relation to these human rights – Do any allegations
of inadequate care relate solely to prejudice about disability or mental health? Is the person treated
differently in terms of access to their children because of their mental health?
Rights of others
Article 8: Right to respect for a private and family life- Is the dependents' right for a family life
respected? Are dependents supported to see the service user to maintain a family life, irrespective
of the service user’s mental health needs? If the dependent has limited access to see the service
user because of their mental health needs, has this been properly assessed as being in the best
interests of the dependent and the service user?
Article 2 of Protocol 1: Right to education – A risk to a dependent child could potentially affect the
child’s education e.g. if the person finds it difficult to take the child to school.
Article 3: Right to be from inhuman or degrading treatment – Serious cases of neglect can cause
inhuman or degrading treatment. Are measures in place to prevent this from happening?
Article 2: Right to life – Neglect of a dependent could potentially be life threatening. Steps should be
in place to prevent this from happening. e.g. support should be available for the person in relation to
their child.
FREDA principles:
You may also wish to consider the FREDA principles: Fairness, Respect, Equality, Dignity, and
Autonomy for both the service user and others.
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Rights at risk staff manual amendments V1 7.2.15
2) Verbal aggression or intimidation
Rationale:
When people are experiencing mental health problems they may become verbally
aggressive or intimidating towards others. It may be that the person is having difficulty
expressing their thoughts and feelings and does not have any alternative strategies for
coping at this time. This domain will enable you to explore verbal aggression or intimidation
jointly with the service user.
Prompt questions:








Do you get angry with people?
Do people seem scared of you?
Do you say nasty things to people when you are
annoyed or upset?
Do you shout at people when you’re annoyed or
upset?
Do you have thoughts about harming other people? Do
you want to act on these thoughts?
Do you get angry a lot?
Do you argue a lot?
Has this been a risk in the past?
Verbal
aggression/
Intimidation icon
_________________________________________________
Human rights which may be engaged:
Rights of service user
Article 8: Right to respect for private and family life - Is there a policy of restraint around the person
to prevent verbal aggression or intimidation? If so, does the person have any input into this? Have
they been involved with any discussions? Is any restriction or restraint, necessary and proportionate
to the risk? Is a Positive Behaviour Support plan in place?
Rights of others
Article 8: Right to respect for private and family life – Verbal aggression may engage
another person’s right to psychological wellbeing. For example, if the person is focusing
their verbal aggression at another service user living at the same address, are their human
rights compromised? If so, is anything in place to prevent this?
Are any interventions proportionate to the risk and the least restrictive course of action?
Are they part of a positive behavior support plan? If so, does the person have any input into
this? Have they been involved with any discussions?
Article 14: Protection against discrimination -– If verbal aggression against someone is as a
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Rights at risk staff manual amendments V1 7.2.15
result of their gender/race/culture etc then their right to be protected against
discrimination in relation to their Article 8 rights may be engaged.
Article 3: Right to be free from inhuman or degrading treatment- In cases of extreme and
systematic verbal aggression this may meet the threshold a person’s right to be free from
inhuman or degrading treatment. Are measures in place to prevent this?
FREDA principles:
You may also wish to consider the FREDA principles (Fairness, Respect, Equality, Dignity, and
Autonomy) in relation to both the service user and others.
Is the service user treated with respect and autonomy by staff despite any verbal aggression
or intimidation they may display? Are others involved treated according to FREDA principles
when they have contact with the agencies involved?
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3) Physical violence (with or without weapons)
Rationale
Guidelines (11, 12) on the prevention and management of violence in healthcare highlight
safety priorities in mental health. The guidelines outline the importance of using preventive
measures to manage violent behaviour, as well as of employing strict guidelines to govern
the use of physical restraint, which remains common in mental health settings (13).
Practitioners must consider several factors when conducting a risk assessment around
violent behaviours, including historical incidents. Practitioners must also be skilled in
viewing violent behaviour as part of a wider context i.e. does somebody’s risk of being a
perpetrator of violence increase when they are in an inpatient setting (14, 15)?
Prompt questions:
 If you are angry or frustrated, do you sometimes hit
Physical Violence
out or hurt people?
(no weapons)
 If you want to hurt someone, do you think about what
icon
objects you are going to use?
 Do you use things like a chair, hot water or a knife?
 In the past, have you ever physically hurt other
people? Did you use a weapon to do this?
 Do you have items in your home that you could hurt other people with, like a knife,
chair or hot water?
 When you are angry or frustrated or scared, do you have ways of coping with this?
Do you sometimes hurt people to help cope with difficult feelings?
__________________________________________________
Human rights which may be engaged:
Rights of service user
Article 8: Right to respect for private and family life - Is there a policy of restraint around the person
to prevent physical violence? If so, does the person have any input into this? Have they been
involved with any discussions? Is any restriction or restraint, necessary and proportionate to the
risk? Is a Positive Behaviour Support plan in place? If the person’s physical aggression is directed
towards staff, family or other service users, are their human rights compromised? If so, is anything
in place to prevent this?
Rights of others
Article 8: Right to respect for private and family life – Article 8 included the right to physical and
psychological integrity. Any injury or trauma relating to physical violence will engage a person’s right
to physical and psychological integrity,
Article 3: Right to be free from inhuman or degrading treatment – e.g. is the person likely to
focus their aggression towards carers / family / service users or the general public? If so, are any
care plans in place to prevent other people’s human rights being compromised?
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Article 2: Right to life – If the physical violence becomes so extreme that it could result in a loss of
life, then the victim’s ‘right to life’ may be breached. There is a duty to put in place measures to
prevent this from happening.
FREDA principles:
You may also wish to consider the FREDA principles (Fairness, Respect, Equality, Dignity, and
Autonomy) in relation to both the service user and others.
Is the service user treated with fairness and respect in relation to any potential violence? e.g. If the
person has a complaint made against them because of their aggression, will it be investigated fully?
Will they be supported? Also, are there consequences following violent outbursts? Removal of
privileges may affect the person’s rights.
Are the victims or potential victims of the aggression also treated according to FREDA principles
when they have contact with the agencies involved?
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4) Sexually inappropriate behaviour
Rationale
Some people may exhibit sexually inappropriate or disinhibited behaviour when they are
experiencing mental health difficulties. These behaviours can be very distressing for the
person and others around them. This domain will enable you to explore any issues relating
to the person exhibiting sexually inappropriate behaviour towards others.
Prompt questions:
• Have you made someone do sexual things even when
they didn’t want to?
 Do you find it hard to tell whether someone wants you
to touch them, or if they want to touch you?
 Have you showed someone private parts of your body
without them agreeing to this?
 Has this been a risk in the past?
 Have you touched someone without them agreeing to
this?
• Have you made someone have sex with you?
Sexually
Inappropriate
Behaviour
Icon
________________________________________
Human rights which may be engaged:
Rights of others
Article 8: Right to respect for private and family life – Steps must be taken to prevent
damage to the psychological or physical wellbeing of survivors of sexual abuse.
Article 3: Right to be free from inhuman or degrading treatment – Sexually abusing
someone else is likely to constitute inhuman or degrading treatment and steps must be
taken by agencies involved to prevent this.
FREDA principles:
You may also wish to consider the FREDA principles (Fairness, Respect, Equality, Dignity, and
Autonomy) in relation to both the service user and others.
Is the service user being treated with dignity and respect – even where their behaviour is
sexually inappropriate? Are the others involved treated according to FREDA principles when
they have contact with relevant agencies?
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5) Criminal or Antisocial acts
Rationale
A Home Office (2002) review of criminal and antisocial acts found that in 60% of cases there
was a mitigating factor such as mental distress, addiction, or learning disabilities (16). This
domain will enable you and the service user to explore the risk of the person engaging in
criminal or antisocial acts.
Prompt questions:
• Have you done things which get you into trouble with the
police? Were you arrested? Did they say that you had done
something illegal?
• Have you taken things from other people that don’t belong
to you?
 Are you doing anything at the moment which could
get you into trouble with the police?
 Do you sometimes find it hard to tell if things are
against the law?
Criminal or
Antisocial acts
icon
__________________________________________________________________________
Human rights which may be engaged:
Rights of others
Article 1 of Protocol 1: Protection of property – Are any care plans in place to protect this
right in relation to other service users who live with the person?
Article 8: Right to respect for private and family life – By stealing, the service user might
affect the victim’s psychological wellbeing. This includes family, carers and other service
users. Are steps being taken by the agencies involved to address this risk?
Article 3: Right to be free from inhuman or degrading treatment– Some criminal acts are
directly targeted at people, and in some circumstances the victims may experience inhuman
or degrading treatment as a result. Steps must be taken by agencies involved to prevent
this.
Article 2: Right to life – If the antisocial behaviour becomes so extreme that it could result
in a loss of life, then the victim’s ‘right to life’ may be breached. There is a duty to take
precautions eg via a Positive Behaviour Support plan to prevent this from happening.
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Article 14: Protection against discrimination in relation to these human rights – If a
criminal act been carried out against someone as a result of their gender/race/culture etc
and the relevant agencies did not take steps to respond to this, then the person’s right to be
protected against discrimination in relation to their human rights (eg freedom from
inhuman or degrading treatment) may be engaged.
FREDA principles:
You may also wish to consider the FREDA principles (Fairness, Respect, Equality, Dignity, and
Autonomy) in relation to both the service user and others.
Is the service user 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
impact on the care they receive, or how they are treated by either staff members or other
service users? Are the victims/potential victims also treated according to FREDA principles
when they have contact with the agencies involved?
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6) Arson (Starting Fires)
Rationale
Some research has demonstrated that the risk of committing arson is higher in people with
mental health problems, in particularly in people who experience psychosis (17). This
domain will support you and the service user to explore any historical incidents of arson in
relation to current risk factors.
Prompt questions:
• Have you set fire to something?
• Have you put someone else in danger by setting fire to
something?
Have you damaged a building by setting fire to it?
Have you got into trouble in the past for setting fire to
something?
• Have you ever tried to set fire to something in the past?
____________________________________________
Human rights which may be engaged:
Arson Icon
Rights of others
Article 1 of Protocol 1: Protection of property - By setting fire to somebody’s property, the
service user is impinging on another person’s right to have their property protected. Is there
anything in place to stop this happening?
Article 8: Right to private and family life – Starting fires may risk other people’s right to
their home. In addition, less serious harm caused by fire could risk a person’s physical and
psychological wellbeing, which is an important aspect of Article 8.
Article 3: Right to be free from inhuman or degrading treatment – If the fire is severe
enough to cause serious injury, it may risk a person’s right not to be treated in an inhuman
or degrading way. Steps should be taken to prevent arson attacks from happening.
Article 2: Right to life - If the fire is severe enough, it could cause death to the service user
or others. This would be a breach of their right to life. If this presents a real risk, agencies
must take steps to prevent arson attacks from happening.
FREDA principles:
You may also wish to consider the FREDA principles (Fairness, Respect, Equality, Dignity, and
Autonomy) in relation to both the service user and others.
Is the service user treated with dignity and respect despite the risk of arson? Are they
treated as an equal? Do they have a reputation relating to this risk? Does this affect the care
they receive, or how they are treated by either staff members or other service users? Are
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the victims/potential victims of the arson risk also treated according to FREDA principles
when they have contact with the agencies involved?
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Section 4: Risk from others
Please turn to ‘Section 4: Risks from others’ in the shared information booklet
This section focuses on the risks from other people in the service user’s life.
1) Discrimination
Rationale:
Research suggests that nearly nine out of ten people (87%) with mental health problems have been
affected by stigma and discrimination (18). People with mental health problems say that stigma and
discrimination affect all aspects of their lives: work, education, friendships, community participation,
going to the shops, going out to the pub, and talking to other people about their mental health
problems. This domain will help you to explore with the person whether they are being physically
harmed or verbally abused by others because of their mental health problems, gender, religious
beliefs, ethnicity, sexuality or any other reason.
Prompt questions:




Do people bully you because of your gender, ethnicity,
religious beliefs, sexuality or for other reasons?
Do people pick on or hurt you because of your gender,
ethnicity, religious beliefs, sexuality for other reasons?
Do people pick on or hurt you because you experience
mental health issues?
Has this happened in the past?
Discrimination
icon
_________________________________________________
Human rights which may be engaged:
Article 8: Right to respect for private and family life - Does the person feel able to express
themselves? Is the person given the opportunity to express their identity by making choices
about their clothes, hair, food, and activities etc? Is the person supported to attend groups
should they wish? Do they feel pressurised to attend groups when they would prefer not to?
Is the person able to access health services that address their specific needs? Has the person
been consulted to see if services are meeting their specific needs? If these things are
happening because of the person’s mental health issues, it may be useful to consider Article
8 along with Article 14 (see below).
Article 9: Freedom of thought, conscience and religion – e.g. does the person feel able to
express their beliefs and practice activities in relation to their beliefs? Is the person
supported to attend meetings and events relating to their beliefs if they wish to do so? You
should bear in mind that a person is not automatically protected when doing things
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affecting other people that are motivated by their belief – such forcing their religion onto
others.
Article 14: Freedom from discrimination in relation to these rights – Are there particular
reasons why the person may be vulnerable to discrimination in relation to their human
rights, from staff or other service users? Is the person treated differently from others in a
way that cannot be reasonably justified, for example, because of their ethnicity.
Article 3: Right to be free from inhuman or degrading treatment –e.g. is the person treated
in a way that might be construed as inhuman or degrading as a result of any issues relating
to their sexuality, religious beliefs, ethnicity, gender or for any other reason? If this is a risk,
steps should be taken to prevent it from happening.
Equality Act:
Article 14, listed in the Human Rights Act, protects our rights not to be discriminated against
in relation to any of the other rights listed in the Human Rights Act. Service users , as well as
workers etc, are also entitled to be protected from discrimination by the Equality Act (2010)
and this doesn’t depend on having a link with one of the rights listed in the Human Rights
Act. The Equality Act states that we should not be treated less favourably because of a
protected characteristic. There are nine protected characteristics: age, disability, gender
reassignment, marriage or civil partnership, race, religion or belief, sex or sexual orientation.
FREDA principles:
You may also wish to consider the FREDA principles (Fairness, Respect, Equality, Dignity, and
Autonomy) in relation to the service user.
Is the person treated as an equal and with respect? e.g. if the person makes a complaint
about how they are being treated, is it taken seriously and investigated fully?
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2) Physical abuse by others
Rationale:
Past or current physical assault is traumatic and may have serious mental health
consequences. Domestic violence is the leading cause of illness and death for women of
childbearing age, with the main contribution being from the mental health consequences of
abuse (19).This domain supports you to ask the person about any experiences of assault or
violence now or in childhood. It includes excessive restraint from services and prone (face
down) restraint.
Prompt questions:






Does anyone hurt you?
Does anyone hit/slap/punch you?
Does anyone spit at you?
Have you experienced domestic violence?
Have you been unnecessarily restrained?
Has this happened in the past?
Physical abuse
by others icon
Human rights which may be engaged:
Article 8: Right to respect for private and family life – Physical abuse will affect the person’s
physical integrity and their psychological well-being. Are strategies in place to reduce this
abuse as much as possible as part of a Positive Behaviour Support plan?
Article 3: Right to be free from inhuman or degrading treatment- If another service user is
abusing the person, is anything being done about this to prevent this? Is the person
vulnerable and likely to be a victim of physical abuse when out on their own? If so, are care
plans and support in place to try and prevent this? (e.g. having a carer with them).
Article 2: Right to life – If the person is subjected to extreme physical abuse by others, this
could result in a loss of their life. Strategies should be in place to prevent this from
happening as part of a Positive Behaviour Support plan.
FREDA principles:
You may also wish to consider the FREDA principles (Fairness, Respect, Equality, Dignity, and
Autonomy) in relation to the service user.
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Is the person treated as an equal and with respect? e.g. if the person has made a complaint
about physical abuse, is it investigated fully and taken seriously? Have appropriate
safeguarding referrals been made?
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3) Sexual abuse by others
Rationale:
Sexual abuse is experienced by between 15-30% of girls, and up to 30% of boys during
childhood (20), and it has been established that childhood sexual abuse is linked to
increased physical complaints, psychological distress, substance abuse, suicide attempts and
ideation in adulthood (21) Asking about sexual abuse can be difficult, and staff can be
reluctant to ask about such a sensitive area. However, research has shown that service users
can experience the absence of this question as silencing, that survivors of sexual abuse want
to be asked and other service users do not resent the question. Being asked about abuse,
listened to and believed can be an affirming first step (22).
Using ‘meta’ questions (questions about questions) can help the service user to have control
of the decision to answer
Prompt questions:






Meta question: The next area we are going to ask about is
about sexual abuse. Is it ok for me to ask you about this? [if
Sexual abuse by
the person says no, offer them the choice to talk about this
others icon
another time, if they wish to, and move onto the next
question]
Does anyone touch you in a way you don’t like?
Does anyone make you have sex when you don’t want to?
Does anyone try to take photos of you when you are undressed?
Does anyone try to make you watch sex you don’t want to see on the internet?
Has anyone done these things in the past?
_________________________________________________
Human rights which may be engaged:
Article 8: Right to respect for private and family life – Is the person supported or given the
opportunity to make relationships? If the client wishes to engage in sexual relationships, is
this supported? Has the person had help and advice about sex? Have they been supported
to know their rights, therefore limiting the chance of sexual abuse? If the person has been
sexually abused, this right is likely to be at risk.
Article 3: Right to be free from inhuman or degrading treatment- For some people, the
nature and type of the abuse they have experienced may meet the legal threshold for
Article 3. Steps should be put in place to prevent this from happening.
FREDA principles:
You may also wish to consider the FREDA principles (Fairness, Respect, Equality, Dignity,
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and Autonomy) in relation to the service user.
Is the person treated as an equal and with respect? If the person makes a complaint about
sexual abuse, is it investigated fully and taken seriously? Should a safeguarding referral be
made?
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4) Financial abuse by others
Rationale:
Financial abuse occurs when someone tries to take advantage of another person’s
vulnerability to steal their money or their property. When unwell, people with mental
health difficulties may be more vulnerable to online or phone scams and fraud. Older adults
may be particularly vulnerable (23)
Prompt questions:






Do you worry about money?
Does anyone else use your cash card/cheque book?
Do you think your money is going missing?
Does anyone make you buy things for them or pressure you
to give them money?
Do you get phone calls or emails offering you money or free
products or asking for sensitive information about your
money?
Has this happened in the past?
Financial abuse
by others icon
_________________________________________________
Human rights which may be engaged:
Article 1 of Protocol 1: Right to respect for property - Are the person’s possessions and
finances respected by others?
Article 4: Freedom from slavery and forced labour e.g. does the person undertake any kind
of work, and if they do, do they receive suitable payment for the work?
Article 8: Right to respect for private and family life – Who handles the person’s money?
Are they informed about this and do they understand why? Does the person have access to
their own money? Are they able to spend their money on whatever they decide? Is
confidential data about the person’s money kept locked away and only shared on a ‘needto-know’ basis?
FREDA principles:
You may also wish to consider the FREDA principles (Fairness, Respect, Equality, Dignity, and
Autonomy) in relation to the service user.
Is the person treated as an equal and with respect? If the person makes a complaint about
their financial situation, is it taken seriously and is it investigated fully?
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5) Emotional abuse by others
Rationale:
Emotional abuse often happens with other forms of abuse. It often involves someone behaving in a
controlling or bullying way and abusing their power. Emotional abuse can be particularly difficult to
pinpoint but can have devastating consequences for a service user’s mental health and wellbeing. It
can happen in any relationship; at home, in the workplace or in the family.
Prompt questions:







Do people make demands on you that you don’t like?
Do people act in a way that scares you?
Do people listen to you?
Are your emotional needs met?
Does anyone try to isolate you or stop you from seeing friends?
Does anyone humiliate you or put you down a lot?
Has this happened in the past?
Emotional
abuse by others
icon
_________________________________________________
Human rights which may be engaged:
Article 8: Right to respect for private and family life – Does the person feel respected in his
/her home? Does the person have any involvement in choosing their staff or housemates?
This is especially important if they feel they are being emotionally abused by somebody they
live with. Emotional abuse is likely to impact on a person’s psychological and physical
wellbeing, an important part of this right.
Article 3: Right to be free from inhuman or degrading treatment - Extreme emotional
abuse
could place at risk the right to be free from inhuman or degrading treatment. Strategies
should be in place as part of a Positive Behaviour Support plan to prevent this from
happening. Staff need to be attuned for signs of potential emotional abuse as it can be more
difficult to identify.
FREDA principles:
You may also wish to consider the FREDA principles (Fairness, Respect, Equality, Dignity, and
Autonomy) in relation to the service user.
Is the person treated as an equal and with respect? If the person makes a complaint regarding any
emotional abuse, is it taken seriously and is it investigated fully? Are appropriate safeguarding
referrals being made?
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Section 5) Protective factors and coping strategies
Please turn to ‘Section 5: Protective factors and coping strategies in the shared information
booklet.
This section focuses on the service user’s strengths and the resources they have in their life.
1) Protective factors
Rationale:
A rights and recovery based approach to risk assessment needs to include the service user’s
strengths. This means identifying protective factors, or things which help to keep the service
user safe.
Prompt questions










Were there people who were there for you when you were
growing up?
Protective
Are there people you have get on well with now?
Factors icon
What do you enjoy doing? (work/education/hobbies)
How are your finances? Do you have money worries or are
your finances secure?
Wanting to engage with services (consider whether the person
is taking medication or not or engaging in appointments)
What do you want to do in the future?
Are you able to tell when you are starting to feel unwell?
What are the early signs you notice when you are starting to feel unwell?
What do other people notice when you are starting to feel unwell?
Do you have an advanced statement which could help us to think about things in your
life which keep you safe and well?
_________________________________________________
Human rights which may be engaged:
Article 8: Right to a private and family life: Working in a collaborative way to identify
protective factors is likely to help ensure service user’s human rights are protected and
respected. This way of working treats service users with respect and dignity and values their
autonomy through asking about their choices.
FREDA principles:
You may also wish to consider the FREDA principles (Fairness, Respect, Equality, Dignity, and
Autonomy) in relation to the service user.
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2) Coping Strategies
Rationale:
A rights and recovery based approach to risk assessment needs to include the service user’s
strengths. This means identifying ways of coping the service user has already identified and
is using to help manage their difficulties.
Prompt questions











What has helped when things have been difficult in the past?
Last time you were feeling unwell, what helped you to feel
Coping
better?
Strategies icon
What helps you to feel safe?
How do you know when things aren’t going well?
What exercise do you do or enjoy?
Are there people who you feel comfortable with you can ask
for help?
Who can you talk to? Who listens to you?
What do you do to relax?
What takes your mind off things?
What makes you feel grounded?
Do you have an advanced statement which could help us to think about ways you can
cope?
_________________________________________________
Human rights which may be engaged:
Article 8: Right to a private and family life - Working in a collaborative way is more likely to
promote the service user’s human rights. This way of working treats service users with
respect and dignity and values their autonomy through asking about their choices.
FREDA principles:
You may also wish to consider the FREDA principles (Fairness, Respect, Equality, Dignity, and
Autonomy) in relation to the service user.
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REFERENCES
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Health Organisation. Retrieved from:
http://www.who.int/mediacentre/factsheets/fs352/en/. [Accessed 4th June 2015].
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(2009). Cross-National Analysis of the Associations among Mental Disorders and Suicidal
Behavior: Findings from the WHO World Mental Health Surveys. PLOS Med, 6(8).
3. HM Government. (2011). No health without mental health: A cross government mental
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8. Driver and Vehicle Licensing Agency. (2013). Current medical guidelines: DVLA guidance
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general practitioners and their teams (2nd edition). Essex: The Princes Royal Trust for
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implementation guide: developing positive practice to support the safe and therapeutic
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disturbed/violent behaviour in in-patient psychiatric settings and emergency
departments. Retrieved from http://www.nice.org.uk/CG25.
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consequences, management (Eds). New York: Springer.
14. Duxbury, F. (2011). Domestic violence, PTSD, and diagnostic enquiry. The British Journal
of General Practice, 61(589), 496.
15. Vincent, G. M. (2006). Psychopathy and violence risk assessment in youth. Child and
Adolescent Psychiatric Clinics of North America, 15(2), 407-428.
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16. Campbell, S., & Markesinis, B. S. (2002). A review of anti-social behaviour orders.
London: Home Office.
17. Anwar, S., Långström, N., Grann, M. & Fazel, S. (2011). Is arson the crime most strongly
associated with psychosis? A national case-control study of arson risk in schizophrenia
and other psychoses. Schizophrenia Bulletin, 37 (3), 580-586.
18. Time to Change. (2008). Stigma and Discrimination. Accessed at http://www.time-tochange.org.uk/what-are-mental-health-problems/stigma-discrimination. [Accessed on
4th June 2016].
19. Hegarty, K. (2011). Domestic violence: The hidden epidemic associated with mental
illness. The British Journal of Psychiatry, 198, 169-170.
20. Gilbert, R., Widom, C. S., Browne, K., Fergusson, D., Webb, E., & Janson, S. (2009).
Burden and consequences of child maltreatment in high-income countries. The Lancet,
373(9657), 68-81.
21. McCauley, J., Kern, D. E., Kolodner, K., Dill, L., Schroeder, A. F., DeChant, H. K., ... & Bass,
E. B. (1997). Clinical characteristics of women with a history of childhood abuse:
unhealed wounds. Jama, 277(17), 1362-1368.
22. Read, J., Hammersley, P. & Rudegeair, T. (2007). Why when and how to ask about
childhood abuse. Advances in Psychiatric Treatment, 13, 101-110.
23. O’Keefe, M., Hills, A., Doyle, M., McCreadie, C., Scholes, S., Constantine R, et al. (2007).
UK study of abuse and neglect of older people: Prevalence survey report. London:
National Centre for Social Research.
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Section 6: Human rights based formulation:
This section focuses on the risks identified in the previous section which have obtained a
score of 4 or higher. The human rights based formulation attempts to pull all the risk
factor information together.
A human rights based formulation can be completed for risks i which have scored 4 or over.
To aid in completing the formulation, answer the questions below and add any other
information which you think is relevant.
1. What’s the rights issue we want to think about?
When you have identified a risk, the human rights which are implicated will be listed. Start
by listing these human rights.
2. Whose rights are engaged? What are they?
You should indicate which implicated human rights belongs to whom including the service
user, others (those in close proximity to the service user e.g. family members, other service
users), staff and the community. Consider who is at most risk in relation to their human
rights.
3. Why has this happened (a)?
You should consider predisposing (historical factors) which have contributed to this
occurring. These do not necessarily have to be linked specifically to Human Rights. For
example, events from childhood would come under this heading.
4. Why has this happened (b)?
You should consider the precipitating (immediate factors or events) which have contributed
to this occurring. These could be factors considered to be “triggers” to the current situation.
5. Why might this happen again? Why is this still happening?
You should consider the perpetuating (maintenance) factors which are likely to contribute
to this being problem again. These might relate to the way in which the situation is currently
being managed, or the way in which the service user or others are responding to it.
6. What is likely to stop it?
You should consider the protective (the service user’s strengths and coping strategies)
which contribute to reducing the difficulty or prevent it from deteriorating.
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7. What opinions and frameworks help me make the decision?
Ask the service user what they would like to happen or what they would think is a
reasonable plan, using the answers to the previous questions to help. Consider what legal
obligations you have e.g. is the service user in immediate risk and require sectioning under
the mental health act. You should consider both of these to determine what you think is fair
and the least restrictive approach which is proportionate to the risk under exploration.
8. What is our intervention strategy?
This formulation collated should now inform your intervention strategy. You should consider
the following points in developing your strategy: Is it proactive? Is it proportionate? Is it the
least restrictive? Does it balance the rights of those involved? Is it legal? Is it necessary and
legitimate? Is it culturally sensitive?
9. What are the barriers?
Any barriers to implementing the intervention should be considered. You and the serviceuser should consider if there are any ways in which these barriers can be overcome, this
should also be detailed in the intervention strategy.
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Rights
at risk staff manual amendments V1 What’s
7.2.15 the rights issue we want to think about?
Why has
this happened(a)?
What are the predisposing factors
giving rise to this rights issue?
Why has this happened
(b)?
What are the precipitating
factors giving rise to this rights
issue?
Is this a legal issue? Is it an issue which is necessary to address? Is your aim in
addressing it legitimate?
Whose rights are engaged? What are they?
SU
Why might this
happen again? Why
is this still
happening?
Others
Are
any
SU’s/family
engaged?
other
rights
What
are
the
perpetuating
factors
giving rise to this rights
issue
What is likely to stop it?
What are the protective factors?
Staff
What is our intervention strategy?
Is it proactive? Is it proportionate? Is it the least restrictive?
Does it balance the rights of those involved? Is it legal? Is it
necessary and legitimate? Is it culturally sensitive?
Community
What opinions and frameworks help me
make the decision?
What does the
SU want?
What needs to
happen legally?
Mental Health Act, Mental
Capacity
Act,
DOLS,
Safeguarding
policy,
abosulute rights/
What is fair?
What are the barriers?
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Section 7: Shared rights, risk and recovery plan
If you have completed the formulation, the information you have discussed can be used to
produce a risk management or a shared rights, risk and recovery plan. The layout below
integrates human rights principles with a Positive Behaviour Support approach.
For each area where the service user’s rights are engaged, the plan should describe;
a) The presenting problem: the rights or the safety issue involved in a clear and
accurate way
b) Precipitating factors: any identified triggers to the rights or safety issue
c) Any identified early warning signs that the rights or safety issue is about to happen
d) any proactive or preventative strategies which aim to stop the rights or safety issue
from occurring (including the person’s protective factors)
e) Any reactive or crisis strategies which aim to minimise the harm from the rights or
safety issue occurring (including the person’s coping strategies)
The plan should be regularly reviewed with the service user.
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Appendix A
Box 1: The 16 Best Practice in Managing Risk Principles
Introduction
1. 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 user’s own experience, and clinical
judgement.
Fundamentals
2. Positive risk management as part of a carefully constructed plan is a required competence for all mental
health practitioners.
3. 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.
4. Risk management must be built on recognition of the service-user’s strengths and should emphasize
recovery.
5. Risk management requires an organizational strategy as well as efforts by the individual practitioner.
Basic ideas in risk management
6. Risk management involves developing flexible strategies aimed at preventing any negative event from
occurring or, if this is not possible, minimising the harm caused.
7. Risk management should take into account that risk can be both general and specific, and that good
management can reduce and prevent harm.
8. Knowledge and understanding of mental health legislation is an important component of risk management.
9. 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 service user in response to
crisis.
10. Where suitable tools are available, risk management should be based on assessment using the structured
clinical judgement approach.
11. Risk assessment is integral to deciding on the most appropriate level of risk management and the right kind
of intervention for a service user.
Working with service users and carers
12. 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.
13. Risk management must always be based on awareness of the capacity for the service user’s risk level to
change over time, and recognition that each service user requires a consistent and individualised approach.
Individual practice and team working
14. Risk management plans should be developed by multidisciplinary and multi-agency teams operating in an
open, democratic and transparent culture that embraces reflective practice.
15. All staff involved in risk management should receive relevant training, which should be updated 81
at least
every three years.
16. A risk management plan is only as good as the time and effort put into communicating its findings to others.
Rights at risk staff manual amendments V1 7.2.15
Appendix B
Mapping of key elements of relevant frameworks to a human rights based approach and method of inclusion in ‘Rights at Risk’.
Framework
Recovery
Key Elements
Recognising
strengths
human rights based approaches
Present? How

PANEL - Empowerment
Present?

Empowerment

PANEL - Empowerment

Sense of purpose

PANEL – Participation

Collaboration

PANEL - Participation

Person-centred

FREDA + PANEL

Developing
perspectives
Resilience

PANEL – Empowerment


PANEL – empowerment
FREDA
- dignity,
resilience

Being believed in

PANEL – Empowerment

Tool
How
Assessment should acknowledge service-users’
strengths and embed a positive risk management
approach within the culture of services.
Helps service users to “own” their own risk
assessment and to be involved in decisions.
Least restrictive approach allows greater access to
community activities or work opportunities.
The tool is completed collaboratively between service
users and staff and opinions are sought and listened to
throughout.
Approach strongly embedded in person-centred
principles. Involves development of a person-centred
plan.
Formulation helps to develop understanding of
behaviour from different perspectives.
Recognises that people can learn from past
experiences, and that working within a “leastrestrictive” approach allows for people to make
mistakes and learn from them rather than be
punished.
A least-restrictive approach encourages services to
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Mental
Capacity Act
Being listened to

Social inclusion

Non-blaming
Assumption
autonomy
Assumption
capacity


PANEL – participation,
non-discrimination,
empowerment
FREDA
FREDA
–
equality,
fairness
PANEL
–
nondiscrimination
FREDA + PANEL
of

FREDA – Autonomy

of




Facilitating
participation

PANEL
–
nondiscrimination,
empowerment
FREDA – Autonomy,
respect
PANEL – participation
Quality of life

PANEL + FREDA


PANEL + FREDA


FREDA

Working
interests
in
Least restrictive
best
- autonomy,

have faith in service users and to believe in them.
The collaborative nature of the assessment
encourages services to listen to SUs and to take their
views into account when formulating and planning
assessments.
The approach focuses on helping people to avoid
being excluded from services or activities through
thinking about ways to facilitate involvement and
minimise risks.
The ethos of this approach is to approach risk in a
person-centred way which does not allocate “blame”
for risk, but instead uses FREDA and PANEL principles
to help think about risk within a wider context
The assessment facilitates asking about choices and
helping these choices to become a reality.
It is assumed that service users have a capacity to
contribute to their risk assessment and to be included
within the decision making process.
The tool is completed collaboratively between service
users and staff and opinions are sought and listened to
throughout.
Through facilitating service users in being able to
make choices about their lives they will be able to
access activities that improve their quality of life.
The approach strongly advocates working in the best
interests of the service user and to consider this when
making decisions which affect them.
A person-centred human-rights based approach
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fairness, dignity
Positive
Behaviour
Support
requires taking the least restrictive approach at all
times when making decisions, and using the
assessment helps facilitate this
This approach acknowledges that it is the right of
everyone to be able to make unwise decisions, and a
taking a least restrictive approach allows service users
to make decisions without being punished for making
mistakes.
Service users are involved in decision making at every
level, and they are encouraged to make choices about
all aspects of their life including their care.
Right
to
make
unwise decisions

FREDA

Encourage
preferences of care


Advocacy

PANEL
–
empowerment,
nondiscrimination,
participation
FREDA
–
fairness,
autonomy
PANEL
–
empowerment, legality
FREDA – autonomy

Knowing service users’ preferences helps staff and
services to advocate for them, and the tool facilitates
service users in expressing their wishes.

FREDA + PANEL

Quality of life

PANEL + FREDA

Collaboration


Least restrictive

FREDA
–
equality,
autonomy
PANEL – participation,
empowerment
FREDA
- autonomy,
By seeking input from service users when completing
the tool, developing a formulation and making a plan,
the tool encourages the rights and values of service
users to be respected.
Through facilitating service users in being able to
make choices about their lives they will be able to
access activities that improve their quality of life.
The tool is completed collaboratively between service
users and staff and opinions are sought and listened to
throughout.
Respecting
and values
rights

A person-centred human-rights based approach
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fairness, dignity
Advocating

PANEL
–
empowerment, legality
FREDA – autonomy
FREDA + PANEL

Person-centred


PANEL – participation
FREDA - equality

Facilitating
communication

PANEL – participation,
empowerment,
nondiscrimination

Expressing rights

PANEL + FREDA

Proactive strategies

PANEL + FREDA


FREDA
–
equality,
autonomy
PANEL – participation,
empowerment
PANEL + FREDA

Working
partnership
Service User Collaboration
Involvement
Facilitating
in



requires taking the least restrictive approach when
making decisions, and using the assessment helps
facilitate this
Knowing service users’ preferences helps staff and
services to advocate for them, and the tool facilitates
service users in expressing their wishes.
The approach is strongly embedded in person-centred
principles. Involves development of a person-centred
plan.
The tool is completed collaboratively between service
users and staff and opinions are sought and listened to
throughout.
The tool facilitates good communication through
encouraging staff and service users to have
conversations about their care, and will give service
users a means to express their views and feel heard.
The visible human rights element to the assessment
ensures that both staff and service-users are aware of
the interaction between risk and human rights, and
gives an opportunity for all to be aware of and express
their rights.
By taking a least restrictive and human rights based
approach, services are encouraged to put in place
proactive rather than reactive strategies to avoid risk
situations.
The tool is completed collaboratively between service
users and staff and opinions are sought and listened
to.
The tool is completed collaboratively between service
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Engagement
Enabling voices



PANEL
–
empowerment,
nondiscrimination,
participation
FREDA
–
fairness,
respect, autonomy
PANEL + FREDA
Sharing power
Participation

PANEL + FREDA

social


centred

PANEL – Participation,
accountability,
nondiscrimination,
empowerment
FREDA - Equality
FREDA + PANEL
Rights

FREDA + PANEL

Values

FREDA + PANEL

Promoting
inclusion
Person
approach


users and staff and opinions are sought and listened
to.
Knowing service users’ preferences helps staff and
services to advocate for them, and the tool facilitates
service users in expressing their wishes. The tool
encourages staff and service users to communicate
about many different topics, and requires staff to
regularly talk to service users about their preferences.
By making decisions collaboratively and taking the
views of all parties into consideration, the assessment
aims to help service users feel in control of their lives.
The tool is completed collaboratively between service
users and staff and opinions are sought and listened
to. Service users are encouraged to participate fully
throughout.
The approach focuses on helping people to avoid
being excluded from services or activities through
thinking about ways to facilitate involvement and
minimise risks.
The approach is strongly embedded in person-centred
principles. Involves development of a person-centred
plan.
The visible human rights element to the assessment
ensures that both staff and service-users are aware of
the interaction between risk and human rights, and
gives an opportunity for all to be aware of and express
their rights.
By seeking input from service users when completing
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Rights at risk staff manual amendments V1 7.2.15

PANEL
–
empowerment, legality
FREDA – autonomy

Promoting Choice


Empowerment

FREDA
–
equality,
autonomy
PANEL – participation,
empowerment
PANEL
Collaboration

PANEL

Advocating


Promoting
Independence

Personcenteredness

PANEL
–
empowerment, legality
FREDA – autonomy
FREDA
–
equality,
autonomy
PANEL – participation,
empowerment
PANEL + FREDA
Least Restrictive

FREDA
- autonomy,
fairness, dignity

Protection

PANEL – legality

Positive Risk Consultation
Managemen
t
from



the tool, developing a formulation and making a plan,
the tool encourages the rights and values of service
users to be respected.
The tool encourages consultation between
professionals and takes a multi-disciplinary approach –
developing a shared risk plan can facilitate this
consultation.
Service users are involved in decision making at every
level, and they are encouraged to make choices about
all aspects of their life including their care.
Helps service users to “own” their own risk
assessment and to be involved in decisions.
The tool is completed collaboratively between service
users and staff. Opinions are sought and listened to.
Knowing service users’ preferences helps staff and
services to advocate for them, and the tool facilitates
service users in expressing their wishes.
Through using a least restrictive approach, service
users are encouraged to be able to make choices
about what they want to do, and to be as independent
as possible within the context of their needs.
Approach strongly embedded in person-centred
principles. Involves development of a person-centred
plan.
A person-centred human-rights based approach
requires taking the least restrictive approach at all
times when making decisions, and using the
assessment helps facilitate this
While working within a least restrictive approach, the
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harm
Mental
Health Act
Least restrictive

FREDA + PANEL

Rights

FREDA + PANEL


PANEL + FREDA


PANEL – participation,
empowerment


PANEL – legality, nondiscrimination
FREDA
–
fairness,
respect
FREDA – respect

FREDA
fairness

Collaboration
Involvement
decisions
Maximising
wellbeing
Protection
harm
and
in
from
Respect

Effectiveness,
efficiency and equity
principle

–
equality,

assessment still puts safety at its’ heart and allows for
open discussions about risks and harm to the service
user and/or to others.
A person-centred human-rights based approach
requires taking the least restrictive approach at all
times when making decisions, and using the
assessment helps facilitate this.
The visible human rights element to the assessment
facilitates both staff and service-users to be aware of
the interaction between risk and human rights, and
gives an opportunity for all to be aware of and express
their rights.
The tool is completed collaboratively between service
users and staff and opinions are sought and listened to
throughout.
Through facilitating service users in being able to
make choices about their lives they will be able to
access activities that improve their quality of life and
wellbeing
While working within a least restrictive approach, the
assessment still puts safety at its’ heart and allows for
open discussions about risks and harm to the service
user and/or to others.
The assessment encourages respect of service users in
terms of ensuring that they are listened to, consulted
and their needs are met within a human rights
framework.
The assessment tool aims to make decision making more
effective in that by making decisions collaboratively they
are more likely to be adhered to, and these decisions are
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Rights at risk staff manual amendments V1 7.2.15
Participation

PANEL - participation

made equitable through the involvement of multiple
stakeholders.
The tool is completed collaboratively between service
users and staff and opinions are sought and listened to
throughout.
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Appendix C
Development of ‘Rights at Risk’
Consistent with a human rights approach, the ‘Rights at risk’ plan was co-produced with
staff in adult mental health services to adapt existing human rights risk assessment tools
developed in learning disability services. Discussions with clinicians, along with a review of
the evidence-base and policy, informed the ‘Rights at risk’ plan.
Interviews with staff in adult mental health services identified that risk management,
ownership of risk, the therapeutic relationship, criminality and mental health and providing
a rationale for asking questions were key considerations in their clinical practice. These are
each discussed in turn below. A key objective of the tool is to facilitate service-user
involvement with risk assessment and management.
Positive Risk Management
Risk assessment was reportedly viewed as being problem-focussed with less attention being
paid to existing coping strategies. Staff also mentioned that social stigma about service
users of mental health services being “risky” shaped their decision-making through
focussing on “concrete” areas to alleviate uncertainty rather focussing on the factors which
mitigate the risk. However, practitioners acknowledged the importance of “weighing the
risk up”.
To help facilitate the principles of positive risk management:
 service user’s protective factors and coping strategies are listed as an assessment
item within the shared safety plan,
 the human rights based formulation offers a framework to “weigh risk up” and helps
to provide an understanding of the context in which the risks identified arise and are
mitigated.
 the principles of proportionality are clearly outlined
 and the language of the human rights based formulation has been changed to focus
on activation of human rights rather than on “risks”.
Ownership of Risk
It was felt that the ‘Rights at risk’ plan should make clear that the ownership of risk was a
shared responsibility between the care team, the service-user and their carers and should
help those involved identify the strengths which they bring to the partnership. Staff
acknowledged, however, that they remained mindful of their legal responsibilities and the
‘blame culture’ within the NHS.
The title of ‘Rights at risk: Shared rights, risk and recovery plan_’ was selected to
communicate the joint venture in the ownership of risk. The process of collaboration with
the service-user at every stage of the process is hoped to promote participation in the
development of the management plan to empower them to take responsibility. In addition,
the ‘Rights at risk’ plan supports you to justify the decisions you make and fulfil your
responsibilities as the Human Rights Act underpins all law. You are asked to consider your
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legal responsibilities within the development of the management plan and decision making
processes are clearly documented within the plan.
Relationships
The risk assessment process was viewed as a dynamic process underpinned by the
therapeutic relationship and rapport developed with the service-user. Risk assessment and
management is therefore more than the tools utilised and relies upon the skill set which
practitioners foster to develop warm, trusting, therapeutic relationships. It was
acknowledged that this can be difficult when service-users disagree with their treatment.
The way in which the ‘Rights at risk’ plan is completed is of central importance in supporting
the development of a warm therapeutic relationship. Your interpersonal style and clinical
skills are largely viewed as the tools to support this. The tool has been constructed in a way
to promote collaboration with the aim to reduce the power imbalance inherent amongst
the roles of mental health practitioner and service user/carer. It also promotes transparency
and respect by attempting to elicit the views of service users’ in relation to their care plans.
Whilst disagreements within the care plan may exist, it is hoped that by listening to these
views, the service user will feel validated and thus contribute towards the development of a
therapeutic relationship.
Criminality and Mental Health
Risks to others was deemed fundamental within risk assessment. It was noted mental health
practitioners were often tasked with the responsibility of determining whether criminal
behaviour was born from mental illness and psychological distress or simply a criminal act. It
was believed that clarification of this distinction would have different implications for the
risk management plan. Whilst noted to be a difficult task, practitioners identified
consideration of motivation and context in which behaviour occurs facilitates clarification of
this distinction. Furthermore they felt exploration of service users belief system was of
paramount importance, particularly establishing if any beliefs which could be classified as
delusional motivated the behaviour.
Risk to others is a key domain of exploration within the ‘Rights at risk’ plan. Prompts are
provided to facilitate consideration of the motivation underlying the behaviour and mental
health, including unusual belief systems. Context is also explored within human rights based
risk formulation to help provide an understanding of why the behaviour occurred to inform
the risk management plan.
Providing a rationale for the questions we ask
Practitioners acknowledged exploration of risk often required sensitive and intrusive
questions to be asked and felt that sometimes the focus upon risk may contribute to service
user’s experience of being stigmatised as “risky”. Practitioners also reported that feeling
confident and having a clear rationale for asking questions helped with asking difficult
questions.
The ‘Rights at risk’ plan aims to offer a clear rationale of why questions have been included.
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Accessibility
The ‘Rights at risk’ plan aims to utilise simple, lay language and avoid the use of clinical
jargon. The layout of the plan, including the inclusion of icons aims to make the information
clear and concise so the ‘Rights at risk’ plan is accessible to service users and their carers
and promotes collaboration and engagement.
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Terms and Conditions
Important information on ‘Rights at Risk’.
By using this guide you agree to comply with the following terms:
1. Disclaimer
The ‘Rights at Risk’ resources have been developed by Mersey Care NHS Trust and funded
by the Equality and Human Rights Commission, in partnership with the British Institute of
Human Rights. The guide has been piloted for use within mental health services but has not
yet been researched on a wider basis. This version is therefore intended for use alongside
the risk assessment and management structures of the Care Programme Approach.
Whilst every reasonable care has been taken to ensure the accuracy and suitability of this
guide, neither the authors, Mersey Care NHS Trust, the British Institute of Human Rights nor
the Equality and Human Rights Commission can accept any responsibility for any action
taken, or not taken, on the basis of this guide.
The authors, Mersey Care NHS Trust, the British Institute of Human Rights, or the Equality
and Human Rights Commission shall not be liable to any persons for any loss or damage
which may arise from the use of the ‘Rights at Risk’ resources.
Nothing in the above disclaimer shall restrict or exclude liability for death or personal injury
caused by the negligence of Mersey Care NHS Trust.
2. ‘Rights at Risk’ Resources Limitations
The ‘Rights at Risk’ resources may become out of date over time, require modification or
replacement as new data and protocols are published. Users of this guide have the
responsibility to be fully aware of current best practice and to use their own judgement in
using the guide to support their decisions.
3. Intellectual Property
The ‘Rights at Risk’ resources are an Equality and Human Rights Commission funded
publication. They should not be altered without the permission of the Equality and Human
Rights Commission and the authors.
93