Risk Assessment and Legal Framework

Question 1

What is risk assessment in mental health?

Answer 1

• The probability of an event occurring
• Dynamic therefore assessment is a continuous process
• Structured re-assessment should occur after any major change in patient presentation or circumstances
  
  • Major changes = admission, discharge, significant life event, illness relapse
• Humans are very bad at judging risk; doctors are no different

Question 2

Explain risk to self

Answer 2

• Main risk to consider is self-harm and suicide
• BUT don’t forget:
  
  • Self-neglect (schizophrenia - negative symptoms, bipolar in mania, depression)
  • Accidental harm/misadventure (can be in dementia)
  • Reputational harm
  • Financial
  • Relationships
  • Emotional or physical suffering

Question 3

How to assess suicidal ideation?

Answer 3

Asking questions in a graded, respectful way:

• How do you see the future?
• Do you ever feel that you just don’t want to be here?
• How often do you get these thoughts?
• Have you made any plans, what are they?
• Have you made any preparations?
• What stops you?

Question 4

What are the static risk factors of risk to the themselves?

Answer 4

• Prior history of self-harm or suicide attempt
• Demographics
  
  • 18-25 and 70+ (2 peaks), male gender, sexuality, employment status, marital status, living arrangements
• History of childhood adversity, mental disorder, hospital admission, substance misuse
• Physical illness/chronic pain
• Family history of suicide

What is a static risk factors?

Static risk factors are like the shore and whatever has washed up on it from years past; difficult to change

Question 5

What are the dynamic risk factors of risk to self?

Answer 5

• Active suicidal ideation
• Opportunity and means
• Hopelessness
• Helplessness
• Feelings of being a burden
• Active substance misuse
• Untreated mental disorder
• Life stressors
• Admission/discharge

What is a dynamic risk factor?

Dynamic factors are like the tide; can be unpredictable, sudden, stormy, dangerous (although unlike the tide, some can be changed)

Question 6

What people are at the highest risk of suicidal attempts?

Answer 6

• Absence of regret
• Violent method
• Belief that method would be lethal
• Efforts to avoid discovery
• No attempt to inform anyone
• Preparations made; organising means, writing notes, wills, arrangements for dependents etc

Question 7

What can cause risk to others?

Answer 7

• Aggression and violence
• Suicide method
• Driving
• Harm via job/occupation
• Neglect of dependents

Question 8

What causes risk FROM others?

Answer 8

• Physical
• Psychological/Emotional
• Sexual
• Financial

Question 9

What are the protective factors of risk to self and others?

Answer 9

• Dependent children
• Pets
• Family
• Hope
• Spirituality
• Connections

Question 10

How to manage violence in a psych ward?

Answer 10

• Always raise the alarm
• Use de-escalation techniques
• Do not get involved in restraining a patient unless absolutely necessary
• Always assume you are missing something that is treatable – mental or physical
• Rapid tranquillisation (IM lorazepam - not in delusions as can make worse and harder to treat/IM haloperidol) if necessary and appropriate

When happens?

• Someone manic
• Dementia patient
• Intoxication/withdrawal
• Criminal/forensic history
• Delirious

Question 11

What is the mental health act of 1983?

Answer 11

• To ensure that people with serious mental disorders which threaten their health or safety, or the safety of the public, can be treated, irrespective of their consent, where it is necessary to prevent them from harming themselves or others
• ‘Any disorder or disability of the mind’
• 2 medical recommendations, one of which must be S12 approved
• Must state presence of a mental disorder of a nature or degree to warrant detention in the interests of patient’s health or safety, or for the protection of others
• Application usually made by AMHP

e.g. Section 5(2), section 2, Section 3

Question 12

What is the mental capacity act 2005?

Answer 12

• Statutory framework to empower and protect vulnerable people who are not able to make their own decisions
• Statutory framework to empower and protect vulnerable people who are not able to make their own decisions
• A person is deemed unable (on the balance of probabilities) to make a decision if they cannot:
  
  • Understand information relevant to the decision
  • Retain that information
  • Use or weigh up that information
  • Communicate the decision