Lousia Ovington independent investigation report ... - NHS North East

CHAPTER 6 – RISK ASSESSMENT AND MANAGEMENT
Chapter 6 – Risk assessment and management
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Formalised risk assessment is a relatively new concept: the panel was told by several
clinicians and staff members in relation to the admissions to the Tony White Unit and
St Nicholas’ Hospital that in 1998 to2000 risk assessment was not formalised but
would be conducted on an ongoing, every day basis as part of their clinical/nursing
duties.
It is now generally acknowledged within mental health services that risk assessment is
an essential component in managing people with mental illness. It is also recognised
that there are a variety of instruments available with which to undertake these
assessments, the choice of which to use being a matter of local preference.
Each mental health trust has its own clinical governance arrangements which will
oversee the risk management measures in clinical areas and these will be subject to
regular audit and review. In addition to ensuring that effective policies and procedures
are in place, each trust has a responsibility to ensure that processes are in place to
monitor risks, whether clinical or organisational and there are structures in place to
review incidents and advise on actions which need to be implemented to minimise or
remove future risk.
For the first part of Louisa Ovington’s journey through mental health services, formal
risk assessment was in its infancy. After December 2000, however, the trust area had
formalised its risk assessment policies. The following description is taken from the
former Tees and North East Yorkshire NHS Trust care coordination policy (December
2000):
• Risk assessment is an essential element of good mental health practice and is not
regarded as, or fulfilled simply by, an exercise of completing a “risk assessment”
form. It is an ongoing process which team members and other involved agencies
must carry out. It is their responsibility to regularly consider risk issues and record
these considerations clearly.
• After the initial risk assessment, further assessments will be undertaken as a
minimum, prior to leave, prior to discharge from hospital and at every review.
Any major life event should trigger a review and further risk assessment.
• The need for positive, supportive and therapeutic risk taking is essential to
effective care delivery and a key element of the care coordination process.
• Risk assessment and its management must be based on detailed evidence of a
person’s psychiatric and social history together with information regarding their
current mental state and functioning. This must also involve consideration of the