The Department of Health’s Best Practice in Managing Risk (2007) defines risk as relating to the likelihood, imminence and severity of a negative event occurring (i.e. violence, self-harm, self-neglect). It is the gathering of information through processes of communication, investigation, observation and persistence; and analysis of the potential outcomes of identified behaviours. It identifies specific risk factors of relevance to an individual, and the circumstances in which they may occur. This process requires linking the context of historical information to current circumstances, to anticipate possible future change (Southern Health NHS Trust 2012). NICE CG133 (2011) Recommendation 1.3.6 states:
When assessing the risk of repetition of self-harm or risk of suicide, identify and agree with the person who self-harms the specific risks for them, taking into account:
- • methods and frequency of current and past self-harm;
- • current and past suicidal intent;
- • depressive symptoms and their relationship to self-harm;
- • any psychiatric illness and its relationship to self-harm;
- • the personal and social context and any other specific factors preceding self-harm, such as specific unpleasant affective states or emotions and changes in relationships;
- • specific risk factors and protective factors (social, psychological, pharmacological and motivational) that may increase or decrease the risks associated with self-harm;
- • coping strategies that the person has used to either successfully limit or avert self-harm or to contain the impact of personal, social or other factors preceding episodes of self-harm;
- • significant relationships that may either be supportive or represent a threat (such as abuse or neglect) and may lead to changes in the level of risk;
- • immediate and longer-term risks.
Method of self-harm can indicate different levels of suicide risk and individuals using more dangerous methods (e.g. hanging or gassing by carbon monoxide or other gas) should receive intensive follow-up (Bergen et al 2012).
Assessing someone’s risk of suicide should be a therapeutic intervention itself and delivered with compassion. The emphasis should be from the outset on engaging the person with the intention of reducing risk rather than estimating or recording it.
The low-risk paradox
In mental health services, risk assessment has traditionally focused on prediction. Patients may be categorised into low, medium or high risk of a particular outcome. Large et al (2011) found about 3% of patients categorised as being at high risk can be expected to die by suicide in the year after discharge. However, about 60% of the patients who die by suicide were likely to be categorised as low risk. The authors conclude that risk categorisation does not help reduce the numbers of patients who will die by suicide after discharge. National data shows that, of those who ended their life after having had contact with mental health services, many had factors associated with high risk of suicide (such as self-harm, substance misuse, economic problems) but the majority (88%) were judged to be at low or no immediate risk of suicide by clinicians at their final contact with services (NCISH 2018). Rahman et al (2013) found the overall quality of risk assessment and management was unsatisfactory in over one-third of cases. Bolton et al (2015) and Large et al (2017) conclude that categorising risk in such a way is unhelpful in guiding the treatment and management of a patient. Further research suggests that categories have poor predictive value (Quinlivan et al 2016; Steeg et al 2018). The National Confidential Inquiries into Suicide and Safety in Mental Health (NCISH 2018) found the immediate risk of suicide at the final service contact was judged by clinicians to be low or not present for the majority of patients who died by suicide (NCISH 2018) and describes this as the “low-risk paradox”.
Checklists of characteristics or risk scales are sometimes used to estimate risk. A national survey of risk assessment in UK mental health services by HQIP (NCISH 2018) found there was little consistency in the use of risk tools and most tools sought to predict future behaviour. Scores on the tool also determined management decisions, which is contrary to national guidance for self-harm assessment. National Institute for Health and Care Excellence (NICE) guidelines on the long-term management of self-harm (2011) state that risk assessment tools and scales should not be used to predict future suicide or repetition of self-harm, or to determine who should or should not be offered treatment but could be used as prompts or measures of change.
HQIP conclude that:
- 1. Risk assessment tools should not be seen as a way of predicting future suicidal behaviour. This is consistent with the NICE self- harm guidelines.
- 2. Risk is not a number, and risk assessment is not a checklist. Treatment decisions should not be determined by a score.
- 3. There is a growing consensus that risk tools and scales have little place on their own in the prevention of suicide.
Graney et al 2020 found little had changed in the UK. 156 risk assessment tools were in use by 85 NHS mental health organisations. There was little consistency in their use; most tools aimed to predict self-harm or suicidal behaviour and scores were used to determine management decisions. The authors recommend that assessment processes need to be consistent across mental health services and include adequate training on how to assess, formulate, and manage suicide risk. They repeat the recommendations that patient and carer involvement is needed, risk assessment should not be seen as a way to predict future behaviour and should not be used as a means of allocating treatment. And that risk management plans should be personalised and collaboratively developed with patients and their families and carers.
NCISH (2018) findings also emphasise that risk fluctuates and the need for carer involvement, and clarity about what to do in a crisis. Patients’ suggestions to improve risk assessment in their survey included: 
The provision of psychosocial assessment following an attendance for self-harm at an ED (previously known as Accident and Emergency, or A&E) reduces future risk of self-harm and premature death by 40-51% in the ensuing 12 months (Bergen et al 2010; Kapur et al 2015). NICE (2011) and the National Collaborating Centre for Mental Health (NCCMH) (2018) recommend risk assessment should take place as part of a psychosocial assessment, i.e. a comprehensive assessment of the patient s needs, taking into account previous suicidal behaviour, psychological and social factors and other problems such as substance misuse. A psychosocial assessment should be collaborative, patient-centred and needs-based (Hawgood & De Leo 2016). It identifies a persons risks and resources with a view to deciding practical next steps towards keeping the patient safe. In one of the few studies of service user perspectives, Hunter et al (2013) analysed 13 interviews with service users following hospital attendance, and seven follow-up interviews conducted three months later. Few participants had a clear understanding of assessments purpose. Assessment had the potential to promote or challenge hope, dependent on whether it was experienced as accepting or critical. If follow-up care did not materialise, this reinforced hopelessness and promoted disengagement from services. The authors suggest re-conceptualising psychosocial assessment as primarily an opportunity to engage service users therapeutically. In order to maintain the benefits established during an assessment in hospital following self-harm or attempted suicide, follow-up needs to be timely and integrated with assessment.
In summary, the assessment of clinical risk in mental health care is challenging but provides an opportunity to engage with patients and their carers and families to promote the patients’ safety, recovery and well-being (Worthington et al 2013). A good risk assessment will combine consideration of psychological (e.g. current mental health) and social factors (e.g. relationship problems, employment status) as part of a comprehensive review of the patient to capture their care needs and assess their risk of harm to themselves or other people. The primary benefits of an assessment derive from (i) identifying steps towards further support and (ii) the patient-centred nature of the interaction. However, if further support is not forthcoming or if the assessment is conducted as a “tick box” exercise, its value is likely to be diminished.
What should a risk assessment cover?
- • past and current suicidal behaviour and self-harm;
- • specific details about suicidal thought, plans; identify if the person has a concrete plan;
- • current psychosocial situation/crisis;
- • identify psychological strengths as well as vulnerabilities.
Once a patient has indicated that they are feeling suicidal and you have assessed their risk, rather than trying to quantify and categorise their risk in a standardised format, it is more helpful to assume the risk is serious and think about how best to support that individual (Hawgood 8c De Leo 2016; Cole-King 8c Platt 2017).
Follow-up and treatment planning
Fazel and Runeson (2020) concluded that when assessing and treating suicide risk, a person who presents with suicidal thoughts may be at risk for suicide even if there are few overt symptoms of a psychiatric disorder. They recommend suicide risk should be assessed by considering predisposing factors (those which make us vulnerable to suicide including genetics, life events or temperament) and precipitating factors (specific events or triggers to suicidality) and that the risk of suicide should be managed through regular follow-up and brief psychological therapy.
As we are poor at predicting risk, we should take any risk seriously; reviewing each persons risk regularly and providing focused interventions directly aimed at reducing suicide risk.
HQIP research has shown that despite common risk factors, risk is often individual and suggests risk management should be personalised (Chan et al 2016; Quinlivan et al 2016). They suggest clinical risk assessment processes might be improved in the following ways:
- • The emphasis should be on clinical judgement and building relationships, and by gathering good information on (i) the current situation, (ii) history of risk and (iii) social factors to inform a collaboratively developed management plan.
- • Families and carers should have as much involvement as possible in the assessment process, including the opportunity to express their views on potential risk.
- • The management plan should be collaboratively developed where possible. Communication with primary care may also be may also be helpful.
- • The management of risk should be personal and individualised,
but it is one part of a whole system approach that should aim to strengthen the standards of care for everyone, ensuring that supervision, delegation and referral pathways are all managed safely.
NICE CG123 (2019) Recommendation 18.104.22.168: If a person with a common mental health disorder presents considerable and immediate risk to themselves or others, refer them urgently to the emergency services or specialist mental health services.
-  a personalised approach, not based on the completion of a checklist’ • a focus on suicidal thoughts, i.e. encourage staff to confidently tackledifficult questions; • involvement of carers/families, including sharing crisis/safety planswith them.