UNIT 8

KEY PRINCIPLES AND VALUES THAT UNDERPIN RISK MANAGEMENT

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Table of Content

1. Key principles and values that underpin risk management

2. Working together within the risk management process

3. How to involve carers and family members effectively

4. Risk factors that should be considered during risk assessments

5. The role of suicide reduction strategies

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KEY PRINCIPLES AND VALUES THAT UNDERPIN RISK MANAGEMENT

A risk assessment involves collecting information about an individual through the processes of

observation, communication and investigation. It is not a one-off planning event but an ongoing

assessment to ensure that individuals remain safe but are also enabled to live their life in the way

that they want to.

In order to be effective, risk assessments must involve the individual, any carers or advocates that

they may have, their family and friends and any health professionals with whom they are involved.

All of those involved must speak freely with each other and this includes raising any concerns about

an aspect of a risk assessment that they may not be happy with. Each time a review takes place, all

of the people involved will need to ensure that any amendments made are discussed thoroughly

before all parties sign to say that they are satisfied with any changes.

Positive risk-taking in addition to risk of harm: any risk that is presented when planning an

individual’s care and support should be considered and not seen as a reason to dismiss

something that the individual wants. Being open-minded about all aspects of risk will build the

individual’s confidence and self-esteem and therefore enable them to live more independently,

which is the overarching aim of person-centred care.

Considering a range of types of risks: there are risks in every aspect of life and these will

vary in severity dependent upon each individual. A risk assessment should be as broad as

possible so that risks in all areas of the individual’s life are considered; this way nothing can

be missed and there is a much greater chance that the individual will remain safe.

Evidence-based approach: this kind of approach uses professional knowledge alongside

well researched interventions in order to ensure that risks are not going to make anyone face

deliberate harm. It is also based on knowledge of the individual, such as their characteristics

and values, all of which combine to ensure that risk assessment planning is thorough and

based on what is already known rather than projecting or guessing about something.

Forward planning to reduce risk of harm: an informed choice can only be made if the

individual has all of the information available to them. This may mean that information has to

be presented in other formats or by use of an advocate. Failure to give all of the information to

someone breaches person-centred care principles and may put the individual at unnecessary

risk, and so using this method to plan ahead will be most effective at ensuring that the risk of

harm is significantly reduced.

Specifying warning signs: a warning sign can be anything which alerts others to the fact

that an individual is going to be put at risk of harm. For example, if a risk assessment

concluded that the individual was able to administer their own medication, a warning sign

around this might be that they tend to become forgetful due to a stressful situation. This kind

of warning sign must be clearly stated within a risk assessment and within the care and support

plan so that an intervention can be put into place before it causes harm.

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Contingency planning: contingency planning means preparing what to do if there is some

form of crisis, emergency or a significant, sudden change in the individual’s needs. Everyone

involved in a care and support plan should know the role they play in contingency planning

and the individual may also have some self-help strategies as part of their own planning. For

example, someone who experiences bipolar disorder may need to have their financial

responsibilities passed to someone else during a manic phase and so a contingency plan for

this might include the individual being aware of warning signs and letting the person who takes

this responsibility know as soon as possible.

Specifying roles and responsibilities: an individual’s family, friends and carers are likely to

be a big part of their life and person-centred care acknowledges this by including them in all

aspects of care planning. This is useful as everyone involved with the individual knows what

plans are in place and it gives confidence to everyone that communication is open, and everyone

knows who is responsible for what aspects of the individual’s care and support. In addition, all

healthcare professionals should know what their roles and responsibilities are so that if there

are any questions, the individual knows who to contact.

Anti-discriminatory practice: if an individual is subject to discrimination during a risk

assessment, this may mean that they are unable to take some of the risks that they want to in

order to make their life meaningful. All professionals involved in a risk assessment should

ensure that they are inclusive and do not base their decisions on inaccurate stereotypes; they

should also suspend their own value and belief

Regular review: reviews must take place to check that the assessment findings that have been

applied in a care and support plan are still relevant. It may be that a person’s condition has

improved or deteriorated, in which case changes will need to be made in order to make sure

that the individual remains safe. The individual must be as involved in a review as they were in

an initial assessment and their wants and needs are still a priority when new risk assessments

are taking place.

Effective record keeping: effective records must be kept so that it is clear what has been

decided, when and by whom. Records must be factual and presented in a way that is fully

accessible by the individual. They must ensure confidentiality and be made available to the

individual should they wish to see them and every entry into a record of planning must be signed

and dated.

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Case Study – Scott

Scott has bipolar disorder, which is usually well controlled by medication. Due to

incidents of attempted self-harm prior to a diagnosis, Scott still has a social worker and

a care coordinator with whom he meets regularly. He has requested a review of his

care and support plan because he feels that he can now return to his university degree,

which was suspended because of the stress it caused him, leading to self-harming

behaviours just prior to his diagnosis.

His care coordinator tells him that this will be subject to a risk assessment because

there are a lot of things to take into consideration. As this is what Scott wants he

believes that he should not need a review but agrees to go along and brings his

mum with him who is reluctant to agree with Scott that a return to education is his

best course of action, just at the moment.

A representative from the university also agrees to attend and the meeting is very

successful. Scott is going to be given a mentor whilst at university who will be

available to him at any time, if he starts to feel stressed or anxious about what is

expected of him. He will return on a part-time basis and the university has agreed

that some of his lectures can be attended by an online forum. His goal is to

complete his first year by the end of May and then he will meet with the university

representative to see what his options are for the next academic year.

Scott's social worker has arranged for him to get a taxi to the university, as it is quite

close, but Scott does not yet feel confident enough to either walk or get public

transport. Scott may need extensions to university deadlines but knows he must be

as proactive as possible in getting things completed to normal deadlines and will

discuss any issues in this area with the relevant lecturer.

Everyone present at the meeting, including Scott, is very pleased with the outcome

and a review is set for three months to see how things are progressing.

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WORKING TOGETHER WITHIN THE RISK MANAGEMENT PROCESS

Everyone who works with an individual should have some form of role within a risk management

process because everyone will have some information which is relevant to the risks that they are

enabled to take. As ever, the individuals themselves should be the focus of this process and it should

be considered what they can do in order to promote risk-taking rather than on what they cannot do

to try and discourage risk-taking.

The risk management process is, therefore, a collaborative task that should form part of a person’s

care plan assessment, the findings of which should be recorded in the plan so that they are

accessible to everyone with whom the individual works.

WHY AGENCIES AND WORKERS SHOULD WORK TOGETHER WITHIN THE RISK MANAGEMENT PROCESS

When everyone works together, a strategy of ‘managing risk positively’ can be applied, which

means that benefits and potential costs of risk are weighed up so that the individual is still enabled

to have their wants and needs met but in a way that still ensures their safety.

This form of risk management process has many benefits, which include:

The empowerment of individuals: working together empowers individuals to take control

of their own life – they are seen as an equal partner in the risk assessment and care

planning procedure, which can be a significant factor in increasing their self-esteem,

resilience and confidence.

Risk-taking is assessed in a holistic way: when all parties are involved, this helps to

ensure that risks are not just assessed in terms of the individual’s medical needs but in

terms of their other needs as well such as social, religious and dietary.

All parties involved are aware of their role in the process: this actively increases

ownership so that if something untoward does occur those who are responsible can take

responsibility and ensure that steps are put into place to learn from what has taken place.

The development of trusting relationships: for any care assessment which involves risks

to be successful, trust must be the foundation. These work in a mutual way between

individuals and professionals, carers and family members and professionals and individuals

and their carers and family members.

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Enabling the individual to learn from experiences: there will inevitably come a time when

a risk assessment does not predict something that ‘goes wrong’ within a plan, which may be

something minor or something which puts the individual at risk of harm. When individuals

can learn from this, they become more self-aware and this can help them to plan more

realistically for the future.

Developing an understanding of what works well and what does not: all parties

involved need to be aware of what works and what does not. These can be assessed by

completion of a simple document where everyone involved gives their opinion about how

things are progressing and what needs to be reviewed as it does not meet the needs of the

individual or may be putting them at risk.

Ensuring a consistent approach to risk management processes: everyone must be

consistent in their approach to risk management as mixed messages from professionals and

others can cause frustration and confusion to individuals who may experience further mental

health distress because of this.

Ensuring that health professionals are aware of their duty of care within the process:

working in a collaborative way helps professionals to ensure that their duty of care towards

an individual is clear and is not breached by any aspect of the risk assessment process.

Professionals may find it useful to liaise about areas of their duty of care that are vague and

can find guidance from others to be very useful.

Accurate records are kept protecting the individual: all decisions must be recorded in a

legal and accurate way to ensure that if these need to be referred to, it was clear who agreed

to what actions and who was present when a risk assessment meeting took place. This is not

to place blame on anyone should something happen but ensures that everyone is consistent

in care and risk management planning in line with appropriate policies and legislation.

HOW AGENCIES AND WORKERS SHOULD WORK TOGETHER WITHIN THE RISK MANAGEMENT PROCESS

All parties involved should meet, which should include the individual and any carer, family member,

friend or advocate whom they wish to have present with them. All parties should be enabled to have

their say about the risks that have been proposed without fear of judgement or discrimination.

Everyone should be aware of the plans that have been put into place and these should be fully adhered

to by all parties to ensure that care and support is provided consistently.

Should a review need to take place, this should be with all relevant people and should always be

carried out in exactly the same way as the original assessment with the individual’s wants and needs

at the centre of any decisions that are taken. It should also be kept in mind by all people involved

that some risks cannot be completely removed just because individuals may be classed as

vulnerable because of a mental health issue. This would almost certainly cause them to feel

disrespected and would have a negative impact on their overall quality of life.

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HOW TO INVOLVE CARERS AND FAMILY MEMBERS EFFECTIVELY

Carers and family members may be less willing to enable the individual to take risks than healthcare

professionals because they feel a continued sense of protection of their loved one, even when they

are adults. Due to this, the importance of involving them in the risk management process cannot be

underestimated and there are many ways in which this can be achieved, for example:

Enabling them to see what the individual is capable of rather than what they cannot

do: it can be very difficult for family members and carers to see the individual as a capable

person if they have been providing care for a long time. They will see risks as an opportunity

to cause harm rather than enhance the life of the individual. If, however, carers and family

members are enabled to see the benefits of positive risk-taking, they are more likely to be

willing to take a more constructive part in risk assessment planning.

Ensure that all information discussed during the process is clear and accessible to

them: making sure that all information is clear and fully understandable can help carers and

families see precisely what the risks and benefits of an activity might be. It may also help to

dispel inaccuracies about what risk-taking is, which may have been a factor in any reluctance

to enable the individual to take risks.

The needs and wants of carers and family members should be considered: although a

care plan is created around the individual, it is very important to let carers and family members

have their say about risk management as they will know the individual well and therefore be

aware of what their capabilities are.

Ensure that carers and family members feel valued and respected throughout the

process: anyone who does not feel as though their input is valued will be unlikely to want to

be involved in risk assessment, so it is really important that health professionals treat family

members and carers as equal partners in the risk assessment process, in line with person-

centred approaches.

When carers and family members are fully involved in a risk assessment process, this should ensure

that decisions are made that are acceptable to all, without the need for conflict between parties, which

can be difficult to resolve, and in a way that does not cause some form of distress for either the individual

or a significant other.

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RISK FACTORS THAT SHOULD BE CONSIDERED DURING RISK ASSESSMENTS

A risk factor is anything that increases the likelihood of something happening, for example a risk factor

for a heart attack is a poor diet and lack of exercise and a risk factor for depression is the experience

of bereavement.

During a risk assessment, all forms of risk factors should be discussed in order for a plan to be

created which reduces those risks as much as possible. For individuals who experience mental

illness there are several situations which increased risk factors may have, which include:

Risk of harm to self: for example, engaging in self-injurious behaviours including potential

attempts at suicide

Risk of harm to others: for example, individuals who may be at risk of losing control due to

psychosis and who may attack people who they do or do not know

Risk of being harmed by others: for example, being subject to some form of abuse

Risk of being harmed by mental health services: for example, not being given

appropriate care or being given the wrong form of medication.

The table below indicates the risk factors that may be present for each type of risk; it must be kept

in mind that some of the risk factors will be related to more than one type of risk and that ‘different

types of risk situation’ is very difficult to specify as risk is a very subjective matter and what may pose

as a risk to one person with a mental health condition may not to another and vice versa.

Potential Risk Potential Risk Factors Harm to self Family history of mental illness

A history of previous attempts of suicide or self-harming behaviour

Anxiety and agitation

Severe depression

Alcohol or drug misuse

Males are much more likely to attempt suicide than females

Chronic mental illness, particularly bipolar disorder and schizophrenia

Feelings of self-loathing and hopelessness

History of trauma or abuse

Unemployment

Social isolation

Poverty

History of involvement with the criminal justice system

Family breakdown.

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Harm to others Serious mental illness where there is a risk of psychosis

A history of abuse

Destructive relationships

Poor access to services when needed

Poor communication

Being the focus of antisocial behaviour

Experiences of prejudice and discrimination.

Being harmed by others

Specific mental illnesses, such as depression and bipolar disorder

Having access to finances, as individuals can be manipulated into giving money to people and being financially abused

Social isolation

Poor capacity to make decisions

Lack of awareness of where to seek help and support and to exercise rights

Physical dependency on others.

Being harmed by mental health services

Poor communication of needs

Being unable to access appropriate information

Lack of identification of being in crisis

Poor access to services

Improper application of the Mental Health Act 1983

Medication instructions not being properly explained

Being treated in a way that is disrespectful and undignified.

THE ROLE OF SUICIDE REDUCTION STRATEGIES

There were 6,581 suicides in the UK and Republic of Ireland in 2014. This equates to someone dying

by this method once every 90 minutes. The government has placed official suicide reduction strategies

at the forefront of mental health services because this group of individuals is at significantly increased

risk of suicide compared to the general population, although this does not mean that all individuals

who experience mental ill health will also experience suicidal thoughts or attempts.

Anyone, however, who may be considered at risk of suicide, should have reduction strategies

discussed and implemented as part of the risk assessment process. Some of these strategies

include:

Reducing prejudice about mental illness: if it appears that an individual is experiencing

prejudice or discrimination because of their mental health condition, this must be

acknowledged by the risk assessment plan, and measures put into place to reduce the harm

it has on the individual, such as offering them therapy or helping them to remove themselves

from destructive relationships where this might occur. They should also be enabled to

exercise their rights where discrimination has taken place in line with the Equality Act 2010.

Reduction of prejudice about mental illness would increase an individual’s willingness to seek

help without fear of judgement, enabling them to make a more effective recovery.

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Adequate training of health professionals to enable them to better identify someone

at risk of suicide: although some individuals will show no signs of suicidal intentions there

are some signs which can identify that they are at risk. Training for health professionals to

identify these signs may mean that interventions can be put into place to help the individual

and, should these be identified at a risk assessment, so that such individuals can be

connected to appropriate support and be monitored for changes or responses to triggers.

Proper access to care and support at a time when it is most needed such as at a time

of mental health crisis: it is vital that individuals who may show suicidal thoughts or actions

have proper care, which may have to be put into place for them because most people who

are distressed will not seek help or support on their own. Triggers for crisis must be identified

in a care plan and everyone must know what their responses and responsibilities should be

at such times, as well as ensuring that the individual themselves knows what these triggers

are.

Sufficient short- and long-term support planning: a care plan should indicate what

support measures are in place in terms of risks both in the short and long terms. Clear

identification of risks at the moment and those which can be predicted should ensure that

the individual is kept safe, but it is important to note that not all risks can be predicted, which

is why consistent review of risk management processes is vital.

Reducing access to means of suicide: it is important to know if individuals have suicide

plans or have planned such actions in the past. This way, the removal of anything which

may increase the risk of suicide, such as attempting to stockpile medication or trying to

obtain a lethal weapon, may help to reduce risks of suicide. It is important that carers and

family members are educated about those who may be in crisis and what means of suicide

might be.

Promotion of social inclusion and connectedness: supportive relationships can help

protect individuals against suicide even though there may be several risk factors.

Connectedness may be part of a care and support plan if individuals are happy to engage in,

for example, support groups or community-based activities. Although these may present

risks themselves, these must be balanced against greater risks such as social isolation,

which may increase the chance of suicide.