Theme: Patient Safety
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Forensic Risk Management Study Circle
Authors: Associate Professor
Consultant Forensic Psychiatrist
Institutions: The Huntercombe Hospital Norwich
The Huntercombe Group United Kingdom

The idea for the study circle emerged following concerns of injuries to staff and patients that were highlighted following a number of un-toward incidents that occurred at The Huntercombe Hospital Norwich. The reduced availability of forensic specific training and the limited length of forensic experience of clinical staff were identified amongst some of the contributory factors to these incidents. This was also compounded by difficulties in promoting an academic and learning culture. A consensus emerged that if forensic specific risk awareness training was made available to staff working in the clinical environment, this would lead to an overall reduction in the number of incidents. Thus, the aims and objectives of the Forensic Risk Management Study Circle were to develop and increase levels of forensic risk awareness and work collaboratively with other team members to reduce the number of incidents.


In increasing levels of forensic risk awareness, the recognition of such issues became easier for  the staff who were dealing with patients on a daily basis. This contributed to the ongoing professional development of staff which in turn impacted upon levels of risk awareness.







Summary of Work

 A Core Group Team Leader was appointed who assembled a core group of five professionally qualified staff. This core group formulated a teaching module which was taught to staff members belonging to a sub-specialty.

Selection of Core Group Team leader (CGTL)


The position of Core Group Team Leader was internally advertised as this was essential to the successful implementation of this training programme. Considering the forensic nature of the setting and the aims of the group – to develop and increase forensic risk awareness, it was essential requirement that the Core Group Team Leader meet the following criteria:


  • More than 10 years experience of working in a forensic setting.
  • Be in possession of a Forensic Psychiatry qualification and higher qualification in Psychiatry.
  • Possess diverse and wide-ranging forensic experience.
  • Demonstrate experience and enthusiasm for teaching post-graduates and mentoring research.
  • The applicant should demonstrate a strong commitment to and evidence excellence in teaching and possess specialised knowledge and expertise which will help reinforce and advance the strengths of the hospital/staff in the broad spectrum of forensic risk management and education.
  • Have a successful track record of being published in peer-reviewed journals.
  • The applicant should have a key role/experience in the relevant field and should demonstrate a key role in developing an academic programme..

It is important to note that after the successful appointment, the Core Group Team Leader had the final decision making authority in the selection of the core group members. It was envisioned that the Core Group Team Leader will have the experience required to identify the pre-requisite skills needed in the initial candidate selection for the Core Group.


Selection of Core group


A core group of five members were selected from applicants based at the Huntercombe Hospital Norwich. Professionally qualified individuals were encouraged to submit applications following the placement of an internal advertisement. The selection of candidates was based on the following criteria:


  • The applicant must possess a professional qualification and be able to demonstrate the ability to participate in the formulation of a forensic teaching module. There was then the expectation that the applicant be involved in the teaching of others.
  • Member of any professionally qualified discipline could submit an application which included nurses who were RGN, RMN or RNLD.
  • The applicant should be able to participate in a discussion group, conduct group meetings and participate in teaching other staff.
  • The appointment of members of the Core Group was determined by the merit of their application and their performance in interview. Therefore, it was possible that two core group members belonging to the same discipline could have been appointed.
  • Be committed to excellence in learning and research.
  • Possess the ability to develop strong and independent research/training in this field.

Following the completion of application forms, the Core Group Team Leader arranged to interview successfully shortlisted applicants, along with the Clinical Director of The Huntercombe Hospital Norwich. Once application forms were received, the Core Group Team Leader interviewed staff members. The initial selection of the candidates for the core group was based on the following criteria:


  • Attitude
  • Awareness
  • Candidates should demonstrate an awareness of Psychological mindedness
  • Awareness of Forensic knowledge and commitment



Following the submission of application forms, applicants were shortlisted and invites sent out for interviews. There were two interviews lasting approximately 45 minutes – 1 hour. The interview process consisted of two separate interviews which were conducted on two different days.


The Clinical Director was invited to join the interview panel with the purpose of ensuring that policies and procedures had been correctly implemented. The Core Group Team Leader had the final decision in the selection of the core group.


Format of interview process


The interview process was not based on a standardised format. To ensure that the most suitable candidates were selected for the core group, other innovative and challenging methods of assessment were used. These included;


·         The discussion of case vignettes selected from (annonymised) medical notes at HHN and/or external sources.


·         Discussion around contemporary forensic cases such as Ian Huntley and Josef Friztl. The candidate should demonstrate an ability to lead and participate in a discussion which would demonstrate the candidate’s recognition, awareness and critical evaluation of risk factors.


·         Evaluation and discussion of a relevant forensic journal article to assess the candidate’s forensic knowledge.


·         A simulated patient case scenario


·         The candidate was also assessed whilst conducting a visit to another ward, where panel members were present. He/she was assessed on factors such as the recognition of potential security risk hazards, identification of risk factors that were present and observation skills (patient safety were not be compromised during this process).


·         Summation and analysis of risk assessment tools such as HCR-20 and HONOs scores.


Selection Criteria for core group


  • A minimum of two years’ service at HHN.
  • A demonstrable interest in academia/research.
  • Ability to work effectively within a team and hold a supervisory role.
  • Demonstrate motivation and ability to participate in the group and possess the ability to teach.
  • Willingness to participate in the formulation and delivery of the curriculum/modules to the sub-speciality groups.
  • Able to demonstrate forensic awareness and risk management.
  • Demonstrate an awareness and interest in Mental Health Law.
  • Demonstrate the ability to analyse and manage complex clinical case scenarios.
  • Provide consent so that any information/data gained can be used for research purposes if required – staff members will not be identified and will remain anonymous.
  • Demonstrate the ability to confirm committment to the group for the next 6-12 months.

Staff members were able to record their involvement and participation in the Forensic Risk Management Study Circle as evidence for their Competency Based Framework (CBF).


Training of core group


The Core Group Team Leader initiated a teaching module, designed to take place over a four-week period. Each teaching session lasted approximately two hours. The teaching module covered the following elements.


  • Informing the Core Group team members about the aims and objectives of the Forensic Risk Management Study Circle.
  • The analysis and evaluation of challenging forensic risk cases and issues.
  • Enhanced communication skills in a forensic setting including;
    • The risks inherent in communication skills.
    • The consideration of communication within the multi-disciplinary team setting included Ward Rounds, Handovers and Occupational Therapy.
    • Lessons learnt from poor communication in forensic settings.
  • Providing the core group with the support and knowledge required to empower them to devise a teaching module which was tailored to the needs of their specialised service.
  • Promoting teamwork and communication skills to ensure that the core group had the ability to convey the learnt risk management skills and strategies to the team on ward.

Identification of sub-specialities


For ease of training purposes and to ensure that teaching was effective as possible, the hospital was divided into sub-speciality groups. These were as follows:


Personality Disorder*


Male Learning Disability


Female Learning Disability


Male Learning Disability


Autistic Spectrum Disorders


(* This service was identified as the first priority)

Selection criteria for sub-specialty team


  • It was the expectation that members of the sub-specialty group would be expected to work for a minimum of two years within that sub-specialty to ensure the success of this programme and that both patients and staff were able to see the benefits of this programme. 
  • Members of the sub-specialty team were interviewed and chosen by the core-group.
  • Each member of the sub-specialty team provided with continuous on-going professional development by members of the core group, thus promoting confidence, motivation and interest.

Applications were initially sought for the Personality Disorder Service which was open to all clinically based staff working at HNN. Nominations were selected on basis and need. In cases, where there were more applications than required, an interview process was adapted to meet the minimum essential numbers of staff required to work on one ward.


Sub-specialty Forensic Risk Management training


Following the interview process and transfer of sub-speciality staff, the sub-speciality group training was completed over a 12 week period.


Teaching to the sub-specialty group involved the following:


  • Case vignettes – derived from HHN cases or published material from medical journals and textbooks.
  • Semi-structured interviews.
  • Lectures, tutorials and case conferences.
  • Group work with the emphasis on working as a team.
  • Enhanced communication skills training.
  • Role plays scenarios.

Review of sub-speciality group


The group’s progress was evaluated after twelve weeks. A review took place to evaluate how far the aims and objectives of the group were met. Modifications were made to the teaching module at any stage (if required) to ensure that the group was functioning to the best of its abilities and that aims and objectives were within the given time frame. .It was carefully considered that teaching was not provided to the next speciality until the on-going sub-speciality group had been successfully taught.


Measurement of Outcome Assessments


  • Measuring of abilities before and after the teaching programme had been delivered.
  • Completion of group tasks.
  • Individual assessments and group assessments.

Alternative methods of Outcome Assessments


Other methods of assessing the progress and success of achieving aims and objectives in the sub-speciality group included;


  • Objective measurements such as AIDOs and security breaches (it is acknowledged that any potential reduction could be due to confounding factors).
  • Questionnaires to assess staff morale and confidence.
  • Logbooks of individual staff members reflecting any clinical improvement in their day-to-day practice.
  • Scenarios/vignettes at the start and the end of the assessment period. Evaluation as to the progress made by the group was measured by the quality of responses given by staff members to different scenarios and vignettes.

FRMSC was pieced together with the help of a series of brain storming multidisciplinary team meetings -- and many of them went on quite late in the cold winter evenings. Of those I can name thanks to Dr Mateen Durrani Clinical Director The Huntercombe Hospital Norwich and Alain Sockalingum the then Hospital Director at the time. I am also grateful to my patients who were extremely tolerant with all their difficulties in helping us find answers to our questions.


 The dynamic nature of the Forensic Risk Management Study Circle helped staff acquire skills and competencies. As the study circle was allowed to evolve according to its needs, it ensured that issues could be addressed and overcome. Frequency of serious incidents were reduced and staff were more confident in risk mangement assessments. Discussion and risk awareness training was tailored according to the needs of the specific service. If weaknesses were identified in a particular area which the Core Group Team Leader had previously not identified, then the structure of the study circle ensured that these were addressed before moving on to other identified issues.



Take-home Messages

Indegenious training programmes save investing in external training programmes related to the sub-specialty. It enhances the confidence of staff to learn from the evidence based clinical practice and promote their competence and skills through their hands on experience.

Key to successful outcome ; 

 I dentify  clinical staff for a sub-specialty. 

Target to complete two hours training per week over an 8 week period.  

The allocated two hours should be protected time and staff must be allowed to attend. Consider the provision of cover staff as second line of defence.


 Staff to be paid overtime if the training schedule doesn’t occur during the participant’s working hours.


 Provide Certificates of attendance and participation.




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Litwack TR, Schlesinger LB: Dangerousness risk assessments: research, legal, and clinical considerations, in Handbook of Forensic Psychology, 2nd ed. Edited by Hess AK, Weiner IB. New York, Wiley, 1999


Otto RK: Assessing and managing violence risk in outpatient settings. Journal of Clinical Psychology56:1239—1262, 2000


Reed J: Risk assessment and clinical risk management: the lessons from recent inquiries. British Journal of Psychiatry 170:S4-S7, 1997

Snowden P: Practical aspects of clinical risk assessment and management. British Journal of Psychiatry 170:S32-S34, 1997

Summary of Work


Take-home Messages
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