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1. Introduction
Risk evaluation and safety-planning are an essential part of mental health services. Accurate clinical risk assessment and prevention/reduction of serious untoward incidents (SUIs), such as suicide and serious violence to others (including sexual violence), is crucial for the service users and their family and carers, staff and the general public (Morgan, 2000). In this paper, we assess the perceived effectiveness of a formulation-based approach to risk management (Wales Applied Risk Research Network (WARRN)[1]) as it is used in clinical practice across the health boards in Wales.
1.1 Risk assessment in clinical practice
The Welsh Assembly Government’s (2010) Care Programme Approach states that a risk assessment must be carried out for every service user who comes into contact with secondary mental health services. Thus, risk assessments (and safety plans) must be usable and interpretable by all qualified mental health staff (Webster et al., 2013). Many clinical risk assessments, such as the HCR-20 (Douglas et al., 2014), are complex and involve extensive training to use within mental health services (Morgan, 2000). It is not practical or cost-effective to be able to train every mental health professional on the multitude of clinical risk assessments that are available. Furthermore, most risk assessment instruments are also resource intensive and take significant amounts of time to complete. These issues are at odds with the fast-moving nature of secondary mental health services and the pressure to meet government policy objectives. In addition, a lack of confidence by staff in their ability to use risk assessments due to unfamiliarity with the instrument or inadequate training may result in poorly executed risk assessments and even complete absence of use. Thus, whilst research has produced risk assessment tools with good predictive validity (Monahan et al., 2001; Gray et al., 2003, 2011), their use in actual practice may not be as affective (Fazel et al., 2012) and they appear difficult to implement in applied mental health services and this may have implications for the safety of service users and the public (Callaghan and Grundy, 2018).
Concerns regarding the large variability in clinical risk assessment instruments used across mental health services have also been raised (Kettles et al., 2003). This large variety leads to the poor communication of risk...