Risk of violence, neglect, exploitation and vulnerability

01Purpose and principlesWhat the assessment is for and the core concepts behind it.

Violence is not explained by diagnosis alone. Establish previous behaviour from the patient, records and collateral sources: what occurred, to whom, in what setting, with what weapon or injury, under which symptoms or substances, and how it ended. Distinguish remote, isolated events from a recent escalating pattern. Explore current grievance, intent, target access, planning, rehearsal and capability. Ask about protective factors such as voluntary distance, treatment engagement and trusted support, testing whether they operate in the proposed scenario.

Formulate dynamic mechanisms. Persecutory belief may focus attention on a named neighbour; alcohol may reduce inhibition; eviction may increase contact; weapon availability may increase lethality. Each link suggests an intervention. Also assess medical and neurological contributors to agitation, including delirium, pain, intoxication, withdrawal, head injury and adverse medicine effects. Use de-escalation and trauma-informed communication, preserving personal space, clear exits and calm explanation. Restriction must be necessary, proportionate and reviewed.

Assess risk to the person with equal seriousness. People with severe mental illness may experience domestic abuse, exploitation, hate crime, financial control, trafficking and neglect. Speak privately with a professional interpreter rather than a controlling companion. Ask who controls money, housing, medicines, telephone, sex, work and travel; look for fear, inconsistent access and unexplained injuries. A person may both cause and experience harm. Avoid forcing a binary victim-perpetrator label when relationships are complex.

Self-neglect includes inability or refusal to meet essential care, health, hygiene, nutrition, accommodation or safety needs. Determine capacity for the specific decisions, underlying mental or physical illness, executive ability, coercion and the seriousness of consequences. In England, the Care Act adult-safeguarding criteria depend on needs for care and support, experience or risk of abuse or neglect, and inability to protect because of those needs. Wales, Scotland and Northern Ireland use different legislation and procedures, so follow the current local pathway.

Information sharing follows purpose. Seek consent where practicable, but GMC guidance permits disclosure when required by law or justified in the public interest to protect someone from death or serious harm. Share relevant facts with the agency able to act, not the entire history by default. Consider warning or protecting an identifiable potential victim with senior, safeguarding, police or legal advice. Document the evidence, alternatives, recipient, content, whether the person was informed and why the decision was proportionate.

Key points

Assess harm to others, harm from others, self-neglect, exploitation, safeguarding of dependants and environmental hazards as related but distinct scenarios.
Start with actual behaviour: previous violence, pattern, context, severity, targets, triggers, access to means, consequences and what previously stopped escalation.
Ask directly about current thoughts, grievances, named people, intent, planning, weapons, stalking, arson, sexual violence and ability to maintain distance.
Identify dynamic drivers including symptoms, substances, pain, humiliation, housing, relationship conflict, peer influence, treatment disruption and anticipated events.
Obtain collateral and records with consent where possible; urgent serious-harm or safeguarding information may justify proportionate sharing without consent.
Use structured professional judgement where the service supports it, but do not let a tool replace formulation, current examination or individual context.
Include vulnerability and victimisation: coercive control, county lines, cuckooing, financial abuse, hate crime, neglect and inability to protect oneself.
Match interventions to the pathway through de-escalation, separation, means control, substance treatment, safeguarding, accommodation, victim support and clinical care.
Record the specific feared event, timeframe, potential victim, warning signs, actions, information sharing and review owner instead of a global risk label.

02Indications, selection and cautionsWhen it is useful, when urgency changes and important limitations.

Targeted violence scenario

A grievance, named person, route of access, available means and recent rehearsal creates a concrete pathway requiring immediate disruption.

Dynamic escalation

Intoxication, insomnia, acute symptoms, humiliation, treatment loss or impending contact is increasing the likelihood or potential severity of harm.

Coercive exploitation

Another person controls money, accommodation, communication, substances, sex or treatment and the patient cannot safely exercise ordinary choices.

Severe self-neglect

Essential nutrition, health, hygiene or environmental safety has deteriorated enough to create serious harm and possible adult-safeguarding duties.

Mixed direction of harm

The person can be threatened, exploited and reactive while also posing danger, requiring separate formulations and protections for each pathway.

Red flags requiring action

A named target, recent surveillance, weapon access, rehearsal, command hallucinations or rapidly escalating grievance makes a violence scenario more concrete and urgent.
Intoxication, withdrawal, acute psychosis, mania, head injury, delirium, sleep deprivation and recent non-adherence can change risk rapidly and require cause-specific treatment.
Unexplained injury, fear of a companion, restricted money or communication, sexual exploitation, trafficking or forced medicine use may indicate that the patient is a victim rather than a perpetrator.
Malnutrition, untreated illness, unsafe housing, fire risk, medication omission or inability to seek help can constitute serious self-neglect even without overt suicidal intent.
A psychiatric diagnosis, ethnicity, homelessness or previous detention must not substitute for behavioural evidence or justify blanket coercion.

03Method and interpretationA systematic approach to the test and its findings.

Investigation order

Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.

01
Behavioural and forensic chronologyFirst step
Why
Define past acts, targets, context, severity, legal outcomes, triggers and previous successful prevention.
Interpretation and limitations
Recent similar behaviour has greater scenario relevance than a remote unrelated event. Records may contain bias and require source checking.
02
Current intent and means assessment
Why
Clarify grievance, target, planning, weapon access, stalking, arson, sexual harm and voluntary distance.
Interpretation and limitations
Specificity and opportunity alter urgency, but disclosure can be incomplete; combine interview with behaviour, collateral evidence and environmental facts.
03
Dynamic clinical assessment
Why
Identify psychosis, mood activation, cognition, substances, withdrawal, pain, sleep and treatment disruption.
Interpretation and limitations
Treatable drivers suggest interventions but do not make violence inevitable. Reassess after sobriety, symptom treatment and environmental change.
04
Vulnerability and safeguarding enquiry
Why
Detect abuse, exploitation, trafficking, financial control, neglect and risk to children or dependent adults.
Interpretation and limitations
Interview privately and assess decision-specific capacity, coercion and immediate danger. Use the jurisdiction's statutory safeguarding pathway.
05
Scenario-based risk formulation
Why
Connect a feared event to trigger, target, means, timing, warning signs and interruption points.
Interpretation and limitations
Record separate formulations for different harms and name responsible actions; a single high-risk label lacks operational detail.

04Clinical next stepsHow the result changes management or prompts escalation.

01Immediate threatSeparate, de-escalate and protectFirst stepEscalationCurrent behaviour or credible information suggests serious harm may occur soon.

1Secure exits, summon trained support, separate potential victim and aggressor where safe and remove accessible means without provocative confrontation.
2Assess physiology, intoxication, mental state, target, intent, plan and capability while activating emergency or police support when required.
3Use the least restrictive effective intervention and share necessary information with safeguarding or protection services, recording rationale and review.

02Violence formulationBuild a behaviour-linked scenarioThere is a history, threat or clinical state requiring forward risk management.

1Map past relevant acts and current grievance, symptoms, substances, access, relationships and environmental opportunities.
2Define the most plausible victim, event, timeframe and warning signs and identify factors that reduce or increase each link.
3Assign interventions for clinical drivers, means, contact, accommodation, substance use and victim protection with named ownership.

03Vulnerability responseCreate private space and safeguardAbuse, exploitation, self-neglect or risk to a dependent person is suspected.

1Speak privately with communication support, assess immediate safety, specific decisions, coercion, essential needs and people exposed to harm.
2Seek consent for referral where possible and use the relevant statutory or public-interest route when serious harm requires action without it.
3Agree safe contact, accommodation and follow-up arrangements that do not reveal information to a suspected perpetrator.

05Risks, monitoring and follow-upComplications, safety checks and further assessment.

Reassess scenarios after intoxication resolves, symptoms change, a target becomes accessible, housing changes or a significant court or relationship event occurs.
Review whether separation, means control, treatment, safeguarding and accommodation actions actually occurred rather than assuming referral equals protection.
Track victim fear, contact attempts, stalking behaviour, weapon access and breaches of agreed boundaries using verified information where possible.
Review carer and staff safety plans without excluding the patient from transparent discussion unless disclosure would itself increase danger.
Document de-escalation, restraint, police involvement and injury, then debrief and revise prevention plans after each serious incident.

06Special situationsVariants, exceptions and circumstances that change the usual approach.

Diagnosis is not destiny

Most people with mental illness are not violent, and formulation should focus on individual behaviour, context and modifiable pathways rather than stereotypes.

Victim and perpetrator coexist

A patient may use violence while also experiencing coercion or exploitation, so each direction of harm needs its own evidence and intervention.

Specificity drives action

A named target, route of contact and weapon suggests different protection from diffuse angry thoughts without intent or opportunity.

Self-neglect is multifactorial

Capacity, executive function, poverty, physical disability, hoarding, coercion and service refusal can combine and require different legal and practical responses.

Tools support judgement

Structured methods can improve consistency in specialist settings but cannot supply current facts, cultural context or an individual management plan.

07Common pitfallsFrequent interpretation and management errors.

01
Inferring violence risk from psychiatric diagnosis, ethnicity, homelessness or appearance alone.
02
Assessing only harm by the patient and missing exploitation, abuse or hate crime against them.
03
Using a global risk category without naming target, scenario, trigger, means and intervention.
04
Letting a structured tool replace interview, collateral evidence and dynamic reassessment.
05
Interviewing about domestic abuse through the accompanying partner or family interpreter.
06
Assuming refusal of support proves capacity or removes adult-safeguarding concern.
07
Sharing the entire record when a limited factual disclosure would address the serious danger.