Risk needs and management differences of high secure patients
Research type
Research Study
Full title
Offenders, prisoners, or patients? Risk needs and management differences of patients in high secure settings referred through different routes
IRAS ID
350730
Contact name
Greco Muratori
Contact email
Sponsor organisation
The State Hospitals NHS Board for Scotland
Clinicaltrials.gov Identifier
TSHRC/020, Study reference number
Duration of Study in the UK
0 years, 11 months, 28 days
Research summary
Summary of study
For a long time, there has been a debate on whether people who have committed an offence have done so because they lack the capacity to know any better, or whether they are morally culpable for their actions. This topic has also highlighted that people tend to view offenders as fitting into one of these two categories – ‘bad’ or ‘mad’. With this in mind, this study predicts that staff in a high secure forensic mental health hospital will have different views of patients: (a) who have been moved from prison for treatment (who we will call ‘Transfer for Treatment Direction patients’ or ‘TTDs’ – with reference to the legislation by which they are admitted to hospital), and (b) who have been admitted through other hospitals or the Courts (who we will call ‘non-TTD patients’). We believe they will have views of the TTDs as ‘bad’ and therefore mainly needing to be managed; while they will see the non-TTDs as ‘mad’ and therefore mainly needing care and treatment.
The study will explore whether TTDs get assigned stricter security measures than non-TTDs, in a high security hospital. This will then be compared to whether TTDs actually show more challenging behaviours or more risks factors for this than non-TTDs – to see if the stricter security measures are justified. It is predicted that TTD patients are managed under stricter security measures, but that they do not display more incidents or risk of challenging behaviour than the non-TTD group.
We argue that this research will be helpful in explore the impact of possible views of TTD patients on the treatment they receive in a high secure hospital. We believe that this will help to highlight areas of training to focus on, to improve the care that is provided to all patients in these settings.
Summary of Results
This study explored whether there are differences between patients admitted to a high secure forensic mental health hospital following transfer from prison and other patients admitted to the hospital through different routes. Patients transferred from prison are referred to in this study as Transfer for Treatment Direction (TTD) patients. Other patients admitted to the hospital are referred to as non-TTD patients. There is a lack of previous research comparing these groups.The study aimed to understand whether these two groups differed in terms of their background risk factors, behaviour while in hospital, and the level of security measures applied to them. There was a particular interest in whether differences in how patients enter secure hospital care may influence how they are perceived and managed by services. Previous research has suggested that people may sometimes be viewed differently depending on whether their difficulties are understood primarily as related to mental illness or as related to offending behaviour and personal responsibility. This study explored whether these different perceptions may influence approaches to risk management.
Information routinely collected during patients’ care was reviewed. This included information from structured risk assessments, previous offending history, records of incidents occurring within hospital, and information about individual security measures. Statistical analyses were used to compare TTD and non-TTD patients and to examine which factors were associated with differences in risk management decisions.
The findings showed that TTD patients had more extensive histories of offending and higher levels of some historical risk factors compared with non-TTD patients. However, there were no significant differences between the two groups in relation to current treatment-related risks or challenging behaviour occurring within the hospital. In other words, despite differences in their previous histories, the two groups showed similar levels of current dynamic and behavioural risk during their admission.
Despite this similarity in current risk presentation, TTD patients were consistently subject to stricter security measures across several areas. These included greater restrictions on access to hospital grounds, increased monitoring of substances and correspondence, and higher levels of supervision during communication and visits. These differences remained even when length of admission was taken into account.
The findings suggest that decisions about security management within high secure services may be influenced by a combination of factors, including a patient’s previous history, referral pathway, organisational processes, and perceptions of risk. While historical risk information is an important part of safe clinical practice, the findings highlight the importance of ensuring that current behaviour, clinical presentation, and individual circumstances are also carefully considered when making decisions about restrictions.
The study does not suggest that security measures applied to patients are inappropriate or unnecessary. High secure hospitals have important responsibilities to protect patients, staff, and the public. However, the findings highlight the importance of regularly reviewing whether restrictions remain proportionate, are based on current individual needs, and follow the principle of using the least restrictive approach possible while maintaining safety.
The results may help inform future practice by encouraging continued reflection on how risk decisions are made, including consideration of potential assumptions linked to a patient’s background or pathway into services. Further research is needed to better understand how staff perceptions, organisational factors, and wider systems influence risk assessment and security decisions within high secure mental health care.
REC name
West of Scotland REC 4
REC reference
25/WS/0058
Date of REC Opinion
9 May 2025
REC opinion
Favourable Opinion