11 Forensic psychiatry11.3 Practising psychiatry in a secure setting
11.3.1 Security in a therapeutic environment
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Written by Resident Doctor Committee · Published
The three domains of security
The Mental Health Act Code of Practice for England describes three domains of security that work together. No domain can do another's job.
Domain | What it covers | Example |
|---|---|---|
Physical | Perimeters, controlled access, alarms, sightlines and ligature reduction | Locks and alarms |
Procedural | Processes for leave, searches, visits and belongings | A safe leave process |
Relational | Staff knowledge of each patient and the ward, and their response when things change | Regular one-to-one contact with a named nurse |
Relational security is built through relationships, communication and purposeful activity. It lets staff spot changes in activity, possessions or family contact that mean something only against a person's usual behaviour.
See Think Act treats the team, other patients, the patient's inner world and outside connections as the parts of relational security.
Levels of security
The level of security follows current violence and escape risk and how long that risk is expected to last, not the offence label alone.
The index offence shows past mechanisms and possible severity, but it cannot establish present risk on its own.
Setting | Who it is for | Example |
|---|---|---|
High secure hospital (Broadmoor, Rampton, Ashworth) | Grave and immediate danger to the public, because its perimeter and relational security resist organised escape | A planned escape with outside help and a stated intent to kill |
Psychiatric intensive care unit | Acute disturbance likely to settle over days to weeks | Mania |
Low secure unit | Persistent longer-term risk to others, usually with offending behind it | A step-down patient whose risk has fallen from serious to significant and who needs graded leave and rehabilitation inside a secure perimeter |
A physical emergency overrides any psychiatric setting and needs an emergency department. An example is neuroleptic malignant syndrome after starting haloperidol: fever, rigidity, confusion, labile blood pressure and a very high creatine kinase.
The DUNDRUM toolkit is a suite of structured professional judgement instruments developed in forensic services. It guides how much therapeutic security a forensic patient needs at admission and along the secure care pathway, and when they can move on.
Patients should move on once their current level is no longer needed, and bed pressure should never drive unsafe progression.
Violence on the ward
Younger age is a consistent patient-level risk factor for aggression on psychiatric wards.
Heavy reliance on bank or agency staff is a ward-level risk factor, because temporary staff lack rapport and knowledge of individual triggers.
Staff-patient contact, structured activity and patient forums protect against ward violence.
Observation and restrictive interventions
The National Institute for Health and Care Excellence guideline NG10 sets observation levels. Staff choose the least intrusive safe level, explain it and review it.
Level | Frequency |
|---|---|
Low-level intermittent | Every 30 to 60 minutes |
High-level intermittent | Every 15 to 30 minutes |
Continuous | At a specified proximity and staffing level |
Seclusion is supervised isolation in an area the patient cannot leave, used only to contain severe disturbance likely to harm others. It is never a punishment, a response to short staffing or a response to self-harm alone.
Long-term segregation is prolonged separation from free mixing with other patients, used for sustained risk to others that needs more than brief seclusion.
NG10 advises that routine manual restraint should not run beyond 10 minutes, and mechanical restraint in adults is limited to high secure settings.
The Code forbids blanket restrictions and restrictions for provider convenience, so each restriction must be necessary, proportionate and assessed for the individual.