ORIGINAL RESEARCH
published: 13 December 2019
doi: 10.3389/fpsyt.2019.00901
A Clinical Feasibility Study of the
Forensic Psychiatry and Violence
Oxford (FoVOx) Tool
Robert Cornish 1,2, Alexandra Lewis 3, Owen Curwell Parry 1,2, Oana Ciobanasu 2,
Susan Mallett 4 and Seena Fazel 1*
1 Department of Psychiatry, University of Oxford, Oxford, United Kingdom, 2 Thames Valley Forensic Mental Health Service,
Oxford Health NHS Foundation Trust, Oxford, United Kingdom, 3 Broadmoor Hospital, West London NHS Trust, Southall,
United Kingdom, 4 Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
Background: Risk assessment informs decisions around admission to and discharge
from secure psychiatric hospital and contributes to treatment and supervision. There are
advantages to using brief, scalable, free online tools with similar accuracy to instruments
currently used. We undertook a study of one such risk assessment, the Forensic Psychiatry
and Violence Oxford (FoVOx) tool, examining its acceptability, feasibility, and practicality.
Edited by:
Björn Hofvander,
Lund University,
Sweden
Reviewed by:
Annette Opitz-Welke,
Charité Medical University of Berlin,
Germany
Peter Andiné,
University of Gothenburg,
Sweden
*Correspondence:
Seena Fazel
seena.fazel@psych.ox.ac.uk
Specialty section:
This article was submitted to
Forensic Psychiatry,
a section of the journal
Frontiers in Psychiatry
Received: 09 July 2019
Accepted: 14 November 2019
Published: 13 December 2019
Citation:
Cornish R, Lewis A, Parry OC,
Ciobanasu O, Mallett S and Fazel S
(2019) A Clinical Feasibility Study of
the Forensic Psychiatry and Violence
Oxford (FoVOx) Tool.
Front. Psychiatry 10:901.
doi: 10.3389/fpsyt.2019.00901
Frontiers in Psychiatry | www.frontiersin.org
Methods: We completed the FoVOx tool on all discharges from six secure psychiatric hospitals
in one region in England over two years. We interviewed 11 senior forensic psychiatrists
regarding each discharge using a standardized questionnaire. Their patient’s FoVOx score
was compared to clinical risk assessment, and the senior clinicians were asked if they
considered FoVOx scores accurate and useful. A modified thematic analysis was conducted,
and clinicians were surveyed about current risk assessment practice on discharge.
Results: Of 90 consecutive discharges, 84 were included in the final analysis. The
median FoVOx probability score was 11% risk of violent recidivism in two years after
discharge. We estimated that 12 (14%) individuals reoffended since discharge; all were
in the medium or high risk FoVOx categories. Clinical assessment of risk agreed with the
FoVOx categories in around half the cases. Clinicians were more likely to provide lower
risk categories compared with FoVOx ones. FoVOx was considered to be an accurate
representation of risk in 67% of cases; clinicians revised their view on some patient’s risk
assessment after being informed of their FoVOx scores. Completing FoVOx was reported
to be helpful in the majority of cases. Reasons included improved communication with
other agencies, reassurance to clinical teams, and identifying additional factors not fully
considered. 10 of the 11 respondents reported that FoVOx was practical, and seven of
11 reported that they would use it in the future, highlighting its brevity and speed of use
compared to existing risk assessment tools.
Conclusions: Senior clinicians in this regional forensic psychiatric service found the
FoVOx risk assessment tool feasible, practical, and easy to use. Its use addressed a lack
of consistency around risk assessment at the point of discharge and, if used routinely,
could assist in clinical decision-making.
Keywords: FoVOx, risk assessment, feasibility, recidivism, secure hospital, forensic psychiatry
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INTRODUCTION
year. The FoVOx tool is scalable, quick, free to use and available
online. All the model coefficients are reported, meeting a key
concern of using clinical prediction models that they should be
transparent. In the derivation sample, the AUC was 0.77, which
makes it as accurate in terms of discrimination as existing tools
(15). Its use could enable clinicians to provide a reasonably
accurate risk assessment in a brief and cost-effective way, and
free up time to focus on clinical care and risk management rather
than risk assessment. Possible limitations of the FoVOx tool are
that it does not specifically predict serious (as opposed to any)
violent reoffending and has not been externally validated to date.
In addition to external validation, prior to introducing any
new risk assessment into a clinical setting, information about
potential users and their decision-making is necessary (16).
Clinical impact should be assessed, including where it could sit
in the clinical pathway and the consequences of its use. Attitudes
towards any tool should be sought, and any preconceptions
about risk prediction models identified. Therefore, we undertook
a feasibility study of the FoVOx tool, assessing its acceptability
to professionals, demand for its use, and its practicality in one
regional English forensic psychiatric service.
After discharge from forensic psychiatric hospital, rates of violent
reoffending are reported to range from 2% to 8% per year in high
income countries, and one cohort study based on around half of
the forensic hospitals in England reported that 1 in 8 men and
1 in 16 women were convicted of serious offences over a mean
follow-up of 6 years (1). Thus, risk assessment has become an
integral part of forensic mental health in order to inform decisions
about admission, management, and discharge (2). Further,
professionals working in forensic mental health regularly advise
court proceedings, which can involve considerations of future risk.
If accurately done, risk assessment should identify those patients
presenting with the highest risk, reduce length of stay, and assist
in treatment allocation. Structured violence risk assessment is
broadly split into two approaches: actuarial tools, which use
statistical methods to give a population-based percentage chance
of reoffending, and structured professional judgment tools, which
attempt to guide mental health professionals by identifying some
risk factors. Structured professional judgment tools are more
frequently used in clinical settings. In the UK, for example, 90% of
medium secure units report using them in one survey (3), and their
completion is used as a key performance indicator (4). However,
there are important problems with using them (5). Structured
professional judgment tools take a long time to complete, for
example 15 person-hours to complete an initial HCR-20 (6). They
often have low to moderate validity in field studies (7), have often
been developed in prison, rather than hospital, settings, and using
methods to derive them which are dated. Further, there have been
low standards in reporting, including few performance measures,
authorship bias (8), wide variations in what constitutes ‘high’ risk
(9), and their underlying risk factors are based on heterogeneous
samples and do not incorporate new evidence on risk (10). In the
case of the commonly-used HCR-20 and PCL-R, for example, it has
been found that most of the factors are not predictive (11). One
new approach has been to use solely dynamic risk factors, but this
may lead to harsher penalties for minority groups by conflating
risk with rehabilitative needs (12) and also poor accuracy as strong
risk factors for reoffending including sex, age, and criminal history
are omitted. Thus, the potential use of high-quality actuarial tools
needs reconsideration in forensic mental health (13).
One such tool is the Forensic Violence Oxford (FoVOx) tool
(14), which was developed using all forensic psychiatric patients
in Sweden and based on the largest forensic psychiatric sample
to date. When reported, the FoVOx study was novel in that it
incorporated independent risk factors tested in a large sample,
reported calibration (observed vs. expected probabilities)
and published a study protocol. The FoVOx tool also has the
advantage of using routinely available data, which are less liable
to bias than interview-based measures (e.g. of a personality
trait). The 12 items within the FoVOx tool are sex, age, previous
violent crime, previous serious violent crime, primary discharge
diagnosis, drug use disorder at point of hospitalization or
discharge, any lifetime drug use disorder, alcohol use disorder
at point of hospitalization or discharge, personality disorder at
discharge, employment at admission, five or more prior inpatient
episodes, and whether current length of stay has exceeded one
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METHODS
The study protocol used a mixed methods approach by identifying
discharged patients and scoring them using the FoVOx tool at
the point of their discharge, which was followed up by qualitative
work assessing clinician views about the use of the FoVOx tool.
Sample
Patients
We identified all consecutive patients discharged from the
Thames Valley Forensic Mental Health Services between March
2016 and March 2018, covering three counties (Oxfordshire,
Buckinghamshire and Berkshire) across different levels of security
(medium and low security, and a pre-discharge unit). All patients,
both male and female, were included in the study irrespective of
diagnosis or any other individual factor. All were over the age
of 18. If any patients were discharged more than once from the
service during that time, the most recent discharge was selected.
Clinicians
We interviewed all the senior clinicians (‘Responsible Clinicians’)
in the service, made up of eight men and three women. In England
and Wales, Responsible Clinicians are the legally considered
the lead professionals involved in the care of detained forensic
mental health patients. All Responsible Clinicians in the service
were consultant (i.e. certified on the General Medical Council
Specialist Register) forensic psychiatrists.
Measures
FoVOx
Two members of the study team (AL and OP) accessed the
electronic healthcare record (‘Care Notes’) of the discharged
patients to obtain the information required to calculate their
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FoVOx Feasibility Study
FoVOx score at the point of the most recent discharge, using an
online calculator available at https://oxrisk.com/fovox/.
the Clinical Lead for Forensic Services as a Service Evaluation
project. Therefore, individual informed consent was not deemed
necessary. No data beyond that collated in routine clinical care
was used, and the management of patients was not impacted
by the study. To identify patients, existing discharge data
being collected by the Trust for audit purposes was used. All
Responsible Clinicians participated in the study voluntarily, and
patient data was anonymized other than for the ‘unblinding’
during the Responsible Clinician interviews.
Questionnaire
A standardized tool was developed to collect views and
information from senior clinicians (Appendix 1). Each clinician
underwent an in-depth interview by one of the study team (RC,
OP, or AL) regarding each discharge. The standardized tool
contained no patient identifiable information. The anonymized
discharge number was the only identifier. During the interviews,
patients’ identities and discharge location were shared in order to
collect the clinician view on risk assessment of their own patients.
The clinician was asked to provide their estimate of the 2-year
risk of a violent conviction (meaning any interpersonal violent
or sexual offence) at the point of their most recent discharge.
They were asked to provide a high, medium or low risk rating
in line with pre-specified FoVOx categories): Low (< 5% chance
of violent offending within two years of discharge), Medium
(5–20%), High (> 20%) or state if they could not recall this. They
were then asked if, according to their knowledge, their patient
had committed a violent offence since that period of discharge.
After this, the patient’s FoVOx score (both probability
and categorical) at the time of discharge was shared with
the Responsible Clinician. Cohen’s Kappa was calculated
for agreement between clinical categorical risk assessment
and FoVOx category. The clinician was then asked if they
considered this to be a fair representation of their risk and if
not, why. Participants were also asked whether it would have
been of benefit to know the FoVOx probability and categorical
score at the point of discharge, for example by altering clinical
management at that point. Reasons were again given for each
case. Answers to the two questions about whether FoVOx was
accurate and useful were recorded, using the interviewee’s
wording and with an opportunity for the clinician interviewed
to confirm that the transcribed notes represented their stated
reasons. One researcher (RC) analyzed these records, creating
individual response codes, noting how often these were each
stated and thematically grouped them. The transcripts were then
read by a second researcher (OC), who re-analyzed according to
themes independently, before the two researchers met to agree a
consensus about the principal themes.
The clinician was next asked whether they routinely use a risk
assessment tool at discharge in order to check whether they were
already using the FoVOx tool and to determine whether they
were using other tools they consider effective.
The unpopulated FoVOx tool was then shown to the clinician.
They were asked their views on its practicality, ease of use, and
future plans for risk assessment. Participants were asked to give
specific reasons as to whether they thought FoVOx was practical
to use, and whether they would use FoVOx in the future. Again,
these responses were recorded and coded and grouped into
themes by two researchers (RC and OC).
RESULTS
Sample
Ninety discharges from forensic psychiatric hospitals were
identified from May 2016 to May 2018. Six patients were
excluded from analysis (two had been transferred to another
secure psychiatric setting, one deported abroad and three were
aged over 65 years). Thus, 84 patients were included in the study
(Figure 1). Of these, 11 were female (13%). One transgender
patient had their assigned gender used for FoVOx scoring (17).
The mean age of patients was 39.2 years, SD 10.7, range 21–60.
The number of discharged patients per clinician was 2 to 18. The
median number of days from discharge to study interview was 485
(interquartile range 339–643). Sample characteristics and FoVOx
scores are included in Table 1. 9 of the 11 clinicians (82%) reported
that they routinely completed a risk assessment process around the
time of discharge. These included a multi-disciplinary clinical risk
assessment, a description of risk in a Mental Health Review Tribunal
Report, the patient’s latest HCR-20, and HoNOS (Health of the
Nation Outcome Scales). One respondent reported regularly using a
structured risk assessment specifically at the point of discharge.
FoVOx Scores
FoVOx scores were calculated from clinical records and took no
more than 15 minutes per case. The median FoVOx probability
score was a 11% chance of violent recidivism in 2 years (interquartile
range 6–19%, range 2–49%). In terms of categories, 12 (14%) were
low risk, 55 (66%) medium risk and 17 (20%) high risk. Some
individual items were missing for 15 patients, and for these a FoVOx
risk score range was generated (as per the online calculator). Of
these, four ranges crossed low-medium or medium-high categories.
In these cases, the higher risk rating was presented to the clinician.
Recidivism
Of the 84 patients included, five were lost to follow up. Of the
remaining 79 who were still in contact with mental health
services, 12 (14%) were reported to have committed a violent
offence since discharge based on information known to the
Responsible Clinicians. Of these, eight had FoVOx scores in the
medium category and four were in the high category.
Ethics
Concordance Between FoVOx Scores and
Clinical Judgment (Case by Case)
The project was approved by the Oxford Health NHS Foundation
Trust Clinical Governance Committee in March 2018 and by
There was agreement for risk assessment based on three categories
(i.e. low/medium/high) between the clinical unstructured
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FIGURE 1 | Inclusion of discharged patients from secure hospital into study.
judgment and the FoVOx score in 49% of cases (41 out of 84;
κ = 0.20 [95% CI, 0.06–0.35]). Where there was disagreement,
clinicians were more likely to score patients in a lower risk category
compared with their FoVOx score (in 36 of the 43 cases). When
considering two risk categories: low and medium/high, there was
agreement between clinical unstructured judgment and the FoVOx
score in 63% of cases (53 out of 84; κ = 0.22 [95% CI, 0.06–0.38]).
For most cases (56 out of 84, 67%), the FoVOx score (combined
categorical and probability) was felt by the clinician to be an accurate
representation of the violence risk at discharge. In the 28 cases
(33%) where it was not, the clinician was asked to give reasons. Two
main themes were identified. The first was that clinicians viewed
certain risk factors as dynamic and modifiable by treatment, such as
substance abuse and the response to medication and psychological
treatment; “The dynamic risk factors have been modified in hospital,
there was no alcohol or drug use on discharge and these were relevant
for previous offending” and “The risk is too high, it doesn’t take into
account any completed therapeutic intervention.” These were thought
to contribute to risk in both directions; if the patient had responded
to treatment the FoVOx score was felt to be an overestimate, and
vice versa. The second theme was that clinicians felt that there were
Frontiers in Psychiatry | www.frontiersin.org
additional factors which influenced risk which were not measured
by the FoVOx tool. These included the recency of offending and
violence, and the nature of supervision in the community, as well
as cases in which the patient was only felt to pose a risk in a specific
set of circumstances: “Risk is over-represented as there has not been
any violence for the past 15 years”, “The estimated risk is too high;
the patient has engaged very well with treatment and supervision in
the community” and “This tool underestimates risk as relationship
instability is a risk factor”. These themes are summarized in Table 2.
Views on Utility At the Point of Discharge
(Case by Case)
Responsible Clinicians reported that it would have been helpful
to know FoVOx scores at the point of discharge in 49 (58%) cases,
and not that helpful in 35 (42%) cases. Qualitative feedback is
summarized in Table 3. The most frequent reasons given for
why FoVOx would be helpful were related to its concordance
with existing clinical risk assessment, including supporting and
providing further evidence of the clinical categorization of risk
if it aligned with the FoVOx score; “(It) can offer confirmation of
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TABLE 1 | Sample characteristics and FoVOx scores.
Overall Opinion of Practicality and Future Use
Demographics
After reviewing individual discharges, 10 (90%) clinicians
reported that the FoVOx tool is practical to use and that it could
be completed without reference to medical notes. All respondents
could complete FoVOx scoring in under 1 minute for their most
recent discharged patient.
Seven of 11 (64%) respondents reported that they would use
FoVOx in the future for a number of reasons (Table 4). In addition to
improved information sharing and possible impact on management,
there were a range of positive comments about the FoVOx tool
specifically. These included the ease with which information could
be found, and the speed with which it could be completed. Criticisms
included the emphasis on static, historical factors, inability to
specifically predict serious (as opposed to any) violence, and a
preference to see validation studies in a UK forensic sample before
local adoption.
Finally, clinicians were asked if they had any other comments
regarding the FoVOx tool. Its potential use at an earlier stage,
either at gatekeeping or to screen referrals, was noted twice. The
benefits of its brevity and speed of use over existing actuarial
tools were repeatedly noted, even among clinicians who felt that
actuarial risk assessment tools were of little value: “If we have to
use an actuarial tool then I would use this” and “Straightforward,
reassuring, also helpful/interesting to consider cases where there is
discrepancy. Nothing to lose, why wouldn’t you?”. Three respondents
stated that the low/medium/high risk categories were unnecessary.
There were also some specific queries about individual cases,
including whether those in full-time education at the time of their
index offence should be considered as employed, and classifying
some UK offences as serious or aggravated/otherwise.
Male:female
Age at discharge (SD)
Median days since
discharge (IQR)
Median FoVOx score
(range)
73:11
39.2 (10.7)
485 (334–643)
FoVOx categories
All included patients
-Low
-Medium
-High
12 (14%)
55 (66%)
17 (20%)
Violent recidivists (based
on clinician recall)
0
8 (67%)
4 (33%)
Responsible clinician
view on FoVOx
-Accurate?
-Helpful?
Yes
No
56 (67%)
49 (58%)
28 (33%)
35 (42%)
11% (2%–49%)
informal risk assessment”. Improved information sharing with
other agencies was repeatedly noted, including being used as
an additional source of evidence; “this was a high-profile case
and the Tribunal was reluctant to discharge, perhaps the clinical
view over-estimated risk and it would have been helpful to have
the FoVOx score”. It was also reported, for 14 cases, that using
FoVOx would identify risk factors which had not been fully
considered by clinicians, suggesting that it could impact on
risk management in addition to risk assessment; “Can confirm
risk assessment and help identify and consider other risk factors”
and “Identifies outstanding areas of risk”. In cases where FoVOx
was considered not useful, the most common reason given was
clinicians not attributing value to any actuarial tool; “Won’t
add value to clinical practice and is unlikely to add to discharge
planning. Doesn’t use any clinical risk factors, such as insight”.
Other comments included that it might lead to unintended
consequences. For example, FoVOx could increase anxiety if
it rated patients at higher risk than clinical assessment. It was
also reported that sharing the FoVOx score could lead to delays
in liaison with other agencies, for example if they refused or
delayed housing or support on discharge on the basis of high
risk; “Can increase anxiety and delay discharge planning, induce
self-doubt in clinical decision-making, make other teams reluctant
to take over care.”
DISCUSSION
We examined the use of a novel violence risk assessment tool
(FoVOx) on 84 consecutive discharges from secure (forensic)
psychiatric hospitals within one region of England over 2 years
to assess its feasibility and acceptability. As part of this, individual
interviews were conducted with senior clinicians regarding each
discharge to assess the potential impact of the FoVOx tool on risk
assessment and management.
TABLE 2 | Qualitative feedback on challenges with FoVOx scoring.
Theme
Sub theme
FoVOx score is too high
FoVOx score is too low
Dynamic Risk
Factors
Primary discharge diagnosis—
medical treatment
Personality disorder diagnosis—
psychological treatment
Substance misuse diagnosis
Supervision
Good response to medication
Poor response to medication
Successful (increased insight, specific work on
offence)
No longer using substances
Engaged with community mental health support,
use of statutory supervision
Unsuccessful (non-engagement, untreated
personality disorder)
High risk of substance misuse after discharge
Uncooperative with supervision
No violence in hospital
Improved relationships with family, good
psychosocial functioning, lifestyle change
No forensic history prior to index offence, long
period of time since index offence, offending
could only occur in a specific context
Frequent violence in hospital
Relationship instability
Risk factors not
identified by
FoVOx
Chronicity of violence
Psychosocial support
Specific circumstances to index
offence
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TABLE 3 | Qualitative feedback on the usefulness of FoVOx scoring.
Theme
Sub Theme
Helpful
Unhelpful
Used as evidence
to support
decision-making
As part of discharge planning
Other agencies more likely to support
discharge, e.g. Mental Health Review
Tribunals, Parole Board
In liaison with third parties
Improved information sharing with
accommodation providers, non-forensic
mental health services, probation and MAPPA
Reassurance if agrees with clinical
assessment, reducing anxiety if FoVOx rates
risk lower than clinician
Could lead the same agencies less likely to
discharge, FoVOx score is less relevant if
patient is discharged due to circumstances
other than a reduction in risk
Negative responses such as not accepting
patient for housing.
Risk assessment
Reassurance
Changing patient management
Existing perceptions of risk assessment
Identification of unaddressed risk factors and
informing management decisions such as
threshold to recall
Highlights over-reliance on clinical factors as
being predictive of recidivism
Need to differentiate between serious and
less serious offending
Discharge due to factors other than risk
reduction
FoVOx
specific
Reasons for not using
Information is easy to find
Based on static, historical
risk factors
No actuarial tool is of value
May narrow thinking about
risk assessment
Not wishing to add another
tool to existing metrics
Lack of sensitive clinical risk
factors (e.g. insight, response
to medication)
Not yet validated in a UK
forensic population
Inability to predict serious, as
opposed to any violence
Information can be found
quickly
Useful adjunct to existing
risk assessment
Has construct validity
Information
sharing
Impact on
management
Information sharing with
other agencies
Resolves disagreements
about risk
Reassurance when agrees
with clinical opinion
minutes. When one or more pieces of data were unknown, FoVOx
generated a range of probability scores. For the lead clinician,
FoVOx could be completed in around 1 minute for their most
recent discharge and without recourse to clinical notes. Therefore,
we conclude that FoVOx is feasible for clinicians familiar with
a case; it is practical to use, requires no additional training, and
minimal resource allocation. The brevity of the tool was repeatedly
considered a strength in the qualitative clinician interviews.
We found a lack of any agreed practice around risk assessment
at the point of discharge in this sample of UK forensic
psychiatrists. Although these clinicians reported that they did
complete a risk assessment, its nature varied. Some used existing
tools completed within the prior 6 months, others a clinical
assessment comprising a descriptive account in a psychiatric
report, and some a multi-disciplinary discussion of risk.
The qualitative part of this investigation found that completing
FoVOx was helpful to most clinicians. Benefits included improved
information sharing with other agencies, reassurance for the clinical
team, and identification of unaddressed or underweighted risk
factors. FoVOx also assisted in guiding community management
after discharge. In the future, 7 of the 11 clinicians reported that
they would use FoVOx as part of their clinical practice. Benefits
over existing tools used included its brevity, the ease with which
information can be found, and how it clearly and transparently
outlined a particular patient’s risk to other agencies who are less likely
to be familiar with more detailed structured professional judgment
tools currently used in forensic mental health settings. Clinicians
who said that they would not use it in future provided mostly
neutral feedback including that it did not provide any additional
value. Specific criticisms were not unexpected, including the lack of
dynamic factors, and the view that clinical risk assessment is more
accurate than actuarial tools. Some of the themes identified when
clinicians thought FoVOx was inaccurate may actually be indirectly
measured by the tool. For example, close supervision was felt to
reduce risk of recidivism. The FoVOx item regarding stay of over a
No added value if agrees with
existing risk assessment
May provide false
reassurance
Helpful challenge when
disagrees with clinical
opinion
Guides community
management (e.g. level of
supervision)
We found that the data required to complete the FoVOx tool
was routinely collected, and there was no need to seek additional
sources of information other than the patient’s electronic healthcare
record. Furthermore, in 82% of forensic psychiatric patients
included in this study, all the information required to complete
FoVOx could be extracted from the individual’s clinical record by
a mental health professional unfamiliar with their case within 15
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Skepticism about the value of any actuarial tool
Inability of FoVOx to predict serious, as
opposed to any, violent recidivism
Discharge was dictated by factors other than a
reduction in risk.
TABLE 4 | Qualitative feedback on whether clinicians would use FoVOx in
the future.
Reasons for using
No added value if FoVOx and clinician
assessment agree, increasing anxiety and
leading to review if FoVOx rates risk higher
than clinician
Over or under-estimates risk due to reliance on
historical factors
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require a large multi-centre study across different regions and/
or nations. One limitation of the current investigation is that
the outcome was based on clinical knowledge, and future work
could triangulate this information with criminal records. When
the available information was incomplete to complete FoVOx
scoring, and a range of risk generated, we chose the higher value.
An alternative would be to give an average value to missing
variables to avoid potential over-estimation of risk.
A high proportion of cases (66%) reviewed were assigned to
the medium risk category. If the majority of the patients are all
assigned to the same risk class, this may reduce the clinical utility
of the tool. Three of eleven clinicians felt that the low/medium/
high categorization was unnecessary. In future research, solely
using the probability score of reoffending can be examined.
Another limitation is that there may have been a positive bias
to the qualitative data as the tool was developed by researchers
locally, including one of the interview team. The study was also
limited to forensic psychiatrists, and the views of other clinicians
are necessary in further work.
Overall, the clinician views on FoVOx were consistently
positive in many respects from informing decision-making to
assisting risk communication. The novel features of FoVOx,
including its brevity, online platform, and ease of use suggest
that it can improve the risk assessment process in individuals
detained in forensic psychiatric hospital.
year also lowers risk scores; patients with a longer inpatient stay are
more likely to be in receipt of statutory supervision after discharge.
Overall, FoVOx scores were thought to be accurate in around
two-thirds of the cases and, for some patients, clinicians revised
their view of the risk of future violent re-offending to a higher
level after being informed of the FoVOx scores, suggesting that
probability-based FoVOx scores could assist clinical decisionmaking. Clinicians were more likely to underestimate risk compared
to FoVOx scores. Reasons identified included FoVOx emphasizing
risk factors underweighted by clinicians. Understandably, clinicians
are most likely to focus on clinical factors which can be addressed,
such as response to medical treatment, engagement in psychological
therapy, and abstinence from substances abuse in the supported
environment of hospital. Being informed of FoVOx scores thus
may enable clinicians to rebalance the relative importance of
these hospital-based clinical factors against static ones that are
independently predictive of violent recidivism. Thus, using FoVOx
routinely would prompt clinicians to keep these factors in mind,
suggesting that FoVOx could be useful as an adjunct to clinical
decision-making. However, local external validation is required
to know the accuracy of FoVOx compared to clinician judgment.
Without this, placing more weight on FoVOx scores would be
unwarranted and clinical decision-making should take precedence.
At the same time, awareness of the factors that might lead clinical
teams to underestimate risk needs careful consideration—from
weighting more recent factors, and structural (such as the need
to maintain sustainable lengths of stay in secure services) and
therapeutic factors.
One useful aspect of this feasibility work was to elicit views
about the timing of FoVOx. As most factors are static and will not
change during hospitalization, this provides some flexibility as to
when it can be administered. At the point of discharge, patients
are well-known to their clinical teams, and a more individualized
and detailed risk formulation is likely to be available. FoVOx
may be of more value if completed earlier in a patient’s pathway
through the secure hospital system, possibly at the point of
referral or gatekeeping into secure psychiatric care, or early in
their admission. Completing the FoVOx tool at an earlier stage
would allow for patient’s future risk to be stratified sooner, assist
to guide their pathway through the secure hospital system and
inform allocation of treatment resources.
One of the clinical implications of this study would be
to integrate the FoVOx tool into patient care, for example
by including it as part of their electronic patient healthcare
record. Future work could compare FoVOx to other current
risk assessment tools to compare acceptability and feasibility
including the time taken to complete them, clinician satisfaction,
and impact on patient care.
DATA AVAILABILITY STATEMENT
Anonymized completed interview questionnaires and Service
Evaluation proposal are available on request.
AUTHOR CONTRIBUTIONS
SF, RC, and AL designed the study. AL developed the standardized
tool (Appendix 1). AL and OP completed FoVOx scoring of
patients. RC, AL, and OP conducted clinician interviews. RC and
OC completed thematic analysis. SF, RC, OP, SM, and AL wrote
the paper.
FUNDING
SF is funded by the Wellcome Trust.
ACKNOWLEDGMENTS
The authors would like to thank Dr Sukh Lally, Dr Susan Hardy,
Dr Hasanen Al-Taiar, Dr Vivek Khosla, Dr Rami El-Shirbiny, Dr
Julia Cartwright, Dr Pankaj Agarwal, Dr Srinivasan Thirumalai,
and Dr Vijay Durge for participating in the interviews.
LIMITATIONS
SUPPLEMENTARY MATERIAL
External validation was not conducted, which is a considerable
challenge in forensic psychiatry due to patient numbers and
event rates. If one assumes around 20% violent reoffending over
2 years, then around 500 forensic psychiatric discharges would
be recommended for a validation study (18). This would likely
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The Supplementary Material for this article can be found online at:
https://www.frontiersin.org/articles/10.3389/fpsyt.2019.00901/
full#supplementary-material
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Cornish et al.
FoVOx Feasibility Study
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Frontiers in Psychiatry | www.frontiersin.org
Conflict of Interest: SF and RC are authors on the original FoVOx paper.
The authors declare that the research was conducted in the absence of any
commercial or financial relationships that could be construed as a potential
conflict of interest.
Copyright © 2019 Cornish, Lewis, Parry, Ciobanasu, Mallett and Fazel. This is an openaccess article distributed under the terms of the Creative Commons Attribution License
(CC BY). The use, distribution or reproduction in other forums is permitted, provided
the original author(s) and the copyright owner(s) are credited and that the original
publication in this journal is cited, in accordance with accepted academic practice. No
use, distribution or reproduction is permitted which does not comply with these terms.
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