Richmond Hill Practice is committed to promoting and improving a safe and secure environment for those who work in or use the NHS so that the highest standards of clinical care can be made available to patients.

It is based upon directions from the Secretary of State for Health to tackle violence against staff and professionals who work or provide services to the NHS on 20th November 2003.

This document sets out the framework for managing violence and aggression within the Practice. The scope of this policy is therefore:

  • Instances of violence or aggression committed by:
  • Any person, whether patient, visitor or any other person working within the practice


  • Any patient, visitor, or other person working within the practice.


The Health and Safety Executive (HSE) definition of work-related violence is:

‘Any incident in which a person is abused, threatened or assaulted in circumstances relating to their work. This can include verbal abuse or threats as well as physical attacks’

The NHS definition of physical assault used for incident reporting purposes is:

The intentional application of force to the person or another, without lawful justification, resulting in physical injury or personal discomfort’

The NHS definition of non-physical assault used for incident reporting purposes is:

The use of inappropriate words or behaviour causing distress and/or constituting harassment’

Inappropriate behaviour is not defined but some examples are given below:

  • Offensive or abusive language, verbal abuse and swearing which prevents staff from doing their job or makes them feel unsafe
  • Loud and intrusive conversation
  • Unwanted or abusive remarks
  • Negative, malicious or stereotypical comments
  • Invasion of personal space
  • Brandishing of objects or weapons
  • Near misses ie. Unsuccessful physical assaults
  • Threats or risk of serious injury to a member of staff, fellow patients or visitors
  • Bullying, victimization or intimidation
  • Stalking
  • Spitting
  • Alcohol or drug fuelled abuse
  • Unreasonable behaviour and non-cooperation such as repeated disregard for NHS policy ie. Smoking on premises, or
  • Any of the above which is linked to destruction of or damage to property

NB – It is important to remember that such behaviour can be either in person, by telephone, letter or e-mail or other form of communication such as graffiti on NHS property

This policy applies throughout the premises, including any car park and grounds. It also applies to any employee or partner away from the practice but only in so far as it relates to the business of the practice.



NHS PROTECT – formerly known as the NHS Counter Fraud and Security Management Service, was established in April 2003 with statutory responsibility for the management of security within the NHS (Statutory Instrument 3039/2002). These delegated responsibilities are exercised on behalf of the Secretary of State for Health, through the issuing of Secretary of State Directions.

THE HEALTH & SAFETY EXECUTIVE (HSE) is responsible for the regulation and enforcement of workplace health, safety and welfare, underpinned by the Health & Safety at Work Act 1974. Employers have responsibilities under the Health & Safety Act 1974 to ensure, as far as is reasonably practicable, the health, safety and welfare of employees at work.

THE MANAGEMENT OF HEALTH & SAFETY AT WORK REGULATIONS 1999 require employers to assess risks to employees and non-employees and make arrangements for effective planning, organisation, control, monitoring and review of health and safety risks. Where appropriate, employers must assess the risks of violence to employees and, if necessary, put in place control measures to protect them.

THE NHS LITIGATION AUTHORITY (NHSLA) handles civil legal liability claims and works to improve risk management practices in the NHS in England. The NHSLA has a risk management programme to help raise standards of care in the NHS through Risk Management Standards for primary care to reduce the number of incidents leading to claims. Risk Management Standards include an assessment of the policies providers have in place covering violence and aggression in respect of good risk management, governance and assurance

THE CARE QUALITY COMMISSION (CQC) was established under the Health and Social Care Act 22008 as the independent regulator for health and adult social care in England. This Act outlines the types of service that must be registered with the CQC and the Registration Requirements Regulations 2009 outlines what service providers have to do to become registered. As part of registration the CQC with develop a Quality Risk Profile (QRP) for each provider to assess. The CQC will continue to check and monitor service providers to ensure that they continue to meet the essential quality and safety standards including preventing violence against staff.


  • Employees have the responsibility to ensure their own safety and that of their colleagues at work. It is essential, therefore, that all employees are familiar with practice policies and procedures, equipment and precautions adopted to combat the risk of physical and verbal abuse.
  • Familiarise themselves with practices policies and procedures, guidelines and instructions.
  • Use any equipment or devices provided for ‘at risk’ situations i.e. alarms.
  • Participate in relevant training made available by the practice.
  • Report all incidents of physical and verbal abuse (threatened or actual).
  • Record details of incidents in compliance with practice procedures.
  • Contribute towards reviews by nominated managers concerning any incidents in which they have been involved.
  • Suggest precautionary measures involving changes in the layout of the work environment that can reduce risk.
  • Make use of any available staff support and counselling through the practice.
  • Advise the practice manager/line manager of any perceived risks involved in work activities.


  • Carry out risk assessments to assess and review the duties of employees, identifying any ‘at risk’ situations and taking appropriate steps to reduce or remove the risk to employees.
  • Assess and review the duties of employees, identifying any ‘at risk’ situations and taking appropriate steps to reduce or remove risk to employees particularly if they are working alone.
  • Assess and review the layout of premises to reduce the risk to employees.
  • Assess and review the provision of personal safety equipment i.e. alarms.
  • Develop practice policies, procedures and guidelines for dealing with physical and verbal abuse.
  • Provide support and counselling for victims, or refer to suitably qualified health professionals.
  • Make employees aware of risks and ensure employee involvement in suitable training courses.
  • Record any incidents and take any remedial action to ensure similar incidents are prevented.


Patient specific risk assessments should be completed or reviewed if:

  • The patient has a history of unpredictable, challenging, violent or aggressive behaviour
  • The patient displays challenging, violent or aggressive behaviour
  • An incident occurs or a patient, relative or visitor becomes aggressive

The LSMS can also provide specific information on violence prevention and staff safety measures.

The patient specific risk assessments may take into account:

  • What is the mental, emotional and physical condition of the patient?
  • Is the patient’s behaviour related to his or her medical conditions or ingestion of drugs, alcohol or medicines?
  • Is the person facing high levels of stress?
  • Has the person got a history of challenging, violent or aggressive behaviour?
  • Does the person consider you a threat?

The prevention measures identified by the risk assessment must be recorded in the patient’s care plan and this information must be brought to the attention of all staff who are likely to be involved with the patient. This should include all staff, not just medical staff, eg Domestics. Where clinical IT systems are in operation (EMIS Web) a flag should be put on the system in relation to the patient identifying any concerns.


Where appropriate this section should be read in conjunction with the Lone Work Policy. This may include the way a service operates to reduce the risk of violence. Common triggers of aggression to consider when completing risk assessments may include:


  • Parking issues
  • Queuing at reception and waiting times
  • Lack of communication about reasons for delay
  • Not knowing where to go and not having anyone to ask
  • Poor communication between professionals and patients
  • Lack of facilities
  • Poorly planned appointments

Addressing or implementing control measures to manage the above issues could significantly reduce the number of incidents that occur.

The appropriate response to such incidents will depend upon the individual circumstances of each incident. Managers must recognise that action is appropriate where non-physical assault or abusive behaviour is likely to:

  • Prejudice the safety of staff involved in providing the care or treatment; or lead the member of staff providing care to believe that he/she is no longer able to undertake his/her duties properly as a result of fearing for their safety; or
  • Prejudice any benefit the patient might receive from care or treatment; or
  • Prejudice the safety of other patients; or
  • Result in damage to property inflected by the patient, relative, visitor or as a result of containing their behaviour

Secondary prevention is focused on reducing the prevalence of the problem by minimising known or suspected risk factors and by early intervention ie. When violence is perceived to be imminent or immediately post-incident. This knowledge can be used proactively to plan positive interventions such as training staff to recognise warning signs and in de-escalation strategies so they can defuse a potentially violent incident.

Staff should be aware of their body language (as well as that of the patient/service user). This is a risk of exacerbating the situation be sending out the wrong signals, particularly; if there are cultural, gender or physical issues to consider. Body language and other forms of non-verbal communication and mannerisms play an important role in how people perceive and behave towards others. Specific training in non-physical intervention skills, customer service and de-escalation is essential and all front-line staff must be trained in conflict resolution with additional training provided over and above this, depending on the risks faced and individual needs.


If violence and aggression is encountered:

  • In the first instance a member of the staff should ask the perpetrator to stop behaving in an unacceptable way.  Sometimes a calm and quiet approach will be all that is required.  Staff should not in any circumstances respond in a like manner.
  • Should the person not stop their behaviour the Practice Manager/GP Partner should be asked to attend and the member of staff should explain calmly what has taken place, preferably within hearing of the perpetrator.
  • If the person is acting in an unlawful manner, causes damage or actually strikes another then the police should be called immediately.
  • Should it prove necessary to remove the person from the practice then the police should be called and staff should not, except in the most extreme occasions, attempt to manhandle the person from the premises.
  • If such a course of action proves necessary then those members of staff involved must complete a written note of the incident, detailing in chronological order what has taken place and the exact words used prior to leaving the building at the end of their working day.
  • It is the policy to press for charges against any person who damages or steals practice property or assaults any member of staff or visitor/patient


  • Review the incident with the practice partners immediately in order to determine severity
  • Determine if the patient should be removed from the practice list forthwith
  • Decide if a written warning should be given
  • Decide whether to take further action if the matter has been sufficiently dealt with by the advice already given

The details of any incident other than no further action will be entered into the patient’s permanent record or the employee’s personal file.

Any employee or patient/visitor who receives any injury, no matter how small, should be the subject of an entry in the practice Accident Book and should always be strongly advised to be examined by a doctor before they leave the premises.

Every violent incident involving staff will be reasonably supported by the provision of medical or other treatment as necessary and all incidents should be brought to the attention of the Practice Manager if not already involved. If an injury has occurred this may be notifiable to the HSE.

The practice re-affirms its commitment to do everything possible to protect staff, patients and visitors from unacceptable behaviour and their zero tolerance of any incident that causes hurt, alarm damage or distress.

Each case of physical assault resulting in an injury upon any member of staff in the course of their duties must be reported to the police. This applies to all employees, including volunteers, contractors and employees of other organisations working on behalf of Richmond Hill Practice.

It is important that patients, relatives and visitors are dealt with in a fair and objective manner. However, whilst staff have a duty of care, this does not including accepting abusive behaviour.


The practice takes a serious view of any incidents of physical and verbal abuse against its employees and will support them if assaulted, threatened or harassed.

The first concern of managers after an incident is to provide appropriate debriefing and counselling for affected employees. Depending on the severity of the incident this counselling may be undertaken by trained professionals.

The Practice Manager/Line Manager will assist victims of violence with the completion of the formal record of the incident and where appropriate will report the incident to the police.


Measures that can be taken as the result of a report of non-physical assault may include the following:

  • A verbal warning
  • Acknowledgement of responsibilities agreement or Behaviour Agreement – an intervention designed to engage an individual in acknowledging his or her anti-social behaviour and its effect on others, with the aim of stopping that behaviour
  • A written warning letter signed by the Partners. A warning letter may also be sent by the NHS SMS Legal Protection Unit if appropriate.
  • The use of secure environments or security chaperone
  • Civil injunctions and Anti-Social Behaviour Orders (ASBOs)
  • Criminal prosecution and police bail condition

Verbal warnings are a method of addressing unacceptable behaviour with a view to achieving realistic and workable solutions. They are not a method of appeasing difficult patients, relatives or visitors in an attempt to modify their behaviour or to punish them, but used instead to determine the cause of their behaviour so that the problem can be addressed or the risk of it recurring minimised

Every attempt should be made to de-escalate a situation that could potentially become abusive or worse. Where de-escalation fails, the patient, relative or visitor should be warned of the consequences of future unacceptable behaviour.

Where it is deemed appropriate to speak to a patient, relative or visitor in respect of their behaviour, this should (where practicable) be done informally, privately and at a time when all parties involved are composed.

The aim of the verbal warning is twofold

  • To ascertain the reason for the behaviour as a means of preventing further incidents or reducing the risk of it re-occurring; and
  • Ensure that the patient, relative or visitor is aware of the consequences of further unacceptable behaviour

A meeting should be arranged and conducted in a fair and objective manner. A formal record should be made and maintained within the Practice.

Members of staff should never be prevented or discouraged from reporting non-physical assaults to the police. In appropriate cases the clinical condition of the assailant should be considered as part of the decision-making process.

The following is a list of possible aggravating factors which should be considered when deciding to report an incident to the police:

  • The effect on the victim and/or others present
  • The assailant’s behaviour is motivated by hostility towards a particular group or individual on the ground of race, religious belief (or lack of), nationality, gender, sexual orientation, age, disability or political affliction.
  • A weapon, or object capable of being used as a weapon, is brandished or used to damage property
  • The incident was an attempted, incomplete or unsuccessful physical assault
  • The incident involves action by more than one assailant
  • The incident is not the first to involve the same assailant(s)
  • There is an indication that a particular member of staff or department/section is being targeted
  • There is a serious concern that any threats made will be carried out
  • There is a concern that the individual’s behaviour may deteriorate or that other NHS bodies should be advised or alerted
  • The response to the incident has caused significant additional expenditure
  • All incidents involving firearms should be reported to the Police