Increasingly, secure forensic mental health services must balance reducing restrictive practices on one hand with keeping a violence free environment on the other. Nursing staff and other hospital staff have the right to work in a safe environment. They should not be subject to intimidation and assaults in the work setting. Patients have the right to care in a safe environment and they need to have confidence that staff members can keep them safe during their in-patient stay. Minimising in-patient violence and minimising past violence for forensic patients is undermining an area of significant treatment need and may seriously limit the patient’s chance of a future successful discharge in the community. We posit in this chapter that active and careful management of ward milieu and dynamics, and active treatment of psychotic and other symptoms, together with proportionate use only of restrictive practice and thorough evaluation of any and all restrictive practice is the most effective way of managing a forensic in-patient setting to effectively reduce and prevent incidents of violence.

Forensic psychiatry is a medical discipline, developed from the foundations of the asylum era, which focuses on the assessment and treatment of offenders with mental disorders. The complexity of the patient cohort is arguable reflected in the complexity of their clinical pathways, which necessitates some understanding of the legal system that for most patients, works in parallel to that of health and social care. In this chapter, we briefly review the historical context through which modern forensic psychiatry has emerged within England and Wales. This includes some high-profile individual cases that led to the development of concepts such as fitness to plead and the psychiatric defence of not guilty by reason of insanity. We then provide an outline of how inpatient secure services are structured, the relevant criminal sections of the Mental Health Act at each stage of the trial process and some of the challenges associated with managing this complex cohort of individuals.