The paper by Wilson et al ^{Reference Wilson, Murray, Harris and Brown1} highlights the serious issue of in-patient violence. The potential benefits of involving the criminal justice system are well laid out and the suggested approach is likely to be useful in practice. Unfortunately, the paper fails to look at the possible downsides of such a practice.

Potential adverse outcomes include short- and long-term stigma for the individual patient and loss of therapeutic relationship between the patient and clinician. These are likely to result in poorer services and longer periods of detention. The critical step in deciding whether to refer a patient to the criminal justice system will be the clinician's judgement of non-trivial violence. Good training can reduce lack of consistency but long-term follow-up and critical examination of this practice will ensure that adverse outcomes are kept to a minimum as we juggle to find the ethical balance here.