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Purpose The purpose of this paper is to explore whether the current forensic mental health inpatient population within a medium secure unit is more or less complex (i.e. clinical and risk presentations) than former years using the Health of the Nation Outcome Scale (HoNOS) secure. Additionally, the use of the HoNOS secure as a service-wide measure is discussed in terms of its usefulness. Clinical implications and recommendations are offered for the continued use of the HoNOS secure in services more widely. Design/methodology/approach A retrospective case review of completed HoNOS secure assessments for 130 patients over three time intervals 2012, 2015 and 2018 was used. A multivariate analysis was performed on the data using SPSS version 25. Findings The findings revealed that contrary to clinical opinion, inpatients’ clinical and risk presentations had not changed significantly overtime. Research limitations/implications The study shows the benefits of using the HoNOS secure at a service-wide level to explore and understand similarities and differences in inpatient admissions over time. It also highlights the usefulness of the HoNOS secure for considering different ward characteristics and the needs of patients residing in these environments. Originality/value Although much research exists surrounding the individual use of the HoNOS secure in relation to outcomes, there is limited research focusing on use of the HoNOS secure at the service level. The paper therefore provides evidence of the utility and value of the HoNOS secure as a service-level outcome measure.