In this study we demonstrate how the Health of the Nation Outcomes Scales for secure and forensic service users (HoNOS-secure) tracks risk and recovery in men with mental illness and men with learning disability in a secure care pathway. Total and individual HoNOS-secure item ratings made by multi-disciplinary teams across the course of a period of admission (mean 15 months) for 180 men were examined. There was significant positive change on the clinical and risk-related scales of HoNOS-secure for patients in the learning disability care pathway (N = 48) between initial and final ratings. In the mental health care pathway (N = 132 patients) an apparent lack of change masked a more complex picture, where initial decline in HoNOS-secure ratings was succeeded by significant improvement. Results suggest that it is challenging to measure clinical and risk-related medium-term clinical outcomes objectively for these patients, particularly in relation to core issues of treatment of mental disorder, and reduction of both problem behaviour and risk to others. However, it is important that practitioners continue to strive to demonstrate the benefits of care and treatment through appropriate outcomes measures.