Mill Lodge is a 14-bed inpatient neuropsychiatric ward in Leicestershire, UK. The service primarily functions for patients with Huntington's Disease (HD), a disorder that significantly reduces life expectancy. End of Life (EoL) care is necessitated in the inpatient setting. This project therefore aims to optimise EoL care in our specialist HD unit. Specific objectives are to: establish the levels of staff confidence in dealing with EoL care; identify specific areas of EoL care that staff felt could be improved; and to introduce a series of initiatives to optimise EoL care for our patients using a QI framework.

We commenced involvement with the local QI team to develop the project. The first stage of intervention included the planning and delivery of a stakeholder event on EoL care specific to HD with the assistance of regional palliative care colleagues.

As well as our inpatient nursing and medical staff and the palliative care teams, local GPs, district nursing colleagues, speech and language therapists and psychologists attended. The session comprised an educational overview for all colleagues of HD itself and palliation was discussed at length.

The meeting also comprised an open forum where we were able to identify barriers and facilitators to optimal care from all aspects of the assembled MDT.

To date our interactions have revealed that staff confidence in dealing with the different aspects of EoL care was low. This included issues with care-planning; medications; communication with patients and staff; and when to refer for specialist help.

Other processes identified as difficult included paperwork that was not consistent across teams; district nursing colleagues having to liaise with multiple medical team members to ensure continuity of care; and the doses of EoL medications required in this patient group to mitigate involuntary movements that were previously controlled with multiple high-dose oral medications.

Staff without specialist knowledge require support. The efforts made to improve collaboration with external colleagues broke down barriers that were preventing optimal care and allowed all parties to express their opinions and feelings. This allowed us to transparently appraise our current processes and provide guidance on this difficult area.

The journey of optimisation continues, with further practical educational interventions planned, such as syringe-driver training, and efforts to improve shared documentation and enhanced communication and collaborative working between different disciplines.

Optimal, collaborative EoL care from a confident staff-group is possible and a most important part of care for this unique patient group.

This article proposes the need for a theoretical framework that can be applied to underpin the varied idiosyncratic mental health systems.

Bowlby's Attachment Theory defines a set of values that are required for a developing child to acquire a stable base which allow for healthy psychological development into adulthood. These values and behaviours may serve as a caring and holistic framework for people using mental health services.

The outcomes in mental health remain unsatisfactory and services are overall fragmented and increasingly specialised. Ongoing recognition of the inter-related relationship between a person's immediate and social environment and their mental health are frequently overlooked as services become ever stretched in terms of finances, capacity and limited resources including support for staff. The emphasis of treatment is on illness instead of the multifactorial humanity of the individuals using the services. A key outcome of mental health provision is recovery but instead, recovery is compromised by a reductive approach to care that may paradoxically compromise rights, autonomy, confidence and self-belief when people are at their most vulnerable. This creates feelings of mistrust, uncertainty and a limited sense of safety toward services.

Attachment theory takes into account the individual, their experiences, their social world and the significant people in their lives. The principles required for the developing child to develop a secure attachment from a stable base are similar to those required for people experiencing mental illness to facilitate recovery and develop resilience to help manage and reduce episodes of relapse.

Systems that work well, frequently exhibit values underlying models of care that include continuity, consistency, respect, safety, autonomy, human rights, freedom, supportive, trusting relationships and collaboration. The opposite of that seen in what presents as autocratic and risk-averse approaches of many mental health services.

The principles required to enable a child to develop into a psychologically well-adjusted adult are similar to those required when a person is at their most vulnerable. Episodes of mental illness can be a time for reflection and growth, with the right care and therapeutic intervention, illness can also be a time to learn and develop skills for greater resilience in future.

This paper outlines the implications and cultural changes that are required so that the principles of attachment theory can serve as a theoretical framework across mental health services to provide a stable base for people using the services and staff providing the care.

There has been increasing recognition that healthy cultures within NHS organisations are key to delivering high-quality, safe care (King's Fund). A focus towards developing systems which recognise and learn from excellence has been shown to improve services’ safety and contribute to staff's morale (Kelly et al. 2016). In 2019 Secure Services at Devon Partnership NHS Trust (DPT) developed an Excellence reporting system. Once successfully piloted, the intention was to extend to other departments before expanding to the entire Trust. Our aims initially were SMART: for 13 reports per week in Secure services and 8 in Perinatal (a smaller team). As we expanded the aim became qualitative: for a system to be embedded so staff could as readily and instinctively report Excellence as they could an error.

We developed our Theory of Change using Deming's theory of profound knowledge, ran a series of PDSAs, and introduced an Excellence system. We engaged early adopters, sent hand-written cards and shared data widely.

Learning included understanding setting up the system, and the importance of a team rather than an individual holding the system. We took this forward to bring the system to Perinatal. We continued to run PDSAs, then ran monthly trust-wide meetings providing space to learn from other directorates.

Staff were initially excited, reports submitted, feedback good, then a plateau and slump.

Something was stopping the system perpetuating. When staff received timely thanks, and others heard about it, staff would go on to promote excellence. However, this was not possible without sufficient admin resources.

In early 2021 we changed tact and approached the top: we presented data to Directors who recognised the value and agreed to support. We then set about publicising the system, and demonstrating at trust-wide meetings.

By July 2021 we saw 10 reports per week in the Specialist Directorate.

By early 2022 reports were being inputted from staff across all directorates and our monthly meetings began to focus on sharing the learning.

We recognised the system's potential impact on safety and staff morale but struggled to sustain the system and support dwindled when staff were stretched.

After approaching leaders, then allocated resources, it allowed for more success. However, it is not yet fully embedded in our Trust's culture.

A lot of our work happened during COVID-19 and despite challenges there has been a new-found flexibility to innovate, greater ease to negotiate, and instigate change.

The pandemic of the COVID-19 variant caused a near-global lockdown, and the psychological impact of the direct effects of the virus, along with the resulting lockdown periods cannot be overestimated. Referrals made to the Liaison Psychiatry service at Derriford hospital during the 2020 lockdown were audited to better understand effects on patients’ mental health and resulting emergency presentations to services. These data were then used to identify areas for improvement, in order to tailor services to better support the population during recovery from the current lockdown, and for planning for future similar events.

Referrals to the Derriford Liaison Psychiatry service between the 1st and 12th of May 202 were audited, totalling 106 referrals and a subsequent 87 assessments. Quantitative data on patient demographics, presentation, and outcomes was extracted from assessments along with qualitative data on patients’ subjective experiences from the initial lockdown period for thematic analysis. Routine data were used for comparator time periods from 2019, and during the second 2021 lockdown.

Despite a lower number of presentations to ED during the first lockdown, the data demonstrate a higher acuity in presentations with more referrals for admission under section. The lockdown is shown to have particularly affected those with pre-existing psychiatric and physical comorbidity, along with specific patient groups. Thematic analysis confirms this, showing the diverse factors contributing to emergency presentations and demonstrating the increased stress of life in the home under lockdown. Comparisons between the qualitative and quantitative data confirm that patient experiences directly match both the routinely collected data and prior research. The project also revealed a reliance on private and third sector organisations for signposting on from assessments, and highlighted frequent changes to services during lockdown as a source of confusion for both patients and staff.

The scale of impact identified affirms that exploration of the lockdown's contribution to presentation should be routine, particularly for identified at-risk patient groups. Areas frequently highlighted by patients can be used to fully explore the impact of lockdown on presentation during assessment. Patient information for self-referral needs to be regularly updated given frequent changes in service provision. Staff also need to be kept up to date on changing service structure at handover meetings.

Osteoporosis is common amongst elderly patient populations and is associated with significant morbidity and mortality. We aimed to assess whether national clinical guidelines regarding the identification, assessment and management of osteoporosis and fragility fracture risk were being adhered to on a female later life psychiatry ward. We then aimed to improve the detection and treatment of osteoporosis amongst this patient cohort and subsequently conducted a re-audit of adherence to relevant clinical guidelines.

In July 2021, the electronic health records of the 20 most recently discharged patients from a female later life psychiatry ward were reviewed. The proportion of patients who appropriately received FRAX screening, DEXA scanning and pharmacological management of osteoporosis and fragility fracture risk was recorded. The results were compared to standards identified in national clinical guidelines from the National Institute for Health and Care Excellence (NICE) and the National Osteoporosis Guideline Group (NOGG). In addition, the proportion of patients who had FRAX scores communicated to their general practitioners on discharge was recorded. Recommendations were made based on audit findings, and several changes to ward processes were implemented including incorporating fracture risk scoring in a structured ward round template and displaying information posters about osteoporosis in clinical areas. A re-audit was completed in February 2022 using the same methodology as baseline to re-assess adherence to the audit standards.

All included patients were female and aged >65 years, and therefore eligible for consideration of fragility fracture risk according to NICE guidelines. 88% (15/17 patients) of those without pre-existing osteoporosis had FRAX scores calculated during their admission on re-audit compared to 50% (8/16 patients) at baseline. 73% (11/15 patients) had FRAX scores communicated to their GP on discharge at completion of the audit cycle compared to 25% (2/8 patients) at baseline. At completion of the audit cycle 10% (1/10 patients) with intermediate fragility fracture risk received measurement of bone mineral density during admission while 30% (3/10) had this recommended to their GP on discharge. None of the high-risk patients (n = 4) were started on bisphosphonate therapy.

On completion of the audit cycle, we found excellent compliance with national guidelines regarding the identification of osteoporosis and fragility fracture risk, which demonstrates the feasibility of considering this aspect of physical health in the setting of a later-life psychiatry ward. Areas for improvement include the assessment and management of patients identified as having intermediate or high risk of osteoporosis and fragility fractures.

1. To ensure there is documented evidence of discussion about legal aspect of dementia with patients and relatives. 2. To Improve documentation of Financial management by 100% at the end of 3 months. 3.To Improve documentation of LPA and other related legal areas by 70% at the end of 3 months

In Kensington and Chelsea and Westminster Memory services, we are seeing patients with cognitive impairment which can be due to dementia. So, it is really important to discuss and help a person and/or relative with making decision about client's health, welfare or finances. Though each team member discusses about what they did for the same, we identified that it was not reflected in the documentation.

After finalising data collection form, we then performed a retrospective collection of number of documented assessment/discharge report/progress notes within an identified 3-month time period from March to May 2021. Our intervention was Email and MDT remainders, developing patient information video, and structured format to document about legal aspect of dementia like, financial management, Lasting power of Attorney, Court of protection, Advance will, etc. We run PDSA cycles and collected a data at the end of each month to see whether change ideas are helping to improve documentation and whether any modification will require with the plan.

Out of 67 patients record which were reviewed as a baseline data, 39% of them has diagnosis of dementia or Mild Cognitive impairment. Discussion about LPA was recorded in only 16% of the documents. There is no mention of how a person is managing their finances in 30.7 percent of documents. After implementing change ideas, 29 patients who were seen during the month of December were reviewed using the same data collection form. Documentation of discussion about financial management was improved to 93.1%. Documentation of Discussion about how to set up LPA, if a person doesn't have one has been approved from 10.4% to 55.2%. The cycles will continue for month of January and February and data will be assessed and compared at the end February 2022.

Basis on the data available till date, a general improvement in the record keeping of notes was seen. Simple intervention like email reminders, reminder in MDT, structured format for documentation and patient information in visual format can improve the documentation of work. More detailed conclusion will be drawn at the end of 3 months.

Mental health disorders, mostly notably paranoid schizophrenia and personality disorders are commonly seen in patients with a forensic background. Section 37/41, within the Mental Health Act 1983, detains patients who are mentally unwell in hospital for treatment, instead of a prison sentence, with the addition of a community restriction order for public safety. Once stable, patients are discharged by the Ministry of Justice (MoJ) on Section 42, otherwise known as a conditional discharge. This means they can live freely in the community but under a set of conditions they must follow in order to obtain absolute discharge. A leaflet on Section 42 was created after a gap in patient knowledge was identified during consultations. Furthermore, a literature review did not retrieve any relevant results on this topic. The aim of this leaflet was to improve both patient and staff knowledge.

A patient leaflet was created using information from relevant legislation, MoJ official documents, trust resources, the charity MIND UK as well as staff knowledge. A checklist consisting of 12 questions was created to test the patients’ knowledge, with space for additional comments. Care was taken to ensure every question on the checklist had a corresponding answer in the leaflet. Six suitable patients were identified and supported to read the leaflet and a structured interview using the checklist was conducted pre- and post-leaflet. In addition, feedback was sought from staff members of multiple backgrounds. A resource questionnaire was also given to participants to collate feedback. The pre- and post-test answers were compared and given a mark out of 12. A mark was given for answers that were sensible and correct, even if parts were missing for questions that encompassed multiple facts.

All patients were previously on Section 37/41 and now on Section 42. All showed a substantial improvement in knowledge base, with 4/6 patients scoring full marks afterwards. Patient feedback obtained was overall very positive, with many describing it as “useful”, “informative” and “helpful”. Staff feedback was also collated and found to be positive too, with comments including “very informative”, “easy to read” and “clear and precise”.

Our leaflet was well received by both patients and staff. It improved their knowledge base as well as confidence in understanding the medico-legal jargon used in day-to-day practice in the forensic setting. Feedback was overall positive, and the additional patient feedback was encouraging, with many of them wishing for sooner access to similar resources.

The project's aim coincides with NHS England STOMP Pledge signed by BDCFT. To maintain up to date records of children and adolescents with learning disabilities eligible for STOMP reviews, implement planned supervised dose reduction, consider alternatives to psychotropics and maintain an up-to-date record of physical health monitoring for patients on antipsychotic medications according to local Trust guidelines.

The sample consisted of the caseload registered with the CAMHS learning disability Team at BDCFT in December 2021. Each case was reviewed retrospectively through electronic records. Data were collected on a data collection tool designed in Microsoft Excel.

Baseline data about Diagnosis and Psychotropic medications prescribed were recorded. The Antipsychotic prescribing practice was audited against local Trust guidelines as part of the project.

The project was registered and approved by the Trust Audit Team.

The study included 106 cases registered in December 2021.

42 patients (40%) were prescribed psychotropic medication only

10 patients (9%) were prescribed psychotropic medication plus ADHD medication

14 patients (13%) were prescribed ADHD medication only

40 patients (38%) were not prescribed any medication

66 (62%) patients from the sample were prescribed medication.

Medications were divided into, Psychotropics and ADHD medication groups. Each group was assessed against a prescription time standard of either less or more than 12 months.

Antipsychotics were the most frequently prescribed psychotropic medications; 60% of those prescribed psychotropics were on Antipsychotics. A smaller number (31%) on an Anxiolytic, and an even small number (12%) on an Antidepressant. Anticonvulsants were prescribed to 6 in our sample, but all by another service provider (Paediatrics). 20 patients (38%) were on more than one psychotropic medication.

The length of the time was divided into less and more than a year on medication. 20% of patients were on psychotropics for less than 12 months and about 80% for more than 12 months.

As there are local BDCFT guidelines for monitoring patients on Antipsychotics, a summary of compliance against standards was included as an audit in the project.

All 66 patients on medications were deemed eligible for STOMP reviews, and 64 out of them had behavioural support plan in place.

66 patients who had eligibility for STOMP:

1. 1. 35%: Undergoing reduction plan.

2. 2. 35%: Reduction was not deemed suitable.

3. 3. 30%: No review or reduction plan in place

With increasing awareness and reduction of stigma associated with Mental Health issues, referrals to services are increased, pushing specificity of commissioning and therefore declining patients of services when referrals are inadequate. Standards would be improved by better inclusion of information necessary for the Single Point of Access process (SPOA) in the Bolsover Community Mental Health Team (CMHT) to make prompt, effective decisions on allocating care.

A Quality Improvement project in a Mental Health Team was devised to improve standards, and acceptance rate, of appropriate referrals to the Bolsover CMHT from General Practitioners (GPs). This would encourage GPs to refer patients whose mental health difficulties do not meet CMHT thresholds to alternative services. A higher acceptance rate and lower rejection rate would indicate that the proportion of suitable referrals had increased.

Using the Plan, Do, Study, Act (PDSA) model, Driver diagrams were used to create a template with the crucial information necessary for GP referrals to psychiatry/SPOA. Data were collected to check aims of the referral, sufficient information of the presenting complaint, personal & family history, safety concerns, protective factors, comorbidities, medication and substance misuse. The outcome of each referral was recorded and categorised as either Community Psychiatric Nurse Assessment, Outpatient Appointment, Referral Rejected, Referred Elsewhere or No Patient Response.

All referrals in September and October 2021 were analysed to assess whether enough information had been included for each variable. The September and October data were compared to check if the template had been associated with improved quality of referrals.

Pre-template, 17.4% of referrals were accepted, 13.0% received a SPOA assessment, 17.4% were rejected, 39.1% were re-referred elsewhere and 21.8% did not respond to the CMHT. After the template was circulated, 28.0% were accepted, 36.0% received a SPOA assessment, 4% received joint Doctor-SPOA care, 8% had a medication review and 12% were waiting for an MDT decision when data were analysed. The results for SPOA assessment and rejection were statistically significant (p < 0.05), while results for other outcomes were not.

Information on presenting complaint (82.1% to 100%, p < 0.05), personal history (39.3% to 92.3%, p < 0.05) and aims (50% to 88%, p < 0.05) increased, while other information did not change in a statistically significant manner.

The template led to an increased proportion of accepted referrals and a decreased proportion of rejected referrals. However, information on variables did not necessarily improve in the same manner. The template is useful to improve decision-making in SPOA.

To Reduced Mental Health Liaison Team (MHLT) handover time to less than 30 minutes within one month and to improve the quality of handover. The non-medical staff have been part of the team for many years, whilst medical staff have recently changed or are on short rotations. Previous changes have not been well sustained. Much of the initial enthusiasm for this project was coming from the medical staff members. We felt that it was important to fully explore the driving human factors to achieve sustainable buy-in.

The total period of the project was 7 weeks. First two weeks were used for daily baseline data-collection and informal and formal discussions with team members to formulate driver diagram and change ideas. Two “Plan, Do, Study, Act” (PDSA) cycles with two intervention points at week 3 and week 4.

Key human factors identified in the MHLT were burnout and emotional fatigue, core team values (cohesion, flexibility, and camaraderie), and disillusion with authority and imposed change. Contributing factors to burnout and emotional fatigue were long and short-term staff sickness, chronic under-staffing, and systemic changes in the general hospital due to the COVID-19 pandemic. The human factors were used to guide key decisions in methodology and creation of change ideas. These decisions included: Avoidance of surveys and questionnaires (staff request), limiting the total number of changes, any additional administration to be undertaken by medical staff, and avoiding a rigid handover system. Following 2 PDSA cycles, there were improvements in average length of handover from 44 minutes (2-week baseline data) to 30 minutes (4-weeks post second intervention). When compared to the baseline data there were also improvements in the average number of interruptions (7 vs 2), availability of key information (69% vs 92%), allocation of staff member (80% vs 95%) and allocation of review date (83% vs 95%). No difference in the average number of patients for handover discussion between 2-week baseline data (15) and the 5 weeks after (15).

The aims for the Quality Improvement Project were met and a plan has been set to re-audit in both 6 months and 1 years’ time to test sustainability of change. Sudden illness and effects of the COVID-19 pandemic have led to short and long-term staff shortage, contributing to burnout and emotional fatigue. Attention to the unique human factors involved in team dynamics and staff morale can help achieve buy-in and real change.

Medication tasks are an integral part of a junior doctor's job. However, these can often be timely and use hours that could be spent doing other therapeutic work, especially due to the cumbersome nature of SystmOne. Our aim was to review the amount, type, and time spent on medication tasks and evaluate ways in which the system could be made more efficient and time effective, to release doctors to complete other clinical ward activities.

We used prospective data collection, with two ten-day cycles carried out across the 46 bedded adult mental health unit (AMHU). Data were collected by all junior doctors working on the AMHU and every medication task was recorded on a designated document at the time of completion. This included data such as time the task was created, related ward, sender, type of task, amount of medications per task and minutes taken to complete.

During the first ten-day cycle of data collection, we found that collectively we spent 21.5 hours completing medication related tasks. 10 hours were spent ordering medications, seven of which were ordering ward stock. Tasks involving completely re-prescribing the medication for the action to be completed took 12.6 hours. The data showed that 42% of tasks were completed on Mondays.

Following cycle one we discussed the data with the AMHU pharmacy team, ward managers and consultants. Subsequent alterations were made to the stocklists for the wards, ward timings were aligned and a collective tasks system created to reduce duplication of tasks.

During the second cycle of data, in total 16 hours were spent on medication tasks. There was a total of 7.45 hours spent ordering medications, 3.35 hours were ordering ward stock. Re-prescribing tasks took 9.7 hours.

From the results of the second cycle of data we can see the recommendations from cycle one have been effective in reducing the amount of time spent ordering medications by 25.8%. This highlights the importance of regularly updating the stocklists and utilising MDT working to maximise efficiency. We also confirmed that Monday was the heaviest day for tasks, which should be considered for staffing. As 46% of overall time was still spent ordering medications, we presented this data at the medicines management committee. Following this, recommendations have been taken to SystmOne for IT system alterations to improve efficiency of the system and allow junior/trainee doctors to focus more time on the clinical care of patients and learning.

In 2021 The Department of Health published a report into the safer use of medicines in health and justice mental health services, advocating sustainable prescribing as a way of improving patient care and reducing carbon emissions. Improving prescribing behaviour could lead to a reduction of 170,000 kg CO2e per year across England, along with cost savings which contribute to higher value service provision and improved service user experience. We aim to evaluate and improve the prescribing of antipsychotic depot and ‘as required’ (PRN) medication in a male secure unit.

Baseline data were gathered from the patient population in a male secure unit (1 low and 2 medium secure wards, total 50 beds) in December 2021. This included the number of patients prescribed a depot, the type of depot prescribed and whether or not these were administered at the longest evidence-based interval. As part of a wider trust initiative “prn” medication was moved to a fortnightly review cycle to ensure medication was used for as short a duration as necessary. Over a six-week period medication rationale was analysed and discussed with the Responsible Clinician for the service user to optimise prescribing. Data collected following this intervention was compared with baseline results.

The project found that 26 patients in the service were prescribed an antipsychotic depot in December 2021. In this group 17 (65%) were prescribed their medication at the longest evidence-based interval. Of the 9 (35%) that were not, 5 had clinical reasons why a change would not be appropriate at present, however it was agreed this could be considered later in their pathway. Of the remaining service users, two had their dose of medication reduced and their prescribing interval increased. “As needed” (PRN) medications of 15 patients were evaluated; 9 (60%) had medications prescribed which were not in use (4 patients had 3 or more prescribed not used within 2 weeks). Following intervention this reduced to 2 patients, both of which had only 1 PRN medication which required review.

Deprescribing can have a significant impact on patient care and safety and can reduce the environmental impact of a service. This project demonstrated the advantages gained from regular medication reviews and taking into consideration dose and administration interval when prescribing antipsychotic depots. Using protocols for prescribing as needed medications, a structure for reviewing prescriptions, collaboration with patients and utilising patient group directions where appropriate can all aid in improving prescribing sustainability.

Somerset drew upon the Community Mental Health (MH) Service Framework, and local experience and recognised that too often service user experience of mental health was beset with artificial barriers, gateways and eligibility with people sometimes needing to deteriorate before they got the vital support they needed. In addition, we recognised that the gap between secondary care and primary care was experienced by service users as a “cliff edge”. The radical redesign of mental offers in Somerset aimed to deliver an experience of “no wrong door” and where, via a partnership between health, social care and Voluntary, Community and Social Enterprise (VCSE), people's needs could be met; both in terms of specific mental health offers as well as tackling the wider determinants of mental ill health.

OMH was launched early 2019, just before the pandemic, and so traditional project methodology did not always apply. Instead all partners focused on standing up the offer at pace in order to support the population within Somerset with the emotional and psychological consequences of the pandemic, and any pre existing challenges. The model was co-produced with Experts by Experience significantly contributing to the shape of the offers.

The model developed comprised of two key facets:

• • A mental health offer, where the needs of individuals, families and carers are met by a range of health, social care and VCSE partners (including the wider determinants of mental well being such as finance / housing)

• • A mental health eco system developed in collaboration with communities (including underserved communities), where support is available throughout geographical communities and communities of identity.

The project has delivered both quantitively and qualitatively. Over 4100 additional appointments are offered to people in Somerset per month and reported outcomes and evaluation has been very positive. Work is underway to collate further Patient Related Outcome Measures. Following a Realist Evaluation methodology, the researcher in residence has highlighted the culture changes that are key to delivering the aspirations of the Community MH Service framework. These include; the narrative of “no wrong door”, an increased and open range of offers and interventions, blended staffing models across traditional organisational boundaries, partnership working, the role of lived experience and the ambition of addressing inequalities.

OMH, the product of Community MH Transformation in Somerset, is a radical and co produced redesign of MH services in partnership with the VCSE and Local Authority that has improved access and support to all people in Somerset.

The National Institute for Health and Care Excellence guidelines state that benzodiazepines (BZD) should not be taken for longer than four weeks. However, there are no recommendations specifically addressing the use and misuse of BZD in inpatient settings and their prescription at discharge. A recent study (Panes et al., 2020) recommended aiming for BZD’ total withdrawal or, at least, dose reduction at discharge to reduce the risk of misuse in the community which can lead to dependence and serious side effects. Our study aimed to 1. describe BZD’ prescriptions on an acute female ward, before admission, during admission, at the time of discharge and at four and eight weeks post-discharge, 2. identify potential sociodemographic, clinical and therapeutic correlates/predictors of BZD’ prescriptions, 3. develop a strategy to reduce BZD’ prescriptions or, at least, to reduce the dose of BZD prescribed at discharge.

Data collection was done retrospectively through electronic medical and prescribing records and included admissions to Avocet Ward, between May and October 2021. Variables collected were age, ethnicity, length of stay, Mental Health Act status, diagnosis, comorbid drugs or alcohol misuse, Home Treatment Team involvement at discharge, community teams, prescriptions of regular and Pro Re Nata BZD and “z-drugs” prior to admission, during admission, at discharge, and at 4 weeks and 8 weeks post-discharge, maximum dose of regular BZD during admission and the dose at discharge.

Among the 59 admissions included, 25.4% had BZD before admission, 81.4% during admission (with a mean maximum dose of regular BZD of 38.8 mg (SD = 17.3) of diazepam equivalent), 50.8% at discharge (with a mean dose of 28.5 mg (SD = 18.5) of regular BZD), 35.6% 4 weeks post-discharge and 27.1% 8 weeks post-discharge. The odds of having regular BZD during admission were 7.4 times more likely for those on regular BZD before admission after controlling for other variables (95%CI: 1.1, 50). The maximum dose of regular BZD during admission was positively correlated with the dose of regular BZD at discharge (r(15) = .67, p < .01). Among the regular BZD prescribed during admission (N = 23), 26.1% were fully discontinued by the time of discharge and 43.5% were titrated down, while 30.4% remained at the same maximum dose prescribed during admission.

BZD prescriptions are common at discharge from inpatient settings and can be associated with BZD misuse in the community. We suggest strategies to avoid this issue.

Ekbom's syndrome (ES), also called delusional parasitosis, is a condition where the patient has an unshakable belief and a perception of being infested with parasites. ES is thought to mainly affect postmenopausal females and because patients are usually mono-symptomatic, they usually seek care from dermatologists. It is advocated to form a liaison between dermatology and psychiatry to ensure a full range of differential diagnoses, in order to form the most suitable management plan.

Case report

An 87-year-old widow was referred to the outpatient psychiatric clinic of King Abdullah University Hospital by a dermatologist because of generalized chronic pruritus that she believes is caused by a bug infestation. The symptoms started one year prior to presentation (soon after an ischemic stroke) with the perception that macroscopic parasites were crawling over her body, biting her face, head, and hands, and entering her eyes. She tried various strategies to eradicate the parasites with no benefit. Psychiatric examination findings included hypochondriac delusional ideas and dysphoria. When her general medical condition and her medications were reviewed, it was found that she had been diagnosed with hypertension and ischemic heart disease. She was taking anti-hypertensive drugs and blood thinners. After haloperidol 5 mg daily was added, she had a progressive clinical improvement.

ES is a neuropsychiatric syndrome that can follow primary psychotic or depressive disorders, dementia, or other organic diseases. Consultation-liaison by psychiatrists and dermatologists will be useful to assure timely referral. Better awareness of such an illness by general physicians, early recognition, good rapport, and empathic treatment are the cornerstones of management in such cases.

Mr AB is a 58-year-old male with diagnosis of Schizoid Personality disorder. An articulate and intelligent man, AB derived happiness and contentment from his work. Due to workplace conflicts, he was asked to resign several years ago and has not worked since. Mr AB then found a sense of purpose in life by looking after his elderly parents. His parents sadly died a few years ago and since then he has been living on his own. He has never married. AB has one brother who helps him with shopping and groceries. Prior to this admission, AB was admitted once a few years ago when he was diagnosed with Depressive Disorder.

Mr AB was admitted last year with profound self-neglect. He was detained under Section 2MHA as he wasn't eating and drinking and wasn't engaging with services. With the initial diagnosis being Recurrent Depressive Disorder, AB was commenced on treatment for the same and eventually received ECT, for which he had strongly opposed. Following 6 sessions of ECT, AB bargained with the team that he would start eating and drinking if ECT was stopped and did so as well. He then requested a transfer to a different ward and consultant, with whom he shared that he doesn't agree with our diagnosis of depression or Schizoid personality disorder. AB expressed that he doesn't find his life worth living and wants to be left alone. He strongly believed that his liberty to take decisions about his life is being unfairly taken away by the NHS and accused professionals of trying to protect themselves. No evidence of SMI found at this stage. Following several discussions, AB was discharged home. He however was readmitted within a couple of days’ time by his brother following disengagement, self-neglect and again, no evidence of SMI.

A capacitous patient, in the absence of Serious Mental Illness puts forth an argument that purely because his way of living and his opinions on life and death differ from that of the society, doesn't mean that his rights over his life can be taken away from him. He, however, struggles to acknowledge that as fellow humans we are strongly inclined to intervene and try to stop anyone from taking their own life.

A Challenging case that raises several questions surrounding Medical Ethics. The team is now looking into guardianship to ensure welfare of the patient.

The amended Mental Health Act (MHA) of 2007 gave Psychiatrists the right to detain, assess and treat individuals with mental health disorders, not only with a view to offer medical treatment but also to ensure their safety and that of the public, by containing them. This meant that patients diagnosed with disorders such as Antisocial Personality (APD), previously un-detainable under the MHA of 1983, would no longer be considered untreatable and could be sectioned, if appropriate. The idea was then generated, that Psychiatrists would now assume the role of custodians of potentially dangerous people and raised the concern that all persons with APD would be perceived as dangerous and find themselves at a dynamic risk of being sectioned under the revised MHA. The balance between the role of Psychiatrists as medical professionals versus this new, unpopular role as figures of public order was and still is, debatable.

We present the case of a patient with a background of Depression and Post-traumatic Stress Disorder with aggressive features, who during a consultation revealed a powerful homicidal urge and fantasies directed to an individual he believed had wronged him. The patient had access to the individual and had attempted to confront him. He had no forensic history, nor had he expressed criminal intent before. This triggered a safeguarding response, the consensus being that advice should be sought from the Forensics team, not only to protect the potential victim but also the potential perpetrator from the consequences of a criminal act.

Considering the lack of police involvement, plans, or weapons; the separation between patient and potential victim; and the patient's distress associated with the disclosure of the homicidal fantasies, the level of risk was deemed to not merit disclosure. Closer risk assessment with ongoing psychological and pharmacological interventions created a therapeutic alliance which allowed for open communication with regards to the dynamic nature of the risk and the potential for any further disclosure.

Within the definition of Duty of Care lie responsibilities beyond the strictly medical role of clinicians. Not unlike the duty to inform the DVLA about a patient's fitness to drive, breaking confidentiality for the purposes of patient or public safety is not a power that makes Psychiatrists figures of Authority, but a responsibility that is part of their role. At the same time, we should bear in mind that the license to disclose is also a license not to disclose.

Catatonia has an effective treatment: benzodiazepines. A first presentation of catatonia may present initially to an acute medical trust. It is important acute clinicians are familiar with its manifestations, medical differentials, and most importantly, understand the role of benzodiazepines in both the investigation and management of catatonia.

Here we describe a case of catatonia in a nineteen-year-old male, who presented acutely to the accident and emergency department with odd behaviour following inhalation of the synthetic cannabinoid ‘spice’. Initially, he was found to be rigid, mute and doubly incontinent, but able to follow vague commands. He was admitted to the acute trust for twelve days in which he was worked-up as a case of drug induced psychosis. As he was not improving, he was then transferred to psychiatric inpatient services for further investigation and management.

The acute medical team did not recognise this as a presentation of catatonia and did not conduct a lorazepam challenge, as suggested by specialist services. A lorazepam challenge is helpful in both diagnosing and treating catatonia. In this case, we believe this may have been missed, due to a lack of knowledge and understanding of the condition. Medical mimics of psychosis, such as autoimmune encephalitis, may be life threatening, but have a good prognosis if treated early. Here, these were not considered, which may have led to disastrous consequences had they been present. This case shows an opportunity for education into the differentials and management of catatonia.

We believe this case highlights a degree of poor understanding surrounding catatonia and its clinical work-up in the acute setting. There were missed opportunities to instigate treatment earlier and consider rarer alternative causes for the presentation. We hope this case will simplify diagnosis and management for acute clinicians, and highlight important medical mimics of catatonia. This case also shows the potential significant harms of synthetic cannabinoids such as ‘spice’ and highlights a need for further research and potential review for grading above Class B in the Misuse of Drugs act 1971.

Emotionally unstable personality disorder (EUPD) accounts for up to 20% of diagnoses in the inpatient psychiatry population. The assessment, diagnosis, and treatment of any personality disorder may be challenging, and its classification remains debatable. Here I will describe a case of a dual diagnosis of EUPD and schizotypal personality disorder. Through the case report I will also reflect on my first experience of working with a patient with personality disorder, as a Psychiatry Foundation Fellowship doctor with little previous exposure to the psychiatry specialty.

The patient was a female in her thirties, previously diagnosed with EUPD, who had not benefitted from a number of psychological treatments. She had a history of suicidal behaviour and previous admissions but presented differently this time. She had short hair that was dyed in a vivid colour, was paranoid that she was being spied upon from an alternative universe and had suicidal plans to join the alternative universe. She also had auditory and visual hallucinations. On exploration it became apparent that she had similar episodes in the past, each lasting no more than a day. An additional diagnosis of schizotypal personality disorder was made, and she responded well to risperidone. Unfortunately, she was transferred to another ward for bed management reasons, whereupon the diagnosis reverted to EUPD and antipsychotics were stopped.

This case highlights how in mixed personality disorders, features of one personality disorder may be more predominant than another at different times. It also contradicts the notion that people with schizotypal personality disorder rarely present to mental health services. The inconsistency of diagnosis and lack of continuity of care caused immense distress to the patient, prolonging the acute episode. This highlights the importance of a good formulation in order to tailor care for the patient.

As a newly qualified doctor, working with patients with personality disorders was a meaningful experience. Through ward rounds and the seemingly trivial conversations along the corridor, I thought about the effect of transference and countertransference for the first time, which is applicable to any interpersonal interaction. I witnessed the harm caused by the lack of continuity of care. I reflected on the intricate balance between the advantage of establishing a diagnosis for the patient, and the drawback of the diagnosis leading to labelling. It made me face the stereotypes I held and allowed me to learn about the patient as an individual.

Intern doctors are the backbone of the hospital infrastructure. While they are the first to provide patient care on an Emergency and Elective basis, they also happen to be the junior most. The interns of the year 2021–2022, apart from working in various departments of the hospital, were also the frontline workers in the 2nd and the 3rd wave of the COVID-19 pandemic. In the current global public health crisis, interns are more exposed to physical and mental exhaustion, owing to being overworked, along with carrying the burden of loss of patients, colleagues, and potentially infecting themselves and their loved ones to COVID-19. Burnout, a psychological syndrome that occurs due to work-related stress, includes emotional exhaustion (EE), depersonalisation (DP), and a sense of reduced personal accomplishment (PA). Intern doctors run a high risk of facing burnout—the prevalence of which is yet unknown. Hence, the survey was conducted.

An online survey was carried out using MASLACH BURNOUT INVENTORY (MBI) among interns with their voluntary participation. 22 symptom items pertaining to occupational burnout were assessed, with three-component scales: emotional exhaustion (9 items), depersonalisation (5 items), and personal achievement (8 items), with a 7-level frequency scale for all MBI scales and 0–6 scoring.

Responses were received from 180 interns (n = 180). Questions regarding current department postings and contraction of COVID-19 were included in the survey.

Burnout was prevalent in most interns who tested positive for COVID-19 = 60% (108), followed by those whose family members tested positive for COVID-19 = 23.8% (43).

Burnout was seen more in female interns = 30% (54) than in males = 10.56% (19).

Burnout was seen more in interns working in the Emergency and Trauma = 41.67% (75), and the least in Ophthalmology = 1.67% (3).

Burnout is significantly prevalent in intern doctors at the end of the academic year, especially due to the COVID-19 pandemic. Burnout can lead to increased medical errors, reduced patient satisfaction, which affects the quality of patient care. Understanding risk factors, improving workplace environment, limiting duty hours, workshops promoting healthy behaviours have been suggested to reduce burnouts and to prioritise both mental and physical health of interns so as to ultimately improve patient care.