To assess the adherence to NICE guidelines CG78 (1.4) regarding the inpatient services provided for BPD patients at an acute psychiatric unit (The Oleaster).

Borderline personality disorder (BPD) patients are frequent users of psychiatric inpatient services. However, evidence suggests that inpatient treatment is ineffective in the long-term recovery of such patients. The inpatient services at the Oleaster will be audited against NICE guidelines for BPD. We hope to improve the care of patients with BPD and ensure effective use of psychiatric resources.

Retrospective case notes review of 35 patients admitted into the Oleaster from 1/11/2018–31/10/2019. This was taken from an initial sample of 72. Patients were excluded if they were admitted for other concomitant mental or behavioural problems (except problem use of tobacco, drugs or alcohol).

69% of patients were referred to other mental health services (e.g CRHT/HTT, other local alternatives, liaison team) prior to admission. There was no evidence of referrals in 31% of the sample population.

The reasons for admission include significant risks to themselves/others (n = 14) and detention under MHA (n = 14). Reasons were not noted in 7 patients.

Advance agreement on the length and purpose of admission took place in 19 and 27 patients respectively. Discussion of potential harms and benefits of admission only took place in 4 patients. Discussion was not applicable in 2 patients who lacked capacity.

Of the patients admitted ≥2 times in the previous 6 months, only 38% had a CPA review arranged. It was not arranged in the remaining 62%.

There is room for improvement in the appropriate admission and documentation of BPD patients. Referral prior to admission was well adhered but documentation was unclear. Implementing a set checklist before admission could be recommended. Active involvement of patients was inadequate. It is especially lacking in regard to informing patients of the potential harms of admission. This can be improved by educating patients and staff on this matter.CPA reviews were not arranged in a timely manner. Placing an alert on patients’ records when they are admitted again within the last 6 months would help to reduce this issue. Overall, greater effort is required to ensure patient's most current needs are met and that limited psychiatric resources are used effectively.

To ensure that service users in in-patient secure services have prolactin, vitamin D and HbA1c monitoring as per current best practice guidance.

Service users prescribed antipsychotic medication are at risk of developing raised prolactin levels and metabolic syndrome. In both sexes, long-standing hyperprolactinaemia can lead to low bone mineral density with an increased risk of developing osteoporosis.

In recent years there has been increasing controversy on the increase in Vitamin D monitoring despite the poor evidence for complications from vitamin D deficiency in adults. Not undertaking this test in the absence of symptoms will potentially reduce anxiety for service users could save £17 per test and £50 for a 12-week course of Vitamin D supplementation. Local and national guidance indicate Vitamin D monitoring should only be done in symptomatic people.

Fifty-five service users in the five in-patient wards had their electronic records and pathology results reviewed over a one-year period. All service users were expected to have a minimum of an annual HbA1c and prolactin level but to only have vitamin D monitoring if symptomatic for deficiency.

Although 100% of service users in MSU were tested, vitamin D testing was consistently undertaken without documented clinical evidence of deficiency. The ranges across all units were: prolactin (72- 1384mU/L), HbA1c (30–90 mmol/mol) and vitamin D (15–124 nmol/L). Local reference ranges are prolactin (53- 360mU/L), HbA1c (<48 mmol/mol) and Vitamin D (50–120 nmol/L).

Prolactin levels were highest on the male medium secure wards.

The other two units had significantly less testing with prolactin and HbA1c levels being the least measured (18% of service users on male LSU and 23% on the female ward respectively). Vitamin D testing on these two wards were 38% on the female ward and 18% on the male ward for both tests.

Northside House has a dedicated physical health team and this is likely to explain its 100% score. However, vitamin D testing was being undertaking automatically rather than based on symptoms.

The recommendation is to add prolactin and HbA1c to the physical screens done before CPA meetings for all service users prescribed an antipsychotic but to stop Vitamin D testing in the absence of clinical symptoms of vitamin D deficiency.

1. This project aimed to review the medical cover available to an Old Age Psychiatry inpatient ward.

2. To discuss with ward staff their view for potential improvements and areas of clinical development.

3. To review the potential of a Full Time Nurse Practitioner role on the ward.

One junior doctor (CT1 or equivalent) was allocated to cover the ward whilst balancing their other training needs and clinical commitments. The inpatient ward was based in a community hospital with no onsite medical team. The patients mostly had complex medical needs and multiple comorbidities.

The Junior Doctor's timetable and the time allocated to the ward was reviewed. Questionnaires were conducted with nursing staff to assess their views on the support of physical health cover. The patient notes were analysed for the time taken to review patients after falls over a one month period.

There were 14.5hours allocated to ward cover. An additional 4 hours was provided by another visiting junior doctor totalling 18.5hours per week- 11% of the time. This figure does not account for annual leave, on call commitments or study days whereby there was no additional cover.

A short survey completed by ward staff showed- (1 = Very Poor/Difficult 5 = Excellent/Easy)

• • They rated medical cover of physical health needs on ward 7 as 1.3.

• • They found contacting a Doctor to discuss a physical problem as 1.7- with particular concern for OOH.

• • It was rated to be extremely difficult for a same day review of physical health problems- 1.7

• • It was rated extremely difficult to get a physical review following a fall on ward 7- 1.4

• • Continuity of care for the patients on ward 7 was rated as 1.6.

Medical cover for the old age psychiatry inpatient ward was inconsistent and a challenge for a single trainee to manage alongside their other clinical commitments and training needs. A case was proposed to management with an SBAR for a Full Time Advanced Nurse Practitioner which has been approved. This role should provide patients with appropriate cover of their physical health needs. It will allow the junior doctor to work alongside them on the ward supporting each other to provide optimal care for the inpatients.

From May 2015 NHS organisations in Wales are expected to report the number of VTE cases associated with hospital admissions which are possible hospital acquired thrombosis (HAT) per calendar month. NICE Quality Standards (QS3) recommend that All patients, on admission, receive an assessment of VTE and bleeding risk using the clinical risk assessment criteria described in the national tool.

VTE is a condition in which a blood clot (thrombus) forms in a vein, most commonly in the deep veins of the legs, known as a deep vein thrombosis (DVT). The thrombus can dislodge from its original site and travel in the blood (embolism). If it becomes lodged in the lungs, a condition known as a pulmonary embolism (PE) arises and can cause sudden death. Hospital acquired thrombosis is avoidable and unfortunately kills patients under our care.

Collected data using a standardised form for 131 patients from 3 inpatient mental health units on documentation of a VTE risk assessment in the inpatient notes. For those patients who had a documented risk assessment, further data were collected on documentation of contraindications, eisk factors, sign and date of prescription and the appropriateness of prescribing.

8% of patients from one mental health unit (n = 48) had a documented risk assessment in the notes. The subsections of documented risk assessment including contraindications, risk factors, sign and date of prescriptions and appropriateness of prescribing were complete at 100%. No patients from the other 2 mental health units (n = 39,44) had a risk assessment documented in the notes.

Recommendations: All adult inpatients in Mental Health units must receive a venous thrombo-embolism risk assessment. This must be documented on the Inpatient Medication Chart. Consider adding a risk assessment checklist tool mapped from the Department of Health guidelines into the Mental Health Inpatient Clerking in pro-forma.

1. To establish if long acting buprenorphine subcutaneous injection retains patients in treatment.

2. To obtain the patient opinion of long acting buprenorphine subcutaneous injection and ascertain if it improved other aspects of their life for example relationships and employment.

Information was gathered from TRAK, the patient record recording system, and Illy, the prescribing system. This allowed data to be gathered on previous opiate substitute treatments and when the patient was commenced on the long acting buprenorphine injection. A patient questionnaire was used to obtain qualitative data on the patient's view of this treatment option.

West Lothian Community Addictions Service starting offering long acting buprenorphine injection as a treatment option in March 2020. Since then there has been a consistent demand from patients to be commenced on this treatment. On 31st January 2021 39/53 (73.6%) of patients who had been commenced on long acting buprenorphine for 6 months had been retained on this treatment. Moreover, 3 patients were lost to treatment due to transfer to Her Majesty's Prison. Patients who were commenced on this treatment option were both new to treatment and those who had previously been difficult to retain on methadone or sublingual buprenorphine. The questionnaire supported the antidotal feedback that patients found this treatment option to be hugely beneficial.

Long acting buprenorphine injection has been well tolerated by patients and there has been a clear demand for this treatment option from patients accessing the service. It appears that the clarity of mind, that is associated with buprenorphine, has not been a barrier to retention in treatment. We have found the retention rate of the patients on this treatment option has been higher than the median 6 month retention for either methadone or buprenorphine, compared to a recent systematic review. In addition, it has helped patients consider employment, improve relationships and maintain a level of stability that they may not have previously achieved on either methadone or sublingual buprenorphine.

An evaluation of the benefits of ECT in patients with schizophrenia who received ECT in Cardiff & Vale UHB, in order to:

• ⋅ Investigate the effectiveness of ECT as a treatment for schizophrenia

• ⋅ Inform future clinical practice

• ⋅ Identify clear outcome measures for use in future research

Schizophrenia is a severe and debilitating mental illness, for which pharmacological treatment is often ineffective. ECT is seldom used for schizophrenia, despite encouraging evidence for its efficacy. Current guidance in the UK is inconsistent, as RCPsych contemplates the use of ECT in schizophrenia in certain cases, while NICE does not. This confusion warrants the need for further evaluation of ECT as a treatment for schizophrenia.

Eight suitable patients were identified, and a retrospective chart review was conducted in relation to the following outcomes:

• • What was the main indication for ECT, and was the issue resolved

• • Change in clinical rating scales

• • Concordance with medication before and after treatment

• • Length of hospital stay before and after treatment, over one year

• • Mental Health Act status after treatment for those treated on section

• • Was the level of observation reduced following treatment

Initial indication for treatment was completely resolved in seven out of eight cases. All patients improved in overall symptomatic score (mean improvement = 59.5%). Five patients (62.5%) improved above the threshold of clinically significant response. At the commencement of treatment, three (37.5%) patients were refusing all medication, three (37.5%) had poor concordance and two (25%) were fully concordant. At treatment endpoint, all were fully concordant. Average length of hospital stay remained unchanged: 30 weeks during the year before ECT, and 33 weeks during the year after ECT. Of six patients treated under Section 3, four (66.7%) had their section lifted within six months. Observation level was reduced in all cases that had been placed under continuous observation.

ECT improved all outcomes except admission duration. These results provide support for the consideration of ECT as a meaningful treatment option for schizophrenia.

PERCEIVE is a service evaluation counting whether nurse demographics correlate with reported subjection to violence and verbal aggression. The setting was a large mental health, learning disability and neuropsychiatry NHS trust in England. This continues our work to understand correlations reported in the literature between temporary staff and violence.

We consulted the Caldicott, legal, equality & diversity, teams and gained service evaluation permission SER-19-031 from CNTW R&D department. We briefly consulted with staff regarding themes relevant to temporary nurse workers. They expressed concern that staff perceived to be “other” would be at more risk.

Employees’ age, ethnicity, employment status, nationality, length of service and seniority are routinely collected for the running of the trust. Therefore, these were anonymously collated then cross-referenced with violence and aggression incident reports (VA IR1s). Chi-squared was used to identify statistical significance. Ethno-national status was taken from self-report. We could not control for hours worked nor could we get agency staff demographic data.

We compared “exposure to at least one violent incident” in June, July and August 2019 against the following demographic categories:

Substantive vs bank staff

Band 5 and above vs band 4 and below

Staff with < 1 year of service vs staff with ≥ 1 year of service

“White British” staff vs Non-“White British” staff

“British” staff on self-report vs “Non-British” staff

Age ≤30 years vs ≥ 31years

A minimum of 1682 nursing staff were analysed for each category in each month.

Substantive staff, “White British”, “British”, younger, and staff of shorter employment length had greater frequencies of at least one VA IR1s compared to the complementary groups. Length of service was significant only in two months but judged significant overall. There was no statistically significant correlation with seniority. Substantive staff have three times the risk vs bank staff, perhaps mediated by hours worked. Other risk ratios were in the region x1.2 to x1.8.

Being British, White British, younger, less experienced or substantive staff correlate with subjection to reported aggression. This did not fit with staff speculation during consultation. Survival effects may be relevant. We are working to get more detailed information. Induction may help reduce aggression against newer staff.

Improve and standardise the quality of medical seclusion reviews (MSRs).

Acknowledge existing good practise.

Highlight areas for improvement.

Improve the awareness of doctors performing MSRs of the requirements in the Mental Health Act Code of Practice (MHA CoP)

MSRs are an essential clinical tool to ensure safe and consistent patient care. Patients detained in seclusion can be at heightened risk of poor mental and physical health, in addition to being a risk to themselves and others. There is clear guidance in the MHA CoP regarding what areas require to be covered in a MSR.

A retrospective audit of all MSRs in September 2019 across all patients within all directorates within Rampton Hospital was undertaken. 281 inpatients were identified within Rampton Hospital, and 61 of these patients were found to have had seclusion in September 2019. A total of 439 MSRs were identified for these patients.

The standard applied was the MHA CoP guidance for MSRs:

1. 1) MSRs should be conducted in person, and should include:

2. 2) Review of physical health

3. 3) Review of psychiatric health

4. 4) Assessment of the adverse effects of medication

5. 5) Review of observations required

6. 6) Reassessment of medication prescribed

7. 7) Assessment of the patient's risk to others

8. 8) Assessment of the patient's risk of self-harm

9. 9) Assessment of the need for continuing seclusion

The results show there is a large variation in compliance with the MHA CoP. The area with the highest compliance was the completion of reviews in person-(99.3%). The criterion with the average worst compliance was whether the need for physical observations was reviewed-(4.3%). Physical health was reviewed in 86.1% of cases, in contrast to psychiatric health at 38.3%. The adverse effects of medication and reassessment of medication prescribed were recorded in only 8.9%. The risk from the patient to others was recorded in 25.3%, whereas risk to self was recorded in 10.7%. The need for continuing seclusion was recorded in 72.7%.

The quality of MSRs at Rampton Hospital is currently inadequate. Improvement in practice is required to meet accepted standards and ensure safe, consistent patient care. Ways to improve this are being considered, including improving the knowledge of the MHA CoP and providing a MSR template.

To evaluate compliance within a Community Mental Health Team (CMHT) to the NICE guidelines for the management of depression.

Reducing the prevalence of depression continues to be a major public health challenge.

Given the complexity and recurrent nature of the condition, the NICE guideline CG90 is an invaluable resource to aid the effective management of depression. Here we present an audit of adherence to this guideline within a CMHT.

A retrospective electronic casenote review of all patients diagnosed with depression between January 2016 and October 2019 under the care of a Birmingham CMHT (n = 35), assessing key performance areas including: quality of assessment and coordinated care, risk assessment, choice of pharmacological and psychological treatment using the stepped care model and appropriate crisis resolution planning.

Key results include:

• The majority of patients were Caucasian (63%). Ages ranged from 27 to 69 (mean age 48 years old).

• Severity of disorder was typically moderate (46%) or severe (48%). Of those with a diagnosis of severe depression, 41% had associated psychotic symptoms.

• Psychiatric comorbidity was high (49%), of which generalised anxiety disorder was the most common (59%).

• Referrals were typically from primary care (77%). Approximately half (51%) had reported suicidal thoughts according to the referral.

• A quarter of patients (26%) were seen by CMHT within 8 weeks of referral; 20% of referrals however waited over 12 months before being assessed.

• Risk assessments were out of date for 71% of patients.

• 100% of patients had a crisis plan noted within their most recent clinic letter; however, none of these met the required standards.

Over half of patients (60%) had been referred to psychology services; of these, 38% had either completed or were in ongoing treatment at the time of review.

CMHTs manage the care of individuals with depression who have high levels of active symptoms and disability, psychiatric comorbidity, care requirements, and complex treatment plans. Pharmacological management was broadly in line with guidelines, and rates of referral to psychology were satisfactory. Risk assessment and crisis planning are clear areas in need of urgent attention in order to comply with guidelines and ensure patient safety.

To assess the incidence and treatments currently used in clinical practice for the treatment of treatment-resistant depression (TRD) in Scotland.

Patients with major depressive disorder (MDD) who have not responded to at least two successive antidepressant (AD) treatments in a single episode are described as having Treatment-Resistant Depression (TRD). Epidemiological data on TRD in Scotland is lacking. Furthermore, there is no data to our knowledge on therapies prescribed in Scottish clinical practice to treat TRD.

A retrospective, longitudinal cohort study was conducted using Clinical Practice Research Datalink (CPRD) medical records. Adult patients were indexed on AD prescription, requiring MDD diagnosis within 90 days, from Jan 2011-May 2018 with 360-day baseline and 180-day minimum follow-up periods. Failure of ≥2 adequate oral AD regimens following indexing constituted TRD classification. Incidence rates of MDD and TRD (within the MDD cohort) and treatment lines following TRD classification were derived.

The analysis included 20,059 patients with MDD (mean age 44 years, 63% female, median follow-up 59 months); 1,374 (6.8%) were classified as TRD. Median time-to-TRD classification was 25 months. The incidence rate of MDD was 15.9 per 1,000 patient-years and for TRD was 14.7 per 1,000 MDD-patient-years. For all first four post-TRD treatment lines, SSRI monotherapy was the most commonly prescribed therapy, followed by combination (dual/triple) therapy and augmentation therapy (at least one oral AD supplemented with lithium, an antipsychotic or an anticonvulsant therapy). At first-line of TRD treatment, 1,050 (76.4%) patients received monotherapy AD, 212 (15.4%) received combination AD therapy and 112 (8.2%) received augmentation therapy. The most common monotherapy treatments at first-line TRD were sertraline (15.6%), mirtazapine (13.8%), fluoxetine (12.2%) and venlafaxine (11.6%). Among combination therapies, mirtazapine, venlafaxine, sertraline and amitriptyline were frequently used. Among the TRD and MDD cohort, no somatic treatments were coded in CPRD, although the use of these treatments was likely underestimated.

Monotherapy AD treatment was the most common therapy type for all four post-TRD treatment lines. These data support the need for new treatments that can achieve and maintain therapeutic response, and avoid continuous cycling through similar AD therapies.

This study was sponsored by Janssen Cilag Ltd.

A service review of specialist child and adolescent intellectual disability provision in South Wales was conducted between March and May 2020. The purpose was to explore the impact of the first COVID-19 pandemic lockdown on children with intellectual disability and their families. The review aimed to explore if the disruption to the systems involved in their care would impact their wellbeing and behavioural presentations. We also measured if there had been an increase in the use of medication. Our focus was on the distress calls, which are requests for urgent clinical review to prevent a crisis.A service review of specialist child and adolescent intellectual disability provision in South Wales was conducted between March and May 2020. The purpose was to explore the impact of the first COVID-19 pandemic lockdown on children with intellectual disability and their families. The review aimed to explore if the disruption to the systems involved in their care would impact their wellbeing and behavioural presentations. We also measured if there had been an increase in the use of medication. Our focus was on the distress calls, which are requests for urgent clinical review to prevent a crisis.

Six clinical areas across three Welsh health boards under the same specialist team were surveyed. Case notes and email correspondence were reviewed to obtain the number and content of crisis calls made to specialist CAMHS across an eight week period during the first UK COVID-19 lockdown. Data were gathered on frequency, purpose, and outcome of calls. Comparison data were also collected for the period October 2019 to March 2020.

Pre-COVID-19: Two crisis calls were identified in two different areas during the pre-COVID period surveyed. Increases in medication and increases in respite care packages were made as a result.

During COVID-19 restrictions: 20 different initial distress calls made (children age 9 and 17 years old (M = 13.2); 75% were boys) across five of the six clinical areas. Of these 20 calls, 17 were active cases and 3 were new referrals. 95% of calls resulted in medication increases and there were few other interventions used due to COVID-19 constraints. Changes to the child's support system were discussed across all cases and return to school was highlighted as a key protective factor in improved well-being. Differences between clinical areas were also identified.

There was a clear increase in distress calls and requests to prescribe or increase psychotropic medication to calm the distress during the ‘lockdown’. Changes in behavioural presentation may have occurred partly due to the disruption to the complex systems that typically support a child and the shift away from community support. Children with intellectual disability and their families are unique and embedded in complex systems comprising schools, respite, and healthcare provision which work together to deliver optimal mental healthcare with psychosocial interventions with medication for higher-risk situations. Any shifts in these systems may lead to an imbalance and a higher likelihood of medication use.

This audit aims to identify whether newly diagnosed dementia patients are offered post diagnostic support and potential factors influencing patient choice.

A diagnosis of dementia can be life changing and hence post-diagnostic support for dementia is key. Multiple guidelines suggest that post diagnostic support need to be offered to all patients diagnosed with dementia. The Department of Health and Social Care and other national/ local guidelines suggest that post diagnostic support is offered to all patients diagnosed with dementia.

Data were collected for 40 patients diagnosed with dementia. Using random number generator, patient group was selected from pool of patients diagnosed with dementia between July’ 2017 - December’ 2017. Data included whether they had been offered support during the initial appointment and what post-diagnostic support was offered. Demographic details obtained to identify patterns of support accessed by patients.

All patients were offered post-diagnostic support. Diagnosis was discussed in appointment in about 93% of patients. Medication was discussed in 82% patients. Driving was discussed in only 64% patients and LPA was discussed in only 63% patients. When given choice between Post diagnostic support group (PDSG) and Dementia adviser (DA), slightly more women tend to choose PDSG group. The only 2 ethnic minority patients chose DA. 21% more patients opted for PDSG group when they had a carer.

The positive is that some post-diagnostic support is offered to all patients. Although discussion of diagnosis with patients was done well, discussion of medication, driving and LPA can be improved upon. Ethnicity and family structure/ carer may have a bearing on patient choice of post-diagnostic support.

The main aim of this audit was to look at documentation in medication charts in an acute mixed inpatient unit in South Manchester. In addition, we also looked at completion of capacity assessment and consent to treatment forms as appropriate.

Safe prescription, administration and monitoring of medication is key to effective patient care. Due to the busy nature of inpatient hospital wards, errors do unfortunately occur both with the medications, and with the recording of their administration.

We will use a data collection tool to collect data as per standards described in our local GMMH policy. The medication chart will be used as the standard, as this is the current chart that is in use in the Trust.

Data were collected from 31 medication charts for inpatients admitted in the ward between the 5/12/19 to 18/12/19. We captured data from each page of the medication chart that required a record to be made by any staff, including details of prescribing, administration and pharmacist checks. Data were recorded as either Yes/No or NA (Not Applicable). Data were then summarised and analysed using MS excel.

Of the 31 patients, 22 (71%) had a capacity assessment form completed and 16 (52%) had a consent to treatment form completed. From the data analysis, it was clear that there are high rates of completion for the ‘essential’ parts of all prescriptions, including medicine name, dose, route and data. ‘Route’ was only recorded for 40% of prescriptions for depot medicines. Details of the administration of a medicine by a nurse was generally well-completed. For as required medications, all information relating to administration (date, time, dose and given by) were fully completed for 100% of prescriptions. For regular prescriptions however, the administration details were not as well-completed, where date of administration was recorded in 84% of prescriptions and signature in 29% of prescriptions. Unique patient identifiers are well-recorded on Page 1 of the prescription chart, though not maintained throughout the prescription chart. Nature of reaction to an allergy or sensitivity was only recorded in 6 of the 21 patients (29%).

Overall, there were good completion rates for the mandatory parts of the prescriptions. However improvements could be made for prescriptions as well as administration and pharmacy checks. The capacity assessment and consent to treatment forms could be improved upon too. We plan to put the recommendations and re-audit in 3-6 months’ time.

The aim of this project would be to understand about the pros and cons/ benefits and risks of using a centralised model of ECT (currently being followed due to COVID restrictions) rather than a decentralised model of ECT (which has been the norm for a long time). A comparative account of both types of systems would help identify whether it could be implemented in Pennine Care and the results could be potentially transferable to other similar settings.

An online survey was undertaken from staff members working in Pennine Care who have been involved in ECT delivery and management. The survey was undertaken between 07/12/2020 and 11/01/2021 and included questions relating to pre-COVID ECT (June 2019 to February 2020) and during-COVID ECT (March 2020 to November 2020). Questions were around travel of staff/patients for ECT, whether they had a preference for a model and their reasons around it. Data were summarised in MS Excel and free text comments analysed to gain an understanding of staff's preferences and reasoning behind their choices.

Although some boroughs had patients attending from other boroughs in pre-COVID times, considerably more staff (53.85%) and patients (61.54%) had to travel for ECT during COVID times. Around 50% staff expressed a clear view for decentralised services; the common reasons being safer for patients, better continuity of care, less travelling issues, patients more likely to consent, easier to manage correct paperwork, easier to send staff who knows patients well, less driving for staff and likely less cancellations. Around 40% staff expressed a clear view for centralised services; the common reasons being less staff needed, better infection control, easier to maintain staff skills, efficiency, developing clinical expertise with larger number of cases, education opportunities, better set-up of clinics, transportation and accessibility. Some concerns raised for the centralised model were managing patients with complex anaesthesia, travelling for unwell/ disturbed patients, too high patient numbers, poor communication and impact on training.

In summary, there was a mixed view of which services are preferable. Further discussion in trust wide ECT forum will be helpful to move things forward. Although it is likely that services may shift from a decentralised to a centralised system, we need to ensure this is done safely and in particular, address the main concerns around centralisation.

The prevalence of catatonia is considered to be approximately 10% in psychiatric inpatients. Clinical experience suggests a lower documented prevalence. This could cause longer admissions and complications, such as Neuroleptic Malignant Syndrome (NMS). We carried out a service evaluation to investigate the recognition and management of catatonia on inpatient units in Southern Health Foundation Trust (SHFT). We reviewed the local documented prevalence of catatonia, treatment offered and prevalence of complications.

We retrospectively reviewed the electronic records of 95 consecutive admissions to four adult inpatient units in SHFT, starting on 1st August 2020. We reviewed notes for the admission to establish whether catatonia was suspected and identified. We applied the screening questions from the Bush-Francis Catatonia Rating Scale (BFCRS) to the documented mental state examinations (MSE) prior to, and shortly after, admission. We also recorded the prescriptions issued during the first 72 hours of admission, and whether patients developed neuroleptic malignant syndrome (NMS), serotonin syndrome or required admission to a general hospital during admission.

Catatonia was documented as a possibility for 2 patients (2.1%). One showed possible posturing and stupor, while there were no documented symptoms for the other. In both cases the possibility was discounted by the clinical team. Twelve patients (12.6%) showed one or more possible or confirmed signs of catatonia. Eleven of these were prescribed regular antipsychotic medication on admission, but only 3 were prescribed regular benzodiazepines. NMS was more likely to be suspected in patients with a BFCRS of 1 or more compared with those with a score of 0, with an odds ratio of 8.1 (95% CI [1.03-64.0], Fisher's exact test = 7.79, p = .076).

Catatonia is likely under-recognised and under-treated locally among psychiatric inpatients. Although only approaching statistical significance, the higher rate of suspected NMS in patients showing possible catatonia is noteworthy and needs further investigation. Regular benzodiazepines were not frequently prescribed in this group, while antipsychotics, prescribed in all of these patients, can precipitate NMS. Alternatively, this finding could reflect the overlap in clinical presentation between NMS and catatonia. Data collection was limited by the frequent use of “remote clerking”, in the context of the COVID-19 pandemic. Additionally, the quality of mental state examinations was often not sufficient to draw any conclusions on the possible presence or absence of catatonic symptoms. This project has highlighted practice in need of improvement, which will be further prospectively investigated and improved via a Quality Improvement Project.

To monitor the quality of physical health monitoring of patients prescribed depot antipsychotic medication in the North West Edinburgh Community Mental Health Team (CMHT). We also evaluated the completeness of prescriptions and Mental Health Act (Scotland) (Act) 2003 paperwork where relevant.

Antipsychotic medications are medicines for treating conditions such as Schizophrenia, but some may be associated with an increased risk of Metabolic Syndrome. Moreover, evidence indicates that patients with major mental disorder have a reduced life expectancy in comparison to those without such diagnoses. These two factors illustrate the importance of the physical health of this patient cohort being monitored on a regular basis. This project will evaluate how a local CMHT is performing, with the possibility of enacting service improvements if required.

The records of the 60 patients prescribed depot antipsychotic medication administered by this CMHT were reviewed. A check-list was created consisting of 14 categories analysing the quality of physical health monitoring, as well as compliance with prescription standards and, where relevant, Mental Health Act (Scotland) (Act) 2003 paperwork. We compared patient records against our checklist for the calendar year of 2019. The Scottish Intercollegiate Guidelines Network (SIGN) 131 (Management of Schizophrenia) section 5.2 was used as the gold standard for physical health monitoring against which the data we collected was compared.

We identified a wide range of flaws with the current system and implementation of monitoring, and difficulty in locating the required information. There was no consistent monitoring of physical observations on electronic record, nor an accepted alternative way in which this was documented. Furthermore, blood tests were not consistently obtained either by the service or GP practices in a reproducible manner. This led to discussions within the CMHT regarding creation of a new pathway for the monitoring of this patient cohort using a Quality Improvement model, with the ultimate goal to establish a regular physical health clinic.

There is significant evidence that patients with major mental disorder do not access healthcare as consistently as those without, leading to a disparity in life expectancy. In light of the fact that antipsychotic medications can be associated with Metabolic Syndrome, we have an even greater responsibility to tackle this marked health inequality by appropriately monitoring our patients. This was not done well in this particular CMHT, but this project will lead to improvements in the service and ultimately patient care.

The aim was to examine the reasons for advice requests by carers of people who live with dementia (PLWD) that attend the Me2u dementia day centre in order to identify key explanatory themes. We hypothesised that requests were related mainly to coordinating care and clinical issues due to limited post-diagnostic support (PDS) in our area.

The Me2u dementia day centre (Merseyside) cares for PLWD and also supports carers. As part of the service, a 24-hour advice line is included for PLWD and their carers who attend the centre. Locally, there is limited PDS and most carers navigate the health and social care system alone mirroring the findings by the National Collaborating Centre for Mental Health (NCCMH).

We undertook a retrospective evaluation of 244 advice calls, from 64 carers, between 01/06/2019 and 31/12/2019. We analysed time of call, type of advice, type of dementia, age and whether the advice was for the PLWD or for the carer.

Of the 244 calls, the most common time to call was between 09.00 - 14.00 (n = 168; (68.8%) peak 09.00 - 10.00 (n = 38). Average age of the person about whom the advice was sought was 79.08 years. 91.4% of the advice calls related to PLWD (most common dementia Alzheimer's) and 8.6% to the carer only. The mean number of calls per person was 3.8 (range 1–24).

Advice data were grouped into 9 broad themes namely, related to symptoms/behaviour (32.79%, n = 80), request for Me2u to coordinate care (20.08%, n = 49), general advice (14.75%, n = 36), personal care (9.42%, n = 23), carer only advice (8.60%, n = 21), social issues (6.14%, n = 15), social care (4.50%, n = 11), safeguarding (2.46%, n = 6), non-health and social care issue (1.23%, n = 3).

Reasons for limited/poor PDS given by the NCCMH are; absence of named coordinators of care, over-reliance on families and carers to manage and facilitate appointments, poor recognition and management of comorbidities. This data show that 52.87% of calls were for clinical advice and coordination of care reflecting NCCMH findings. The interventions post-call reduced the impact on providers of urgent care.

These findings provide support for the provision of a [24-hour] advice line as a routine part of post-diagnostic support services, especially in areas that have limited or poor PDS. Commissioners of PDS services in areas that have limited or poor PDS should make this a priority to prevent unplanned admissions to hospital and carer breakdown.

To audit the investigation, identification and treatment of Vitamin D deficiency within Men's Secure Services.

Vitamin D and/or vitamin D deficiency has been suggested to play a role in the pathogenesis of mental illness. There is evidence that Vitamin D inadequacy is pandemic among rehabilitation patients in inpatient settings. Patients within secure hospitals are similarly considered to be at high risk, due to their limited solar exposure during often lengthy admissions. It has been suggested that these patients should be considered an ‘at-risk’ cohort, for whom Vitamin D supplementation should be routine. Men's secure services in Birmingham comprise of two medium secure units and a low secure rehabilitation unit. Here we present an audit of Vitamin D monitoring and treatment completed in 2019.

A three year retrospective review of electronic patient records, for all inpatients admitted within men's secure services as of 1 September 2019 (n = 188). Standards were based on the Trust accepted guidelines for management of Vitamin D deficiency.

Key findings included:-

• The majority of inpatients were Caucasian (43%) and African-Caribbean (24%). Ages ranged from 18 to 70, with a mean age of 39.

• Approximately two-thirds (65%) had been in hospital for over a year, of which 44% had been admitted for more than 3 years. The average length of admission was 885 days.

• Only 47% of patients had their Vitamin D level checked within the study period.

• Of those checked, 24% were tested within 1 month of admission. The mean duration between admission and Vitamin D testing was 464 days.

• Results ranged from 10.3 to 118.5nmol/L. A high rate of Vitamin D deficiency was identified (54%), whilst a further 16% had ‘inadequate’ levels.

• 23% of those identified as requiring treatment did not receive any supplementation, whilst 59% of those with sufficient Vitamin D were prescribed treatment.

• Only 48% had their levels rechecked following treatment; of these, only 59% now had an adequate Vitamin D status.

This audit demonstrates limited Vitamin D monitoring within male forensic inpatients. There was a high prevalence of Vitamin D insufficiency in this population, yet a substantial proportion of patients with identified deficiency were not prescribed any treatment. Ongoing monitoring and review of treatment effectiveness was poor. We argue that more consideration should be given to this population, with robust guidelines introduced for the treatment of this specific ‘at-risk group’.

Recently, there has been a greater focus on how mental health in young people (YP) can be improved. Up to 10% of YP in Scotland have a diagnosable mental health condition1 and half of all adults with mental ill-health have had symptoms from their mid-teens2. Poverty is an important factor associated with poorer mental well-being from an early age which worsens if left untreated3. The aim of this audit was to answer the question: Are more YP referred from the least deprived areas, and are they more likely to require medication intervention or high intensity (tier 4) care? The results of which could help identify possible avenues for intervention to help improve retention of those most at risk of negative outcomes.

NHS Grampian CAMHS provides service to Aberdeen City, Aberdeenshire, and Moray. Pre-collected data over 15 months from these areas were analysed using the Scottish Index of Multiple Deprivation (SIMD) deciles to distinguish any differences between referrals made. In addition, this audit evaluated the data to define any trends of deprivation linking YP to medication intervention or tier 4 care.

Results showed that more referrals were made for YP in low-ranking areas (3.19% of decile one compared to 1.74% of decile ten). The referrals were also more likely to be rejected based on the referral criteria, 33% in decile one versus 21% in decile ten. The increased rejection of referrals is most likely a reflection of the health inequalities faced by communities in more deprived areas. In terms of service provision, the patients from the most deprived areas are 3 times more like to require tier 4 care while the least deprived are 1.5 times more likely as compared to percentage of population. With regards to medication intervention patients from deciles one, five, six and seven have significantly higher numbers.

This project set out to look at the current service provided by CAMHS and found that despite best efforts deprivation has had an impact on the acceptance of referrals. Going forward this data will be shared with multiagency stakeholders to develop service provisions, in particular the issues identified with the rejection of referrals in more deprived areas. Higher level of medication use in more deprived population is not unexpected but highlights the need to share the findings with a multiagency network.

The Central and North West London NHS Foundation Trust ADHD clinic offers diagnosis and medication stabilisation for adults with ADHD, in preparation for discharge back to GP for continued prescribing and monitoring. Referral waiting time is shortened by efficiently managing the service and soon transfer of care to GP whilst referrals have been increasingly accepted years on years. A snap shot service evaluation was made to understand characteristics of service exploring its strength and areas to improve.

All 115 patients offered in March and April 2019 for an ADHD specialist assessment were sampled from the new electronic patient record SystmOne in use since 1st March 2019.

Data were collected for

Male & Female ratio

Age range distribution

Clinical Commissioning Group referral source

Clinic attendance characteristics

ADHD diagnosis, sub-types and psychiatric comorbidity

ADHD Medication prescribed

FP10 Prescription duration by prescribers

Patient data were anonymously encoded into Microsoft Excel Sheet for sorting, counting, summating and illustrating into tables and pie charts.

The male & female ratio of the sample was 6:5 and nearly half were in age range 20-29 years. Majority were referred from Westminster and West London Clinical Commissioning Groups.

107 patients completed the assessment, of which 106 were diagnosed as having an adult ADHD.

22% of follow-up clinics were cancelled or not attended (DNA) by patients. The majority of the patients (62%) required 1-2 follow-ups before transfer to GP, whilst 8% did not require or want follow-ups either already being on ADHD medication, not wanting medication or having lost to reviews. Only 3% require six or more follow-ups.

Majority were reviewed after two- to five-week prescription, the peak being four-weekly.

91% of completion to GP were discharged on ADHD medication, majority being singly on Elvanse (48%) and Concerta XL (25%). Discharge without ADHD medication was due to concerns for its addiction, preference on non-medication treatment, intolerance of medication adverse effect or mental health priority treatment.

Collaboration with GPs for their pre-treatment physical health screening facilitated prompt prescribing initiation on assessment with most discharges taken place after 1-2 follow-ups, enabling service turn-over with short waiting time (6-9 months in 2018/2019). Service expansion for increasing referral uptake is probably feasible from this baseline by appointing additional sessional clinicians and further efficiency management on clinic scheduling & DNA with a target majority likely requiring 1-2 follow-ups with average four-weekly prescribing.