Child and adolescent mental health (CAMHS) wards treat patients with variable presentations. During diagnosis and treatment, psychiatric professionals use structured criteria, but also honed awareness of countertransference. Unacknowledged emotional responses can produce powerful dynamics and impact patient care.

Limited information exists on possible emotional responses and team dynamics when working with catatonia.

This project aimed to establish common themes relating to staff felt-experience of working with a specific case of catatonia on a Child and Adolescent Mental Health (CAMHS) ward. A secondary aim was to establish potential areas for future training and service improvement.

Trust Research and Development department approved this work. Inpatient professionals working with the specified patient during admission were eligible. Participants were invited via email and face-face discussion with one of the authors. Participants, patient and mother provided written consent.

A questionnaire was created and disseminated via email to eligible staff (n = 33). 27 questions asked individuals to rate responses on Likert scales, plus space for further comments. Questions involved emotional responses to different catatonic states, feelings towards self, patient, colleagues and plans. Descriptive analysis was completed on this anonymised data.

Qualitative data were gathered via 1-hour recorded focus group, led by a systemic psychotherapist and psychologist. The session was transcribed anonymously. Two clinicians, using Thematic Analysis, reviewed the transcript independently.

16 (48.5%) questionnaires were completed. Participants felt negatively about themselves and colleagues more frequently than about the patient. Participants felt positively about themselves less frequently than about colleagues and the patient. Participants identified with more feelings during immobile patient states than lucid states. During immobile states, participants identified with abusive, guilt, hopeless and neglectful responses; during lucid states, with helpful, caring, happy responses

Eight (50%) participants felt they sometimes did not understand their feelings towards colleagues/plans. Nine (57%) participants felt they sometimes did not understand their feelings towards themselves. Ten (66%) participants felt they sometimes did not understand their feelings towards the patient.

Ten (62.5%) participants felt confused by their emotions at least some of the time. Two (12.5%) frequently felt confused by their emotions.

Four participants attended the focus group. Themes included confusion, internal and team conflict.

Working with catatonia involved confusion and team splitting. Staff conflict between plans and morals resulted in painful emotions. Prompt psycho-education within teams working with uncommon presentations was identified as a focus for improvement. The authors plan to explore possible avenues for future teaching, learning and team support.

The prevalence and recognition of mental health conditions in young people is growing. Around 50% of lifetime mental illness (except dementia) begins by the age of 14. Around 75% of adults requiring secondary mental health services developed problems prior to 18.

The TRACK study of young people's transitions from CAMHS to AMHS has found that up to a third of teenagers are lost from care during transition and a further third experience an interruption in their care.

A CQUIN for Transition has concluded that young children should have a transition plan 6 months before they turn 18.

All young people aged 17 and a half years old were included in the data collection for this audit. Clinical information was reviewed using the West London RIO computer system. While reviewing the clinical documentation I was recording whether:

Transitional plans had been discussed with the young person.

If yes, what were they?

Had a referral been made to the appropriate service?

There were 180 open cases to the Hounslow Adolescent Team. 35 cases were over 18:

At least 16 of these cases needed to be closed as no intervention was being provided.

14 cases had an unclear plan.

Of the 25 cases aged between 17.5 and 18 years of age transitional plans were:

Transition was discussed in 11 cases (44%). This meant that transitional plans were not discussed in 56% of young people.

Of these 11 cases 7 referrals were completed. (28%)

The lack of consistent protocols for transition remains a significant barrier to health care provided to young people.

Transitional planning needs to take place in an effective and timely manner to ensure continued patient centred care.

Transitional discussions to be made a regular agenda item at team meetings.

Care co-ordinator to be informed and reminded that transitional plans need to be explored with young people.

Following a re-audit of this data 6 months on 100% of cases over the age of 18 were closed and transition was discussed in the remaining 56%.

Errors in the pathology sampling process can be costly for all stakeholders in any clinical setting; however, this process is often overlooked within psychiatry. Over the space of just a few short months at Hollins Park Psychiatric Hospital (HPH) such errors were reported to be numerous with staff raising multiple issues relating to the pathology sampling process. These issues often had a negative impact on patient care, leading to outcomes such as as re-bleeding of patients and delays in interventions. Here, we aim to identify the predominant sources of error in this process and suggest possible improvements to minimise these errors in the future.

Initially, we mapped and analysed each step of the sampling process as it is currently performed in order to identify areas of possible improvement. We then distributed questionnaires to all junior doctors - who are responsible for the handling of samples within the clinical setting – in order to establish error type and frequency. Questions also assessed individual confidence and familiarity with the sampling process.

When mapping the sampling process, we identified all key steps required when sending samples from HPH to Warrington and Halton Hospitals laboratory. This included one pathway for sending routine bloods, and one pathway for urgent bloods. The process for sending routine bloods required more steps and ultimately took longer for samples to reach the laboratory – as expected. Of the issues identified during mapping of the pre-analytical phase, a majority of 77.7% of clinicians reported samples had gone missing or were unreported – with the reasons for this being undetermined in most cases – and 55.5% reported their samples never reached the lab. While on the whole participants were comfortable with the steps involved in sending samples to the laboratory, 77.7% were not aware of the requirement to log samples as they were being sent.

The reasons underlying errors in the sampling process at HPH were multifactorial and included a lack of clinician familiarity with correct procedure, poor sample recording/tracking and lengthy transit times between the patient and laboratory. Here we outline some simple evidence-based recommendations (including education of staff and improved tracking through an electronic requesting system) to help reduce errors and streamline the sampling process in the hopes of improving both efficiency and accuracy, reducing the financial and clinical impact.

To quantify how many patients were prescribed high dose antipsychotic treatment (HDAT) and establish whether guidance for monitoring HDAT was being followed in an Assertive Outreach Team.

Severe mental health disorders are associated with significant premature mortality, predominantly due to physical health conditions. Antipsychotic medications are associated with side effects, including metabolic syndrome and QT prolongation, which increase the risk of serious physical illness. HDAT is defined as when the total dose of antipsychotics prescribed exceeds 100% of the maximum BNF dose, if each dose is expressed a percentage of its maximum dose. There is limited evidence of clinical benefit with HDAT but an increased risk of side effects. Patients prescribed HDAT should therefore be monitored for side effects and clinical benefit. Sussex Partnership NHS Foundation Trust developed a form specifically for this purpose, to be completed in addition to a physical health assessment.

All patients on caseload were audited using the electronic notes. Current inpatients were excluded, as inpatient HDAT monitoring forms are attached to paper drug charts and therefore were not available for review.

A total of 61 patients were audited. Nine were excluded due to being inpatients. 16 were on community treatment orders and 26 were prescribed a long-acting antipsychotic injection. 10 were prescribed clozapine. The median number of medications prescribed was one. Four patients were prescribed HDAT ranging from 117-150% of the maximum BNF dose. Of these four, one had a HDAT form but this was out of date. 39 of 52 (75%) patients audited had had a physical health assessment in the past 12 months. Two of the 13 missing a physical health assessment were on HDAT.

Physical health monitoring should be carried out for all patients on antipsychotics, but is particularly important for patients on HDAT. This audit identified a problem in both general physical health checks and HDAT monitoring. On discussion with the multi-disciplinary team a number of barriers to appropriate physical health monitoring were identified. There was a lack of awareness within the multi-disciplinary team that patients were receiving HDAT and regarding the implications for side effects. A reliable system to highlight the need for physical health checks was also missing and the team did not have sufficient equipment to perform the necessary checks. Identifying these barriers should enable improvements in physical health and HDAT monitoring which can be re-audited.

Early assessment, diagnosis and management for people living with dementia is essential, both for the patient and their carers. We recognised delays in established local pathways when patients had unplanned acute hospital admissions preventing them from attending memory diagnostic appointments. The Psychiatric Liaison Team (PLT) Memory Pathway was introduced as we had the skills and expertise to resume the process and to find new undetected patients.

Our aim was to determine how well the newly implemented PLT Memory Pathway follows the standards outlined in the National Institute of Health & Care Excellence (NICE) Clinical Guideline 97 (CG97): Assessment, management and support for people living with dementia and their carers.

A retrospective analysis of all PLT referrals from July 2018 to February 2020 (20 months) was performed to identify patients on the community memory pathway and those with possible undetected cognitive impairment. Data were collected from electronic patient records which included demographics, primary and collateral history, cognitive testing and imaging, dementia type among others. Results were analysed using Microsoft Excel.

41 patients were included (59% female). 80% of patients were referred for memory problems or confusion. 63% had previous referrals to a memory service and was on the community memory pathway at the time of the referral. 34% were on anticholinergic medication but in only 14% were this documented as reviewed. 100 % were offered and had head imaging. A finding worthy of note was the absence of any from the ethnic minority background. 63% of patients were given a memory diagnosis and 34% had anti-dementia medication started. Patients’ families were made aware of the diagnosis in 83% of cases, due to the absence of next of kin details in the patient record. Primary Care was made aware in 100% of cases; post-diagnostic support was 100%.

The PLT is well placed to bridge the service gap between the acute care trust and established community memory services when dealing with patients with dementia. A dedicated Memory Pathway has helped to close this gap and adherence to NICE CG97 standards was good, but there is room for improvement. A particular focus will be on improving documentation of anticholinergic medication review and exploration for the absence of ethnic minority patients. Aiming to achieve 100% family involvement is also recommended.

This study has been submitted to the Royal College of Psychiatrists' Faculty of Old Age Annual Conference 2021.

Addictions services had to respond rapidly to reduce COVID-19 transmission to protect patients and staff. Patients with opioid dependence are particularly vulnerable, with high risks. Our community addiction service changed practice in line with COVID-19 guidelines. For patients with opioid dependence; face-to-face contacts were initially reduce and mainly for new starts, restarts and non-attenders. Prescribing changes were completed on an individually risk assessed basis to reduce attendance at the chemist, specifically to reduce transmission, keep patients in treatment and to ensure chemists could continue to function. We document some of the service changes during the COVID-19 lockdown.

Service evaluation had approval from Humber Teaching NHS Foundation Trust. Data retrieved on one Hub of a community addictions service in North England, UK. Patients prescribed opioid substitution treatment for opioid dependence were assessed, with data retrieval through electronic healthcare records. Data were analysed by Microsoft Excel anonymously.

In lockdown (March 2020 to June 2020), we identified 112 patients with opioid dependence prescribed opioid substitution (OST) with methadone or buprenorphine at the Hub. All white British, mean 42 years, most male (75%) and prescribed methadone (78%). Ten were new starts and 8 restarts to OST. Attendance rates did not change: 91% before and 92% during lockdown. Appointment format changed from predominantly face-to-face (92%) to telephone (99%). Most patients (91%;n = 88) were offered take-home naloxone and overdose prevention training of which 14 refused. Supervision days at the chemist for OST reduced significantly from 75% collecting daily at the chemist, reducing to 20% during lockdown. Five patients were shielding and 7 had covid-related symptoms. There was one death during lockdown which was not attributed to covid or overdose.

The addictions service continued to be open and work proactively throughout lockdown, seeing new patients and continuing treatment interventions safely. Major changes were made in line with COVID-19 guidelines, to respond to the threat of transmission. Our service was flexible and able to adapt quickly to remote working. We maintained excellent attendance rates despite changes to the format of consultations. There were no related incidents e.g. overdoses linked to prescribed medications, despite a reduction in supervision, and therefore patients having extra medications. This important finding may be related to the individual risk assessments that we conducted before making changing to prescribing. This was supported by most patients were receiving naloxone to prevent overdoses. Some of the changes, such as telephone consultations, may be beneficial to continue post COVID-19.

The aim of this audit was to determine whether the duty doctor of a 4 ward inpatient psychiatric unit is contacted safely, effectively and in a manner that can be monitored. This is in line with trust protocol and the method stated is via switchboard. Should a deficit be found it was the aim to make an appropriate intervention.

In the Abraham Cowley Unit, there is a Senior House Officer ‘on-call’ duty doctor 24/7. The shifts are 2 x 12.5 hours daily and at all times the duty doctor should be contacted via switchboard. Contacting via switchboard is important to ensure there is an audit trail of calls made. Issues that arise from using other methods of contact, e.g. calling direct extensions, include miscommunication and the doctor not being reached in a timely manner. This had been identified as an issue anecdotally by junior doctors on call and also highlighted following an untoward incident.

The method by which the on call doctor was contacted was recorded in Excel for 5 consecutive 12.5 hour shifts in October 2019. The standard set for calls via switchboard was 80%. Following the initial results and the subsequent intervention, a repeat audit was performed using the same method.

Initial Outcome

Initially it was found that only 25% of calls received where through the appropriate channel (5 out of 20 calls). This fell far below the 80% standard and an intervention was therefore devised.

Intervention

In order to ensure that all ward staff were aware of the trust policy posters were created and placed above all ward telephones and the telephone in the assessment suite office. This information was also handed over to the nurses in charge directly in order for it to be filtered through to other staff during handover.

Post Intervention Outcome

Following the intervention 88% of calls received where through the appropriate channels (7 out of 8 calls) and the 80% standard was achieved.

There has been a demonstrable improvement in the adherence to trust policy when contacting the duty doctor, with the percentage of calls made through the appropriate channel rising from 25% to 88%. This has now met the agreed standard of 80% and will improve the trust's ability to monitor contact of the duty doctor effectively.

To assess whether patients have a good knowledge of basic nutrition compared to a group of staff. We hypothesise that the patient's knowledge will show deficits compared to the staff despite the group interventions.

The Royal College of Psychiatrist's core standards for inpatient physical health outlines that patients should be engaged in healthy lifestyle groups. The women's secure service at Ardenleigh has developed healthy lifestyles groups to promote a better understanding of nutrition.

An adapted University College London general knowledge nutrition questionnaire was used to investigate nutritional knowledge.

All 22 inpatients and a random selection of staff were offered the chance to complete the questionnaire. As the groups run on a regular basis, it was presumed all patients had attended at least one group session. The staff are the comparator group.

18 staff responses and 12 inpatient responses were obtained (54.5% response rate for inpatients).

No participant in either group scored 100%. Both groups had a good awareness of what foods they should be eating more and less of. 83.3% of patients were aware that they should be eating breakfast everyday as opposed to 100% of staff.

Poor areas of knowledge included knowledge of the number of oily fish servings per week. Staff and patients also performed poorly when estimating their recommended daily salt intake. 1/3 of patients were unable to provide an example of a serving of fruit and vegetables.

The knowledge of the structure of the Eat-Well plate was poor in both groups. Only 16% of patients and 22% of staff were aware that starchy foods should make up 1/3 of the Eat-well plate. Knowledge of protein sources was poor. 25% of patients and 16.6% of staff thought that fruit and butter were good sources of protein

Furthermore, only 50% of patients were able to choose the healthiest evening meal choice from a list of 3 options compared to 100% of staff.

In conclusion staff had better knowledge of nutrition than patients but knowledge was poor in areas amongst both groups. We conclude that groups should have more focus around practical applications of nutritional knowledge to everyday life.

The aim of this audit project was to establish the practices in prescribing and de-prescribing of psychotropic medications for patients on a specialist dementia ward.

There is a great deal of evidence demonstration high rates of polypharmacy, defined as ≥5 drugs, in older adults in general and in those with dementia more specifically. NICE guidelines recommend a structured assessment of a patient with dementia to exclude other potential causes, e.g. pain or delirium. Psychosocial interventions are recommended as first line. Antipsychotics should only be offered second line who present a risk to themselves or others. These should only be used for the shortest time possible and reassessed at least every 6 weeks.

Data were collected for patients (n = 20) discharged from a specialist dementia ward between September 2018 and March 2019. The unit has 14 beds caring for patients with predominantly severe behavioural and psychological symptoms associated with dementia (BPSD). The team is comprised of doctors, nurses, a clinical psychologist, occupational therapists, physiotherapists and pharmacists who meet twice a week to review patients. Data were coded by drug class and counts of medication on admission, at the midpoint and at discharge were conducted. Antipsychotic and benzodiazepine dosages were converted into haloperidol and diazepam equivalence.

Of the 20 patients, 70% were male and 30% female. 95% of the patient (n = 19) were admitted under the Mental Health Act (1983). 20% were managed on 1 to 1 observations and 80% were on 15 min observations. In general, the results show little change in the overall rate of psychotropic prescribing. The mean number of psychotropic medications prescribed per patient on admission was 2.30, at the mid-point of admission it was 2.30 and at discharge it was 2.05. Mean benzodiazepine dosage in diazepam equivalence reduced between admission and discharge from 3.20 mg to 2.10 mg. Mean haloperidol equivalent dosages increased at the midpoint of admission from 1.11 mg to 2.27 mg before reducing to 0.78 mg at discharge.

The results demonstrate minimal change in the overall average number and composition of drugs prescribed. There are differences in the use of regular antipsychotics and benzodiazepines between admission and discharge which are consistent with NICE guidelines. Patients had a structured assessment with regular medicines reconciliation supervised by the team pharmacist. Therefore, the ward environment did allow for detailed discussions about de-prescribing which may not be the case elsewhere.

To understand the factors underpinning junior doctors’ decision-making processes regarding their choice of psychiatry as a speciality, and why they chose to pursue specialty training in Wales.

Over recent years there have been significant challenges in recruiting junior doctors into psychiatry specialty training, both within the UK and in Wales. To counter this a number of measures have been instituted, including advertising campaigns from the Royal College of Psychiatrists (‘Choose Psychiatry’) and Health Education and Improvement Wales (HEIW) (‘Train Work Live’), together with financial incentives. To date there has been no published evaluation of the effectiveness of these measures.

Two focus groups were run (in August 2019 and January 2020) with trainees appointed to new training posts in August 2019. The focus groups featured set questions acting as prompts for discussion. These focused on various factors behind making decisions to train in Psychiatry and choosing to train within HEIW. The focus groups were recorded and transcribed. Following this a thematic analysis was conducted to identify key elements arising from the discussions.

The focus groups were attended by 14 trainees in total (eleven CT1s, four ST4s.) Living in Wales prior to appointment was the most common factor in leading participants to choose to train in Wales, jointly with having a support network (friends or family) in Wales (each present in 57%, n = 8.) Perceptions around a favourable work-life balance were also important (45%, n = 5.) Interactions with staff in an ambassadorial or support role were a significant driver, especially for international medical graduates. Financial incentives and advertising campaigns appeared to have limited influence over participants’ decision-making, awareness of these being highest among those already working in psychiatry or in Wales.

Having a foundation year job with a psychiatry placement was a common theme in choosing psychiatry as a specialty (43%, n = 6.) Work-life balance of the specialty was also important (21%, n = 3.) Again, after these it was hard to identify coherent themes.

We identified three separate groups, namely CT1s, ST4s and international medical graduates, each with distinct themes underlying a range of needs. There was a broad range of factors underlying trainees’ decisions which should be reflected when planning future recruitment strategies. It appeared that advertising campaigns and financial incentives were of limited influence.

To identify the number of patients currently on melatonin

To determine the average duration of use of melatonin in patients under the care of S-CAMHS in ABUHB

To investigate whether behaviour interventions were tried and reinforced from time to time

To identify any areas of improvement

Data were collected at St. Cadoc's hospital, in January, 2021. S-CAMHS database was used. Out of total 346 patient currently being managed with pharmacological therapies, 115 (33.2%) are currently on melatonin. 57/115 were randomly selected as a sample for this this project. Patient notes and EPEX software were also used to collect information regarding the sleep management practices.

During analysis, it was noticed that within the sample, only 46 patients were actively on melatonin. Melatonin is prescribed for sleep related issues in ASD (8/46), ADHD (15/46), ASD and ADHD (10/46), ADHD and mood disorder (0/46), ASD and mood disorder (6/46), ADHD and behaviour difficulties (2/46), ASD with behaviour difficulties (1/46), mood disorder (4/46).

39/46 patients are currently on melatonin for more than a year (85%). These patients also include 10 patients who have been using melatonin for 5 years or more.

35 patients (76%) reported improved sleep or some benefit from melatonin.

Evidence for implementation of parent-led sleep behavioural interventions:

Prior to commencing melatonin- Clear evidence available for 35 patients only (76%). These interventions were however not deemed helpful by most of the service users.

While prescribing melatonin- Clear evidence available for 39(85%) patients. Evidence base for melatonin was also discussed during this visit.

During last follow-up visit- Evidence available for 31 patients only (67%).

Majority of patients under S-CAMHS ABUHB remain on melatonin therapy for longer than one year. Most of these patients have reported benefit from this therapy and preferred to remain on it despite being informed about evidence base for melatonin. Also, there is evidence for implementation of sleep behavioural interventions prior to prescribing melatonin, however their benefit remains unclear.

Recommendations:

The quality of education on sleep hygiene offered should be assessed and improved if needed

Formal group sessions/workshops on sleep hygiene/parent-led sleep behavioural interventions at regular intervals might be useful in reducing the chances of long term polypharmacy or unlicensed drugs

Use of outcome measures such as Child Sleep Habits Questionnaire at intervals can be helpful in identifying any improvement from educational/pharmacological interventions

S-CAMHS database (for patients actively on medications) needs a review and update

This audit aimed to evaluate the standard of initial physical health assessment that young people receive on admission to Mill Lodge.

Adherence to recommendation 2.6.3 of the service specification for Tier 4 CAMHS was assessed. Standard 2.6.3 of the service specification for Tier 4 child and adolescent mental health services states that “on admission all young people must have an initial assessment (including a risk assessment) and care-plan completed within 24 hours. Where admission is for day/in-patient care this will include a physical examination.” In line with this standard this audit will evaluate the use of physical examination, baseline blood tests and ECG carried out on young people.

Mental health problems in children and young people are associated with both short- and long-term physical health problems. It is therefore important that they undergo full physical health assessment on admission to a Tier 4 inpatient unit.

Electronic records were reviewed for all patients admitted within a 6 months period, between 1st August 2018 and 1st February 2019. Data were collected in March 2019 and entered directly into an excel spread sheet designed for data collection. A total of 23 patients were identified for inclusion in this audit.

Simple statistical analysis was carried out using excel.

Over 80% of patients who did not refuse had a completed physical examination (85%), blood results recorded (82%) and ECG (84%) within the first 24 hours of their admission. 100% of patients who did not refuse had bloods and ECG checked at some time during their admission, with 90% having a physical examination.

For several patients (3 physical examination, 2 bloods, 3 ECG), no reason was documented as to why the procedure or examination did not take place. For 1 patient, blood tests were delayed due to having no blood tubes available.

Taken into account the result of this audit and bearing in mind the importance of physical examination as part of the admission process, it is important to try and support both regular Mill Lodge staff and on-call junior doctors to follow Standard 2.6.3's guidance around physical examination on admission to hospital. While good results were seen in many areas, the ward is not yet achieving the standard of 100%. A re-audit will take place in twelve months’ time to review recommendation and compliance.

1. The aim of this study was to assess the appropriateness of referrals to Whiston Mental Health Liaison Services (WMHLS) according to Royal College of Psychiatrists and local trust guidelines.

2. To assess whether the referrals were being reviewed in timely manner as per the trust's guidelines.

Data collection was completed using a proforma to ensure uniform data collection. The proforma included information on patient demographics, previous mental health service involvement, other details like reasons and time of referral and their outcomes. Data sample comprised of 46 patients who had been referred to the WMHLS in the month of August 2019 were randomly selected.

44 of the 46 referrals analyzed were found to be appropriate. 40 patients were deemed to have appropriate documentation. The ratio of males to females was 20:26. 21 referrals were from the observation ward, 14 from A&E, and 11 from medical wards. 40 patients were previously known to mental health services. The reasons for referral ranged from suicidal ideation/attempt (48%), Drug related (12%), Assessment (7%) and more. There were various outcomes recorded. One of them was that 18 (28%) referrals were assessed for Depression and for other mental health problems.

78.6% of patients referred from A&E, and 95.2% of patients in the observation ward, were not seen in the 1 hour window set out by the Trust's guidelines. 91.1% of patients referred from the wards were seen within the 24 hour target.

The vast majority of referrals were found to be appropriate (44/46). It was found that the referral form used across the Trust, contained different levels of details and information on the patient depending on the source of referral. Using a standard process to complete referral forms to be used across the whole trust may ensure that all patients receive a standardized and appropriate referral based on the guidelines. Making the form electronic may reduce problems deciphering handwriting, and could allow WMHLS have a better understanding of the patient, and allow them to identify a patient that may be more appropriate for another service, e.g. drugs and alcohol team. This may and make the overall referral process quicker and reduce waiting times in A&E, as well as faster referrals to the appropriate services.

To ascertain the length of time defendants wait for a Mental Health Act assessment (MHAA) and where necessary, how long they are waiting for a hospital bed.

The Liaison and Diversion Service in North West London (the Service) is provided by Central North West London Foundation NHS Trust (CNWL), Barnet Enfield Haringey (BEH) and Together to Willesden Magistrates Court in North West London.

One of the core activities of the Service is diverting individuals from the criminal justice system to hospital under the Mental Health Act (MHA).

The Code of Practice allows for a period of 14 days between the medical recommendation and conveyance to hospital. Defendants needing admission under MHA are remanded to custody if a bed is not available. This prevents them from receiving the assessment and care they need. We consider that all defendants found to be liable to detention under the MHA should be admitted to a hospital bed on the same day.

Data were collected between October 2018 and February 2019. All patients referred for a MHAA were included. The time a MHAA was requested, took place as well as how long the defendant waited for a bed was noted.

A total of 42 MHAA were requested. 25 individuals were detained under Section 2 of the MHA 1983.

The time between referral for a MHAA and the MHAA taking place was obtained in 25 of the 42 referrals. The range of times between a referral being made and the assessment taking placed varied between 1.5 hours and 22 hours. Two defendants were remanded overnight in prison as the MHAA could not take place on the same day as the referral.

In the 25 cases where an application for detention under Section 2 of the MHA was made, beds were not available on the same day in 7 cases. In 4 cases defendants required remand in prison custody due to beds not being available.

There were some limitations to this audit as data were not available for all 42 individuals referred for a MHAA.

Individuals referred for MHAA by the Service had both medical recommendations completed within 5 days and those who required admission to hospital were admitted within 14 days of the recommendations being completed.

Whilst these standards are being met, individuals referred for MHAA and those requiring admission to hospital are still facing remand to custody.

This project aimed to assess the use of handcuffs in a secure forensic mental health hospital.

Handcuffs are used by secure forensic psychiatric wards where patients need to leave the ward and require added restrictive measures for their own or other's safety. The decision to use handcuffs is made by the multi-disciplinary team, with the input of the unit's clinical security team and is assessed based on individual risk and need. This study investigated the frequency, duration and purpose of handcuff use in one secure forensic mental health unit, encompassing 8 male medium secure wards, 5 male low secure wards, 1 adolescent secure ward,1 female low secure ward and 5 female medium secure wards.

Handcuff use was recorded contemporaneously by ward staff in a specialised handcuff proforma. This data were then compiled to assess the number of instances of use, the mental health section applicable to the patient, the reason the patient needed to leave the unit, and the duration of use (including the time period for which the handcuffs were removed during the visit, if applicable.) Data from these forms over an 18 month period were analysed.

Over the 18 months, there were a total of 347 uses of handcuffs, with an average of 18.3 occurrences per month. In 55 cases, the patients were detained under a civil section, with the remaining instances occurring in patients detained under forensic section. 47% were unsentenced prisoners.

The most common destination for patients was the general medical hospital, which accounted for 49% of all visits. Court was the second most common destination, with 39% of uses.

The average duration spent in handcuffs was 3.3 hours. The average time that the handcuffs were taken off during the transfer was 1.2 hours.

Through ongoing education and supervision by the clinical security team, handcuff use in this forensic service was limited to essential situations, most often to allow treatment of physical health issues off-site. A large proportion of instances involved unsentenced prisoners and court attendances, where the risk of absconsion might be particularly high. Duration spent in handcuffs was kept to a minimum, with cuffs being removed where possible. The service strives to continue such good practices and to identify further ways to reduce handcuff use, such as using video-conferencing as an alternative court attendance.

To evaluate the role of the Emergency Medicine team (EM) within a London Emergency Department (ED) in assessing and managing patients detained under Section 136 of the Mental Health Act, 1983 (S136).

S136 allows detention and transfer of people to ED and psychiatric hospitals for further assessment. EDs are optimised for the investigation and management of the medically unwell, but attending ED may also delay access to psychiatric services if required. Minimal research has been performed to investigate the relative benefits of transferring people under S136 to ED versus psychiatric hospitals.

Electronic notes were searched to identify those attending under S136 between 01/04/2017 and 31/03/2018. Scanned medical notes were reviewed and data extracted regarding patient demographics, length of ED stay, reason for S136 use, investigations and interventions undertaken by EM.

This identified 95 attendances by 87 patients. The mean age was 35 years (range 15-75) and 59% of attenders were male. The mean duration of stay was 7 hours 34 minutes (range 6 minutes - 25 hours 50 minutes).

Reasons for S136 use were abnormal behaviour (32), expressed suicidal ideation (29), overdose (15), self-harm (13), overdose plus self-harm (4), being found wandering (1) and was unclear for 1 presentation.

In 39 attendances no investigations beyond history and examination were performed by EM. Only 6 patients had investigations that were not bloods, electrocardiogram or urinalysis. These included X-radiograph trunk (4), computed tomography (CT) head (3), X-radiograph limb (3), CT cervical spine (1), Focused Assessment with Sonography for Trauma (1).

No interventions were given by EM in 55 attendances. Twenty-nine different medications were prescribed and 18 patients were prescribed intravenous fluids. Three had wounds dressed, 3 glued, 3 sutured and 1 stapled.

There were difficulties categorising the reason for S136 use, as clear documentation was often unavailable, but the vast majority of patients were detained due to abnormal behaviour, expressed suicidal ideation and self-harm.

Few attending ED under S136 received investigations or interventions that could not be offered within a psychiatric hospital. There was a wide range in duration of stay within ED, however 65% of attendances were longer than the standard 4 hour target.

Future research may assess the relative benefits of ED versus psychiatric hospitals in assessing those detained. This could aid services in meeting both the physical and psychiatric needs of patients whilst making efficient use of available resources.

NICE guidelines recommend that all patients who undergo a successful alcohol detoxification programme should be considered for treatment with acamprosate or oral naltrexone. This audit studied the proportion of patients considered for acamprosate or naltrexone treatment in a North-East Addictions Service.

• Primary aim

• To explore whether naltrexone/acamprosate had been considered for each patient completing alcohol detoxification.

• what proportion of those offered agreed to be prescribed acamprosate/naltrexone

• whether these patients were being adequately followed up in terms of prescription

There is a significant evidence base for both naltrexone and acamprosate in the maintenance of abstinence in patients with alcohol addiction. NICE recommends the consideration of both medications for patients following successful alcohol detoxification from alcohol. The addictions service at Plummer Court in Newcastle upon Tyne has a comprehensive pathway for alcohol detoxification patients, which involves multiple reviews by keyworkers and medics. The attendance at these appointments is often poor, and it is often unclear whether these patients have been offered anti-craving medication.

A list of patients referred for inpatient or outpatient alcohol detoxification between June to August 2018 (n = 23) was curated. The progress notes were reviewed for any evidence that there had been clinical consideration of acamprosate/naltrexone. If evidence was found that the discussion had taken place, the notes were further scrutinised to assess if the client had accepted a prescription. The clinical documentation was further reviewed to see if follow-up for anti-craving medication was in place.

There was evidence that anti-craving medication had been considered in 47% of patients during the treatment process

In all but one case, acamprosate was offered rather than naltrexone

In cases where medication was offered, it was accepted in all but one case

Anti-craving medication was universally well tolerated

There was considerable difficulty with assessing who was following up the prescription. On scrutiny of the notes, several GPs had contacted addictions services stating that they would not prescribe acamprosate because of local policy prohibiting its prescription from Primary Care (this policy is in fact no longer current)

Practice changed to offer patients monthly follow-up with addictions services for six months

Template letter sent out to GPs with discharge from addictions requesting acamprosate prescription, outlining current policy and offering support if GPs not comfortable

Audit presented to medical team. Treatment pathway amended to specify medical team's role in offering anti-craving medication at initial appointment

Re-audit in six months

The main aim of this audit was to determine the prevalence of HDAP in Havering Community Recovery Team (CRT). The secondary aim was to determine how well HDAP has been monitored and documented - specifically, whether discussions around the reasons for continuing and the risks and benefits have been discussed.

There is a focus to reduce high dose antipsychotic prescribing (HDAP) due to the lack of evidence that it is efficacious and that smaller doses have an equivalent effect and are better tolerated. Similarly, the consensus by the Royal College of Psychiatrists is that any prescribing of high dose antipsychotics should be an 'explicit, time-limited individual trial’ with a distinct treatment target. There should be a clear plan for regular clinical review including safety monitoring. The high-dose regimen should only be continued if the trial shows evidence of benefit that is not outweighed by tolerability or safety problems.' Following a CQC inspection in 2014 of NELFT which found that the trust was failing to comply with the relevant requirements of the Health and Social Care Act 2008 with regards to safe use of medicines, yearly audits of inpatient HDAP have been undertaken. Although improvements have been made in the inpatient setting, no such audits have been performed in the community setting and consequently there is no data in NELFT regarding community services compliance with the above regulations.

All 349 patients in Havering CRT clinical records were screen by either using RIO or GP letters from recent CPA reviews. A data collection and analysis tool was created using Microsoft Excel. Data collection and analysis was carried out by the project lead and checked by a fellow project member.

Of the 349 patients included for analysis:

• 16 (4.58%) of patients were prescribed a high-dose antipsychotic

• 0 out of 16 had the high dose antipsychotic monitoring form available

• 12 (75%) had well documented evidence of review of HDAP.

• 4 (25%) had no documented evidence of review of HDAP.

There is a small group of patients receiving high dose antipsychotic therapy for which better monitoring is needed. This should include education of staff regarding HDAP, better documentation in their care plans and working with pharmacy to make HDAP monitoring forms available widely in the community.

This study aimed to identify whether contact with the Ealing Liaison Psychiatry Service (ELPS) improved patients’ mental health using the Clinical Global Impressions (CGI) scale, and to understand the utility of this tool.

CGI is a frequently used outcome measure in psychiatry and also forms part of the RCPsych Framework for Outcome Measures in Liaison Psychiatry (FROM-LP) across the NHS's LP Services. However, there is minimal literature discussing the meaning of the quantitative results of the questionnaire. What would be a cut-off point associated with the provision of good care? It is not possible to draw conclusions about the quality of service and care based on the proportion of the patients who report an improvement on CGI in the absence of a gold standard.

Patients and their ELPS clinicians filled out a CGI questionnaire, rating the patient's mental health condition after contact with the clinician. The 1-7 rated CGI scale indicated the following: 1-3 signified varying degrees of improvement, 4 signified no change and 5-7 signified varying degrees of feeling worse. This study looked at all 205 patients with completed CGI questionnaires who had more than one face-to-face contact with a clinician in 2018 and 2019.

Patient and clinician ratings were compared for concordance and patient notes were reviewed to identify potential reasons for patients with low CGI scores.

Randomised sampling of patients who scored 1 ‘Very much improved’, 2 ‘Much improved’ and 3 ‘Minimally improved’ was conducted to identify differences in number of face-to-face contacts between the groups.

59% of patients reported an improvement, 40% felt that there was no change and 1% (3 patients) indicated feeling worse. Of the latter, 2 patients had been admitted to a mental health unit.

91% of cases showed concordance between patient and clinician ratings.

Randomised sampling identified 9 patients scoring ‘1’, 22 patients scoring ‘2’ and 16 patients scoring ‘3’. The vast majority of patients had only two contacts with ELPS (77%).

ELPS intervention improves patients’ self-reported wellbeing in 59% of patients according to CGI.

There was no correlation between number of face-to-face contacts and the degree to which patients felt better. However, in the absence of a nationally-recognised gold standard, it is not possible to draw conclusions about whether care provided by ELPS is good compared to other services. Data from other centres are required to elucidate what constitutes a gold standard to aspire towards.

Studies show the prevalence of Autism Spectrum Conditions in EIP populations is 3.6-3.7% compared to approximately 1-1.5% in the general population. The Equality Act 2010 and the Autism Act 2009 make it a requirement for services to make ‘Reasonable Adjustments’ for people with Autism. The aim of this study was to improve how our service makes Reasonable Adjustments for people with autism.

There were 15 patients in our service with a confirmed diagnosis of Autism. Pre and Post a discussion about reasonable adjustments, we invited them to rate, on a 5 point Likert scale, how well they felt the service was making Reasonable Adjustments for their Autism and whether discussing it had been helpful. We offered face to face or telephone discussions with someone with autism expertise to discuss reasonable adjustments. We allowed at least a month after the discussion before repeating the Likert scale.

The pre-discussion rating, of whether the team was making reasonable adjustments for Autism, showed agreement (mean 4.2/5). This improved to 4.6/5 after a month post discussion about reasonable adjustments. Patients agreed to strongly agreed (4.6/5) that the discussion had been helpful. Reasonable adjustments identified were quite individual but responses followed the following main themes; (1) No adjustments were needed or wanted as some patients saw special arrangements for them as stigmatising and wanted to be treated like everyone else; (2) Adjustments around personal space in appointments eg sitting face to face, not sitting too close, explaining reason before moving closer; (3) Simplification/clarification of written information – eg some identified simpler language use and use of pictures; (4) Environment e.g. quieter, dimmed lights, clarity of signage in reception.

Autistic patients in our service already rated the team highly at making reasonable adjustments pre and post intervention and found it helpful to have a specific discussion. Reasonable adjustments were highly individualised but some themes emerged around personal space, written communication and clinic environment which staff could consider exploring routinely. Some patients did not want reasonable adjustments as they felt it could be stigmatising. Discussing reasonable adjustments is likely to benefit all patients, not just those with confirmed autism, we would suggest this should be built into routine practice.