A survey is described of people presenting with psychiatric problems to a north London accident and emergency (A&E) department over three months. Forty per cent presented with deliberate self-harm and 25% of these left before being assessed. Twenty per cent of those with problems compatible with a diagnosis of severe mental illness also left before being seen by a doctor. Differences between presentations ‘out-of-hours' and ‘in-hours' are described. Factors predicting admission were: previous psychiatric admission, symptoms of a psychotic or affective disorder and non-permanent accommodation. The survey has implications for the process of triage in A&E departments and the organisation of mental health liaison services.

Little is known about how posts are allocated to enable Individuals to experience a comprehensive pre-membership psychiatric training. A questionnaire survey of 26 teaching hospital training schemes was carried out. This concentrated on registrar training – post-Part 1 MRCPsych (now known as senior house officers since the Caiman changes). Four main methods of allocation, with varying degrees of trainee involvement, were identified. The amount of prior notice given of the trainees' next placement and perceived advantages and disadvantages were compared between the four methods. Implications for practice are discussed.

Hyponatraemia is usually defined as a serum sodium concentration below 135 mmol/1. The condition is rarely symptomatic until serum sodium falls below 120 mmol/1 and symptoms are more usually associated with values around 110 mmol/1. These symptoms include confusion and restlessness, progressing to drowsiness, myoclonic jerks, generalised convulsions and eventually coma. In a general hospital population about 1% of patients develop hyponatraemia (Rutsky, 1992), whereas in psychiatric patients the prevalence has been reported to range from 3.3% to 12.2% (Ohsawa et al, 1992).

This paper highlights the role that the World Wide Web (WWW) has to play as an aid to psychiatry. A basic history of the WWW is provided as is an introduction to some search techniques involved with the WWW. The literature on applications potentially relevant to psychiatry is reviewed using computer search facilities (BIDS, PsychLit and Medline). The WWW is one of the aspects of the Internet that possesses a huge potential for exploitation, both the clinical and research psychiatrist are able to benefit from its use.

The seclusion of general adult psychiatric patients is still a common nursing Intervention of questionable therapeutic benefit. It is often initiated as a last resort to maintain safety where there are staff shortages. Historically concerns over the abuse of this procedure led to the Involvement of medical staff to oversee or monitor the procedure and this practice has become fossilised in the seclusion policies of many trusts. This paper argues that the routine involvement of trainee psychiatrists in this procedure, for which they are rarely trained, is archaic, impairs inter-professional relationships and should be regarded as an inappropriate duty.

Clinical standards were compiled for prescription of psychotropic medication in adults with learning disabilities, and used in a community population for comparisons of current practice in two audit studies 12 months apart. Completing the audit cycle led to improved clinical practice and a rationalisation of prescribing practices. Improvements were achieved on all standards and the methods used to obtain them are discussed.

After the fall of South Vietnam to North Vietnamese forces in 1975, Vietnam has remained virtually isolated from the rest of the world. With the global political changes of the past 10 years. the Hanoi Government succeeded in reducing Vietnam's international isolation in part by attempting to open the country's door to foreign visitors. The country stretches along the eastern coast of the Indo-Chinese peninsula and is slightly larger than Italy. It is ‘S-shaped’, broad in the north and south and very narrow in the centre (Fig. 1). The country's main cultivated areas are the Red River delta in the north and the Mekong delta containing Ho Chi Min city (Saigon) in the south.

There is growing concern with psychiatrists' knowledge of mental health law, in particular with the introduction of new legislation and more complex statutory arrangements for after care. Despite this, little systematic research has been undertaken in the UK. This study was designed to determine the knowledge of a sample of doctors in psychiatry in Scotland, of part of the Mental Health (Scotland) Act 1984 which provides for urgent involuntary admission to hospital. A one in three sample of all non-consultant grade psychiatrists throughout Scotland was interviewed on the aspects of the Act considered essential to lawful detention. Knowledge of even this restricted part of the Act was poor regardless of experience. Evidence emerged which suggested that at times civil liberties might be compromised or the right to treatment denied. The findings clearly point to the need for increased emphasis on training in mental health law.

Pre- and post-change audits of the effect of the changes in community care assessments and funding intro-duced in April 1993 were carried out on a psychiatric in-patient rehabilitation unit in Dundee. There was a substantial reduction in throughput in the rehabilitation unit (from 43 to 22) and in placements to funded staffed accommodation (from 11 to three) despite an increase in void community tenancies. By three months, 17 of 22 referrals for needs assessment were still incomplete, and at one year only three patients had had their needs assessed and appropriately met. Recommendations arising from these findings are discussed.

The recent reforms to the MHS have resulted in a need for management training to be a part of higher professional training. The trend towards competition within internal markets requires that all doctors become managerially accountable for the quality and efficiency of their service (Waters, 1985). The beed for management training has been recognised by the Collegiate Trainees' Committee (CTC, 1990, 1995). Some training schemes offer no organised management training, and some provide training as a short course (Reder, 1996). Many residential management courses are available, providing one or two weeks of ‘Intensive training’. Inevitably, the amount of management theory and techniques which can be learned on such courses Is limited.

Following a series of well-publicised tragedies the Department of Health published guidelines on the discharge and aftercare of psychiatric patients (Department of Health, 1994). These guidelines stipulate that at the time of discharge from in-patient care the treatment team will have carried out a risk assessment, with the expectation that professionals will be criticised if things go wrong. Risk assessment is now a routine, if poorly understood, element of clinical practice. The allied concept of risk management, which lacks a simple definition but is “aimed at reducing the likelihood of harming patients during treatment, minimising trauma to those who are affected, and controlling the possibility of subsequent litigation” (Vincent, 1995), is much less familiar to clinicians. The Editor has commissioned a short series of articles that address the topic of risk in psychiatry, covering suicide, dangerousness, the exposed role of Mental Health Review Tribunals in the case of Restricted patients and a variety of professional risks. The aim is not to be didactic but to raise the level of debate about the risky business that psychiatrists are engaged in.

Tardive dyskinesia (TD), literally meaning a late occurring, abnormal movement disorder, was first described by Schonecker in 1957, about five years after the discovery of chlorpromazine (cited in Kane, 1992). TD generally occurs after long-term antipsychotic therapy: Kane et al (1984) reported that the incidence was increased with each subsequent year of exposure to antipsychotics, starting with an incidence of 5% after one year of exposure and increasing by 5% each subsequent year. Certainly, the prevalence of TD has increased over the last 20 years, probably as the result of more patients being exposed to antipsychotics for longer periods.

An audit of antipsychotic prescribing was carried out on community and in-patient samples. A novel method of expressing total daily antipsychotic dose as a percentage of the British National Formulary maximum recommended dose was used. Of 226 patients who had been prescribed antipsychotics, 16 (7%) were found to be on high closes. Their medical notes were examined to ascertain whether the Royal College of Psychiatrists guidelines were being followed. Recommendations on ways in which practice could be improved were made and a re-audit was carried out. The number of patients receiving high doses fell to 6 (3%) out of 206.

The report indicates that a psychosurgery service can be established on a regional basis. The outcome study of the Yorkshire Regional Psychosurgery Service indicates that the treatment should retain a place in the treatment of patients who have failed to respond to other available approaches. For such patients (and their carers) life is a state of persisting torment. Some psychiatrists consider psychosurgery as a procedure not to be countenanced, or outmoded, but patients have a right to know what may be achieved by the treatment and at what cost in terms of possible failure to improve and adverse effects. An audit of the Regional Psychosurgery Service indicates a favourable result of the Intervention. All patients improved to some extent, some very remarkably, and no adverse effects were encountered.

Health professionals are increasingly expected to take a share in the management of risk in a systematic manner. At its most blunt, clinical risk management is defined as the identification and planned response to negative events that occur during the provision of clinical care and can lead to litigation, the cost of this to the NHS is rapidly rising (Vincent & Clements, 1995). There are, of course, much broader risks to any healthcare organisation, and the approach to risk management in any organisation needs to be systematic. At the start of the process the development of a list of clinical and non-clinical areas in which failures might occur can be overwhelming to clinicians and support staff alike. Rigorous prioritisation of the process is essential, and for practitioners the first rule of sound clinical risk management is common sense.

The former East Anglia Regional Health Authority initiated a 3-year project beginning in 1993. This aimed to introduce audit skills and to promote sustained audit activity across a diverse group of statutory and independent sector drug and alcohol agencies. Prior to this there had been little interest in audit for this area of care and no good models of practice were available from elsewhere in the NHS which could readily be adapted to the needs of the Anglian services. Eventually 24 agencies collaborated in this project, which introduced a system of reciprocal peer audit between the agencies which was supported by a dedicated facilitator, a programme of auditor training, and an Agency Audit Representative Group to prioritise topics for audit and to agree common standards. Progress was very slow to begin with. By May 1995, 12 agencies had completed an initial audit of 2–4 topics each from a regional menu of 12 priorities. One year later, 12 more services have undertaken such an initial audit and nine out of the original dozen (75%) have completed their first ‘audit cycle’ with a re-audit of the same topics. There has been an increase in the number of agencies meeting all the standards in their chosen topics, and in the number of topics where all standards are met, wherever those topics have been audited. Two new practice guidelines have also been developed by the agency representatives.

In a survey of services conducted by the Section of Old Age Psychiatry in 1993, Wolverhampton was identified as one of 24 Districts with no consultant Old Age Psychiatrist in post (Benbow & Jolley, 1996). This encouraged the newly formed NHS Trust responsible for mental health and other community services to arrange for the secondment of D. J. from South Manchester, for a period of two years, with a view to setting up and running an appropriate service for older people with mental illnesses (Jolley, 1996). We are reporting here some of the changes which have occurred during the first year of this secondment.

Little advice is offered in the literature for the novice report writer, despite the gravity of the situation, for example, a patient appealing against detention. Section 20, which renews the authority for detention after periods of 6 months or a year, is a useful reminder for clinicians, as it outlines the components that must be present in order for detention to continue.

This audit established guidelines for the completion of reports for Mental Health Review Tribunals and Managers' Reviews. A structure and list of ‘features to be included’ was compiled. This was used to rate the standard of reports prepared in the Warneford Hospital between 1991–1993. Following peer consultation within the hospital, the guidelines were considered acceptable and useful. At re-audit after 8 months the standard of reports had improved in most respects.