In 2000, an article published in this journal described a method of reviewing serious incidents based on peer group discussion, a model then in its sixth year (Rose, 2000). This paper describes how the model has changed in response to the National Health Service (NHS) developments since then.

People with a mental handicap may have a variety of behavioural symptoms, and according to DSM-III-R those commonly seen include passivity, low self-esteem, low frustration tolerance, aggressiveness, poor impulse control, and stereotyped self-stimulating and self-injurious behaviour. There is, however, no diagnostic subclassification of these in DSM-III-R.

For more than a decade there has been no opportunity for formal post-graduate training in psychiatry in Romania. In February 1992, as part of a World Health Organization (Regional Office for Europe) initiative, we travelled to Romania as WHO temporary advisers to give seminars on: (i) the role of primary health care services in providing mental health care; and (ii) the development of community-based services for the mentally ill and disabled. Our seminars were designed to complement the biological and clinical elements of a developing psychiatric training programme.

In 1991, Derek Humphry published Final Exit – The Practicalities of Self-Deliverance and Assisted Suicide for the Dying. The book was written for mature adults who were suffering from terminal illnesses and required guidance in committing suicide, but it has encouraged suggestive and susceptible people to attempt suicide (Lavin et al, 1992). There appears to be a thin line between assisted suicide and culpable suicide. ‘Culpable suicide’ is used here to describe contributory negligence attributed to persons who unknowingly assist another person's suicide.

A survey of 101 new attenders at a regional drug and alcohol service found that 46 adults had a total of 88 children at home. Twenty-three children were considered by their carers to show signs of emotional or behavioural disturbance. Difficulties had only been discussed with professionals in a minority of cases. Help for troubled children from primary care services was preferred to secondary services. Closer liaison between child psychiatry and primary health care workers should be considered.

Large psychiatric hospitals are notoriously resistant to change. Their size and organisational complexity inevitably hinder their capacity to keep pace with trends. The serious consequences of a system that has ceased to adapt have been documented many times. Stereotyped routines and practices combine with rigid and bureaucratic management structures to produce the phenomenon of staff ‘burn out’, the “I've seen it all before and it doesn't work” syndrome.

In 1987 the Charing Cross General Psychiatric Training Scheme incorporated an exchange with the National University Hospital, Singapore (NUH) sponsored by Glaxo Pharmaceuticals. Four selected UK trainees have now spent nine months at NUH as part of their general rotation. A description of psychiatric training based at NUH is outlined here.

One of the topics discussed at the recent Trainees Day of Thames Health Authority, Southern Division, was part-time training. Trainees were concerned about difficulties experienced by those wishing to train on a part-time basis.

The structure of mental illness services is changing rapidly. Large hospitals are closing or preparing to close and the service will be provided in other ways, partly by smaller units, partly by increased care in the community outside hospital and partly by amalgamations of two or more large hospitals. Smaller units allow closer working relationships with GPs, social workers and other professionals.

Forensic mental health services are low-volume, high-cost services. Payment by results (PbR) is the UK s latest attempt to improve efficiency and controls pending behaviours within the secure services. This article discusses the utility of the PbR mechanic in forensic mental health. It explores PbR implementation in non-forensic mental health settings, similar funding processes internationally, and early PbR implementation work in the UK's secure services. Finally, the article discusses the challenges faced when implementing PbR in forensic mental health services and puts forward possible next steps in determining the utility of PbR in forensic mental health.