Our aim was to see if the following have been done during medical reviews:

1. 1. For service users with a diagnosis of psychosis or schizophrenia; is there clear documentation of employment status in case notes?

2. 2. To see if supported employment/alternative education or occupational activity is being offered to unemployed service users in their Outpatient Clinic Appointments.

3. 3. Whether acceptance or refusal of offered support is being documented and followed up.

This is a re-audit and it was done to check the compliance of our service with recommended NICE guidelines following the first cycle audit.

The NICE Guidelines (CG178 – Psychosis and Schizophrenia in Adults: Prevention and Management and NG181 – Rehabilitation for adults with complex psychosis) recommend the following for all patients with diagnosis of psychosis or schizophrenia.

Standard 1:

Offer supported employment to people with psychosis or schizophrenia who wish to find or return to work (CG178 Psychosis and schizophrenia in adults: prevention and management – 1.5.8 – Employment, Education & Occupational Activities).

Standard 2:

Facilitate alternate educational or occupational activities for people who do not wish to pursue mainstream education or work (NG181 Rehabilitation for adults with complex psychosis – 1.8.9 Engagement in community activities, including leisure, education and work).

This re-audit was carried out in the Community Adult Mental Health Services at Taylor Centre, Southend.

A list of service users that attended Outpatient Services at the Taylor Centre during the months of August and September 2023 was obtained.

Case notes of service users with diagnosis of psychosis or schizophrenia that attended an Outpatient Clinic over the 2-month period as new appointment or follow up were reviewed retrospectively. The 2 months (August and September) were chosen at random to achieve a reasonable sample size.

Service users within age range of 18–68 years were selected as they fall into the working age group range in UK.

The following details were checked:

1. 1. Is the service user's employment status recorded in case notes?

2. 2. For those who are unemployed – is supported employment offered?

3. 3. Service User's acceptance or refusal and any alternative educational or occupational activity facilitated if they refuse mainstream work.

The data was collected on an Excel spreadsheet and analysed.

Findings:

• • In the case notes of our sample, Employment status was documents in 97% of the cases; 78% were not actively seeking work.

• • The type of appointment in which employment was most often discussed was in the follow up appointments = 87% of the cases.

• • Supported Employment was offered to 38% of the sample. It was noted that 64% of service users that were offered supported employment had declined the offer.

Based on individual service users’ circumstances alternative educational or employment options like prevocational training was offered to 47% of the sample. This is a notable improvement from 26% in first cycle.

There was good documentation of employment status in the case notes of 97% of the sample which shows that Employment history is being taken for almost all the service users that attend our Outpatient Service.

The type of appointment in which employment was most often discussed was in the follow up appointment (87% of the cases). This could be due to service users’ mental state at the time of their first appointment, with them being unwell; hence it may be unsuitable to discuss employment options at that time.

Supported Employment was offered to 38% of the sample. The initial audit showed that this was offered to 35% of the non-working sample; therefore, a small improvement in offering supported employment has been noted. However, it is worth noting that 64% of the people that were offered supported employment have declined the offer, which reiterates the attitude towards mainstream employment in people with serious mental illness.

Only 33% of the service users were followed up, but this could be due to the fact that some of the service users are still waiting to be seen in clinic.

Overall, there has been an improvement following the initial audit especially in offering other educational activities if supported employment is not appropriate or if the service user is not interested.

1. 1. To develop an understanding of transfers in both directions between Psychiatry and the other Acute wards within FVRH.

2. 2. To improve compliance with National standards of handover as laid out by NICE and GMC.

Data was taken from a combination of the care partner, trakcare, and HepMA systems looking at the quality, content and professionals involved in handover. This was done for all transfers in and out of 2 old age psychiatry wards over a 2 week period. The auditing of transfers into MHU and transfers out of MHU initially started as 2 separate projects with staggered data collection; these were combined after baseline data was collected, and the intervention and re-audit phases treated the two as a single project. Data was compared with the standards collated from GMC and NICE guidance.

Transfer handovers in neither direction met audit standards at baseline assessment.

Interventions focusing on behavioural change in the mental health unit did achieve behavioural change but failed to solve issues with handover between departments.

It is worth noting that there was significant delay in some transfers out of mental health being escalated, considering the reduced facilities in mental health wards versus acute wards.

Transfer handover between Psychiatry and Acute Wards is a multi-system issue and as such will require a multi-system approach to achieve meaningful change. New local guidance for handover between mental health and acute wards is being drafted in response to the findings of this audit.

NEWS 2 is integral to post-admission physical health monitoring, guiding baseline establishment and observation frequency decisions. MDT discussions, involving medics or nurses per guidelines, ensure tailored care. Trust Standard Operating Procedure (SOP) and Physical Health policy, provides detailed procedures for assessment, recording, and actions. Adhering to NEWS 2 and SOP 1.62a, aligned with Trust standards, facilitates prompt escalation in case of patient deterioration, reinforcing our commitment to superior healthcare.

AIM

• • To evaluate if NEWS2 monitoring is done as per set Trust standards/guidelines.

• • To identify areas of improvement in the use of this observational tool.

• • To improve the services and care of patients.

We conducted a comprehensive review of each section of NEWS 2 charts for 39 patients admitted to Ward 6 and 7 at Harplands Hospital over a 3-week period. Patient stays varied from 21 to 67 days. No pregnancies were noted; all patients were aged between 59–96, with a near equal gender distribution. Utilizing SPSS, we conducted data analysis, comparing results against Trust-set standards.

Of the 39 charts, 37 were completed at admission, with notable issues: 9 lacked demographics, 13 had date/time missing. Weekly NEWS was predominant, but challenges included 6 missing signatures, 9 illegible entries, and 12 incomplete sections (4 without connecting observations). GCS completion issues were identified in two charts if CPVS score was more than 3. Escalation patterns varied: scores 1–4 were often routed to a Registered Nurse before medics, while scores >4 were mainly escalated directly to medics. Most charts were uploaded to electronic records, yet the electronic versions were frequently left unfilled.

In conclusion, the implementation of NEWS charts at admission, consistent chart uploads to Lorenzo, and effective escalation practices underscore a commitment to patient monitoring. The detailed procedures, including demographics completion, trend identification, and weekly reviews, contribute to a comprehensive approach. The incorporation of printed patient information labels and targeted education sessions for ward teams further reinforces the emphasis on standardized and meticulous documentation practices, enhancing overall patient care and safety. Discussions with ward management will further support the ongoing success of these initiatives.

Above recommendation has been completed and Re-Audit in planned few months.

• • To determine the demographics of the patients prescribed medications for ADHD under the CAMHS teams within Southern Trust (NI).

• • To assess whether the physical health monitoring guidelines (as outlined by NICE – nice.org.uk/guidance/ng87) have been followed.

• • If monitoring is not up to date, to determine why not.

We reviewed records from clinical notes and NIECR (Northern Ireland Electronic Care Record) to collect demographic details.

Following NICE guidelines, we used the clinical notes to determine which patients had physical health monitoring up to date, including heart rate (HR), blood pressure (BP), weight and height.

For any patient with monitoring not up to date, we reviewed the notes or contacted the practitioners to determine why this was the case.

96 patients were found to be prescribed ADHD medications. Full demographic details were obtained and collated for these patients, including age, sex, diagnosis, co-morbidities, and medication information (e.g. preparation, dose, polypharmacy).

Of the 96 patients, 1 was excluded as their monitoring was carried out by paediatrics.

71 out of the remaining 95 had their monitoring up to date, leaving 24 patients with monitoring not up to date. Of these 24:

• • 8 were due to non-attendance

• • 4 were due to equipment issues (e.g. faulty/unavailable)

• • 3 only had partially completed monitoring (e.g. BP, weight, height but no HR recorded)

• • 1 was only reviewed virtually

• • 1 had documented completion of monitoring, but no figures documented

• • 7 unknown – no reason given.

After 1 patient was excluded, 71/95 patients had monitoring up to date (~75%).

Of the remaining 24, some were due to systemic issues affecting all services, e.g. non-attendance or faulty equipment. However, some were due to issues more easily addressed.

This led to a discussion at a trust-wide patient safety meeting, with the following outcomes:

1. 1. Staff were given a presentation on NICE guidelines for ADHD medication monitoring to ensure knowledge is up to date.

2. 2. The importance of completing all aspects of monitoring and documenting these each time was highlighted.

3. 3. If monitoring could not be completed, the reason must be documented, to avoid further “unknowns”.

4. 4. An agreed plan to schedule monitoring appointments following virtual reviews.

5. 5. Annual re-audit using the same data template, with the aim of improving each year.

Citalopram and escitalopram are commonly used serotonin-specific reuptake inhibitors (SSRIs) for the treatment of depression and anxiety. These medications are known to cause corrected QT interval (QTc) prolongation, with risks of further arrhythmias. In 2014, the Medicines Healthcare Regulatory Agency (MHRA) published guidance outlining this risk and advised decreased maximum daily doses of citalopram 20mg and escitalopram 10mg in the elderly population. The aim of this audit was to explore the prescribing patterns of citalopram and escitalopram in a community sample of older adults with psychiatric disorders, against MHRA guidance.

Older adults (aged >65 years) in the community mental health services in Wolverhampton, who were prescribed citalopram or escitalopram, were identified through a search of clinic letters in June 2023. We checked the medications, doses, history of QTc prolongation, concurrent medications that may prolong QTc, electrocardiogram (ECG) reviews, and any discussion about the risk. The data was collected by accessing the electronic patient record and related health records. In total 17 patients were included, with no exclusions.

Most of the patients (94.1%, n = 16) were on citalopram and only one patient was on escitalopram. The most common dose of citalopram was 20 mg (62.5%, 10/16), with one patient having a higher than the recommended dose (30 mg). Escitalopram was within the recommended dose. There was no history of QTc prolongation in any patient. Concurrent medications that could prolong QTc were identified in 35.3% (n = 6) of the patient population; all of these were antipsychotics. A small proportion (11.8%, n = 2) of the patients had documentation stating about QTc prolongation and arrhythmia risks for citalopram or escitalopram. A review of ECG when initiating or adjusting treatment was noted in only one patient.

Most of the older adults had citalopram and escitalopram within recommended limits. A considerable proportion of patients had concurrent medications with an additional risk of prolonging QTc and subsequent arrhythmia. It is essential to consider ECG in all elderly patients before starting medications with a risk of QTc prolongation. There is a need to discuss the cardiac risk associated with citalopram and escitalopram with the patients and improve documentation. It may be better to provide written information to the patients and caregivers regarding this.

The National Drug Treatment Centre in Dublin is the longest established treatment service for drug users in Ireland. Led by Addiction Psychiatry teams, it provides specialist multidisciplinary input for patients with complex medical and psychiatric needs secondary to substance use. Many patients attending the centre engage poorly with other healthcare services in the community. The aim of this audit was to improve physical healthcare engagement in a caseload of 60 patients, through improving GP registration rates and possession of medical cards (providing access to free public health services).

The comparison standard for the audit was the Irish Health Service Executive (HSE) Clinical Guidelines for Opiate Substitution Therapy: 2016. These stipulate that all drug users entering treatment and rehabilitation should have a care plan based on assessed need. Specific domains covered include: Drug and Alcohol use, Physical Health, Psychological Health and Social Functioning.

During the initial audit cycle, electronic care plans in a caseload of 60 patients were reviewed for information on their GP and medical card status.

Intervention: Following the initial cycle, results were presented and discussed at a multidisciplinary team meeting. A combined MDT effort was made to discuss medical card and GP status with patients during each interaction. Patients were referred to social work for support in application/renewal of medical cards and GP registration where required.

Results following re-audit:

The percentage of patients with GP registration clearly displayed on their care plan increased from 66% to 93%.

The percentage of patients with an up to date medical card increased from 12% to 45%.

The percentage of patients whose medical card status was unknown reduced from 72% to 44%.

The percentage of patients with their medical card number displayed on their care plan increased from 25% to 55%.

There was a significant improvement in the number of patients with GP and medical card information documented clearly on their electronic care plan. This has assisted National Drug Treatment Centre staff in supporting patients' physical health needs more effectively, through close liaison with primary care providers and onwards referral to other services where required. It was noted that further efforts were required to build upon these results and reach 100% compliance. Recommendations and an action plan were developed to ensure ongoing improvement in standards.

Antipsychotic medications are one of the major iatrogenic causes of hyperprolactinaemia with the attendant short- and long-term effects and risks associated with it.

• • The audit sought to answer the question: Are we monitoring and managing hyper prolactinemia caused by anti psychotic medications appropriately?

• • A literature search for relevant data and standards with regards to monitoring and management of hyperprolactinaemia was conducted.

• • The audit was based on the standards derived from South West Yorkshire NHS Partnership Foundation Trust’s (SWYPFT) standards, NICE guidelines, and the Maudsley Prescribing Guidelines in Psychiatry (14th edition), focusing on the Trust's standards.

• • The total population under consideration included every patient under the care of the North Kirklees, Community mental health team (CMHT), Old age psychiatry services (OPS) that was using antipsychotic medication in the time period between 16 June 2022 and 15th July 2023.

• • Total patients 61

• • Female 30

• • Male 31

• • Age: 65 and above

• • Already on antipsychotic: 49

• • Started on antipsychotic: 12

• • Two or more antipsychotic: 2

• • Switch from one antipsychotic to other: 4

• • Prolactin monitoring not required: 27 because were already using olanzapine, quetiapine and aripiprazole

Monitoring required: 34

• • Initiation: 12

• • Prolactin level done 2/12

• • Prolactin level not done 10/12

• • LAI (long acting antipsychotic) 11

  Prolactin level done 7/11

  Prolactin level not done 4/12

  Not done: 75% were with Care coordinator

  25% Wellbeing team

• • On oral antipsychotic that require prolactin level monitoring: 11

• • Prolactin level done 5/11

• • Prolactin level not done 6/11

Patients who were on antipsychotics in community required prolactin monitoring. In more than 50% of patients prolactin were not monitored regularly because of communication gap between Psychiatrist and GPs as no clear instructions were mentioned from Psychiatrist to GPs, patients and care coordinators.

A small number of patients in whom prolactin was raised were highlighted to their respective medics and managed accordingly.

The aim of this audit was to review the availability of recommended resuscitation equipment in Prospect Park Hospital (PPH), a psychiatric hospital based in Berkshire.

The objective was to improve patient safety standards and address staff concerns by ensuring that recommended resuscitation equipment was accessible and fit for purpose.

Our hypothesis was that the current standard of resuscitation equipment at PPH was unsatisfactory.

Background

This review followed concerns by doctors who struggled to obtain the necessary equipment required for emergency situations, particularly during their out of hours shifts.

This project was significant as within the previous year there had been two incident reports and extensive anecdotal evidence of equipment failure/absence.

Whilst each ward had been tasked with completing a weekly checklist issued by the Resuscitation team, these had not been audited to ensure that standards were being met.

Data was collected from ten locations at Prospect Park Hospital from 9th May to 15th May 2023.

Information was obtained by two doctors visiting the specified wards, reviewing the resuscitation bag equipment based on the standardised checklist.

The standards used were from local trust policy and Resuscitation Council UK policy.

7/10 locations did not meet the standards for resuscitation equipment, including missing or expired equipment such as adrenaline, suction devices and oxygen masks.

4/10 wards had not completed the weekly emergency drug checklist within the stipulated time frame.

70% of staff completed checklists were incorrect.

Our hypothesis was proven to be correct, in that the current standard of resuscitation equipment at PPH was unsatisfactory.

We worked closely with the Resuscitation lead to recommend improvements, including an updated, more detailed checklist, a standardised procedure for ward managers and regular future audits.

Due to the significance of the findings, this has since been re-audited and is in the process of being rolled out Trust-wide, including all inpatient and community settings.

As a result of this audit, the Resuscitation team have been granted additional staffing to action these changes and increased their remit to monitoring equipment in addition to training.

These findings demonstrate that it is vital that the recommended resuscitation equipment is available and suitably maintained, particularly in a community hospital setting with limited resources where it can be life-saving.

Many antipsychotics are known to adversely affect prolactin levels causing hyperprolactinemia. National Institute for Health and Care Excellence (NICE) guidelines have suggested monitoring of prolactin levels. It specifies that prolactin should be checked 6 months after starting treatment, then every 12 months; and to ask about symptoms of raised prolactin which include low libido, sexual dysfunction, menstrual abnormalities, gynaecomastia, and galactorrhoea. This also mentions that it is not required for aripiprazole, clozapine, quetiapine, or olanzapine (less than 20 mg daily). We intended to audit the monitoring of prolactin in a sample of inpatients who are on antipsychotic drugs and to check whether action was taken in the event of a high prolactin level.

All the adult inpatients of a general psychiatric hospital on a specific date (34, 16 (47.1%) female and 18 (52.9%) male patients), who were on antipsychotics were considered for the audit. We checked the antipsychotic drugs, prolactin assessment within one year and level, action taken if there was hyperprolactinemia. The data was collected from electronic patient records and medication charts.

The mean age of the sample was 39.1 ± 14.2 years (range 18–63). Most inpatients (91.2%, 31/34) were on antipsychotics and 25.8% (8/31) were on two antipsychotic drugs. Prolactin was measured in 80.6% (25/31) patients in the last year, with 48% (12/25) having hyperprolactinemia; and amongst these action was taken in 5 (41.7%). Hyperprolactinemia was present in 58.3% of female and 38.5% of male patients. Specifically, out of 31 patients, 14 (45.2%) were on antipsychotic drugs that need monitoring, and 9 (74.3%) of them had taken it for at least one year. Out of these 9 patients, prolactin was measured in 8 (88.9%) patients in the last year, it was elevated in 5 (55.6%), action was taken in 3 (60%) and action was not clear in 2 (40%) patients.

Almost half of the patients on antipsychotic drugs had hyperprolactinemia, highlighting the need to monitor prolactin levels. Along with this, symptoms of hyperprolactinemia should be consistently checked in routine clinical evaluations. Clinician and patient education regarding hyperprolactinemia and its symptoms might improve its monitoring.

This study aims to evaluate dietary history documentation by junior doctors in a psychiatric hospital setting in Scotland. With emerging evidence in nutrition psychiatry highlighting diet's impact on mental health, especially ultra-processed foods, this aspect often receives insufficient attention in clinical assessments. The audit benchmarks current documentation against UK Public Health nutritional guidelines and UK Parenteral & Enteral Nutrition Guidelines on Malnutrition, assessing adequacy and consistency across psychiatric diagnoses.

This audit conducted a systematic review of medical records in psychiatric wards, focusing on patients newly admitted over six months. The data collection examined admission sheets by junior doctors, covering patient identifiers, admission time, diagnosis, doctor's grade, and comprehensive details on dietary habits, eating behaviours, BMI, and substance use. The review incorporated a dietitian's input to align dietary assessments with UK Public Health Nutritional expectations and the prevention of Malnutrition Guidelines. The goal was to assess the regularity, quantity, variety, and documented changes in patients' dietary behaviours, screening for potential nutrient deficits, impacts of psychotropic medications, and eating disorder psychopathology.

The results showed significant deficiency in the detail and consistency of dietary history documentation across all wards, regardless of the doctors' grade or the patients' psychiatric diagnoses. Most entries were inadequately documented or entirely missing. A particular discrepancy was noted in documenting dietary habits in patients with low BMI or those on metabolic altering antipsychotics, which should necessitate health behavior change dietary interventions. Furthermore, even in severe psychiatric conditions, there was a gap in dietary documentation indicating a widespread oversight in recognising the potential relevance of nutrition in the overall health and treatment planning of psychiatric patients, regardless of the severity or type of their condition.

The audit reveals a gap in psychiatric patient care concerning detailed dietary relevance history documentation. While Scotland's wards routinely use the Malnutrition Universal Screening Tool (MUST) for identifying malnutrition, this tool often overlooks key dietary elements like variety, quantity, and regularity, which are vital for linking diet content to mental health. This oversight is significant given the burgeoning field of nutritional psychiatry. Our findings suggest the necessity for systemic changes to improve dietary history documentation in psychiatric settings. This includes a more structured and systematic approach, integrating insights into the harmful effects of ultra-processed foods on mental health, to provide holistic care.

This audit evaluates the adherence of nursing and medical staff to local protocols for managing distress in older adults (aged >65 years) using non-pharmacological approaches and rapid tranquilisation (RT) in a psychiatric hospital's dementia ward, an acute medical unit, and a geriatric ward in a general hospital. We hypothesize that operational differences between these wards significantly influence the management of older adult patients.

Conducted from September 17 to October 8, 2022, in hospitals in Inverness, Scotland, this study reviewed 322 case notes and drug charts from patients who underwent RT in three wards: the Old Age Psychiatric Ward, Acute Medical Unit (AMU), and Geriatric Ward. Focus groups and informal discussions with ward nurses and junior doctors were organized to understand their perspectives on handling distress in dementia patients, with an emphasis on de-escalation techniques.

Data focused on key parameters:

• • Patient Diagnosis and Legal Status.

• • Administration Details: including initiation time, de-escalation techniques, consultation with senior doctors, and details of drugs administered (route, drug, and dosage).

Staff nurses in all wards prioritized non-pharmacological de-escalation techniques, such as recognizing early signs of agitation, employing distraction and calming tactics, and acknowledging the importance of personal space, even in the face of staffing challenges and high patient loads. These measures were consistently employed prior to considering RT, adhering to the local protocol. Physical restraint was employed only in scenarios where there was a risk to the patient or others, executed by personnel trained in managing violence and aggression.

Conversations with junior doctors, particularly in the AMU, revealed a limited understanding of the RT protocol, suggesting a need for enhanced training and awareness. Overall, the study indicates that while RT is regarded as a last resort after the failure of psychological and behavioral approaches, there is a clear necessity for further education and training to ensure the safe and effective administration of RT.

This audit demonstrates that despite the varying environments and pressures in the three wards, adherence to the local protocol for managing distress in older adults is largely effective, with a strong preference for non-pharmacological methods. The findings highlight the need for ongoing education and reinforcement of RT protocols, particularly among junior doctors, to ensure patient safety and adherence to best practices. The results suggest that with proper support and training, the use of RT can be a carefully controlled and beneficial tool in managing distress in older adult patients.

Emotionally unstable personality disorder (EUPD) is characterized by affective instability, unstable interpersonal relationships, poor self-image and marked impulsivity. Patients may present with a variety of symptoms including impulsivity, suicidal behavior, affective instability and intense anger. This makes the treatment very patient specific.

Treatment guidelines support the use of Dialectical Behavior Therapy (DBT) as the first line treatment of EUPD. Currently, no medications are indicated for the treatment of EUPD which leads to off label use of medicines by clinicians.

More than 90% of individuals receive a variety of pharmacologic treatment with psychotropic medications, especially second-generation antipsychotic drugs for the treatment of cognitive perceptual symptoms and impulse control behavior. Additional psychotropics are usually added leading to psychotropic polypharmacy which should be avoided.

Aim of this study is to assess the frequency of prescription of antipsychotic medications in patients with a primary diagnosis of emotionally unstable personality disorder.

Protocol was registered with the Audit and Quality Improvement project team of the NHS trust and the audit registration certificate was obtained.

Case records of 42 patients with EUPD who attended psychiatric outpatient department from June to August 2023 were collected and screened. A retrospective study was carried out.

Inclusion criteria

Patients above 18 years of age, with a primary diagnosis of emotionally unstable personality disorder.

Exclusion criteria

Patients with comorbid diseases like Attention Deficit Hyperactivity Disorder, Bipolar Affective Disorder and Psychosis where use of antipsychotics is warranted.

All other personality disorders.

After screening 42 case records, 20 cases of EUPD which fulfilled the inclusion and exclusion criteria were found and analyzed. Descriptive statistics were used.

Retrospective data of 20 patients with a primary diagnosis of EUPD were analyzed which included 18 females and 2 males. The mean age of the participants was 27.1.

70% (14) of the patients diagnosed with EUPD were treated with antipsychotics. 20% (4) patients received antidepressants. 10% (2) of the patients received only DBT.

Quetiapine was the most commonly used antipsychotic – 43% (6) followed by Olanzapine – 22% (3), Risperidone – 21% (3) and Zuclopenthixol long-acting injection – 14% (2).

Dialectical behavior therapy is the first line treatment of EUPD. National Institute for Health and Care Excellence (NICE) guidelines do not recommend the use of antipsychotics in the treatment of EUPD. Contrary to the guidelines, antipsychotics are prescribed long term for patients with EUPD who are without any comorbid conditions. This audit has found that 70% of patients with a primary diagnosis of EUPD are being prescribed antipsychotic medication. This needs to be kept in check so that polypharmacy can be avoided.

The primary aim was to identify areas where there may be a significant gap in following the NICE recommendations.

To compare how antipsychotic and benzodiazepine prescribing practice in Community mental health team, measures against the national prescribing practices as identified in the POMH-UK Quality Improvement Project (QIP) 12b.

The medical secretaries were contacted and asked to provide a list of patients seen as outpatients between March–September 2021 who have a diagnosis of personality disorder.

As there were multiple psychiatrists working in a team the cases to include were taken evenly from each caseload.

The frequency of diagnosis of personality disorder was more likely in females (31/40). Most common personality disorder diagnosed was EUPD (88.5%) followed by mixed Personality disorder (11.5%).

Among sample of patients selected, around 75% were prescribed some psychotropic medication including 52.5% (21/40) who were prescribed an antipsychotic medication.

Around 47.6 % (10/21) of the antipsychotic prescriptions were a new recommendation. Out of all the antipsychotic medications prescribed, quetiapine was by far the most common antipsychotic prescribed followed by aripiprazole.

In 38% of cases where antipsychotics were prescribed specifically for the management of Personality Disorder a rationale was given. Predominantly they were prescribed to reduce mood instability and impulsivity, and to aid sleep. Furthermore, none of the rationales given was in line with NICE recommendation.

Only 3.8% (5/21) of those prescribed antipsychotics were given a written information about antipsychotic effectiveness in PD and a plan to reduce antipsychotic medication was documented in only 28.57% (6/21).

A comorbid diagnosis was present in 62.5% (25/40) of the patients and the most common one was complex PTSD. The frequency of antipsychotic prescription was higher in those with a comorbid diagnosis (57.1%) and 42.8% in those without a comorbid diagnosis. However, there were differences in comorbidities present for patients prescribed antipsychotics as compared with those not prescribed antipsychotics. Those on antipsychotics tended to have comorbid diagnoses on the psychosis, bipolar spectrum disorders and PTSD whereas those not on an antipsychotic tended to be on the depressive or anxiety spectrum.

The other psychotropic medications used were antidepressants and benzodiazepines.

In general, the frequency of prescribing antipsychotic medication to patients with personality disorder in the community mental health teams across Cumbria (52.5%) appears to be lower than the national average (57%). However, the prescriptions did not meet the requirements set out by the NICE guidelines. A significant gap between the recommendations and practice was identified.

In 38% of cases, in which antipsychotics had been prescribed specifically for personality disorder there was a rationale given. Even when a rationale was given it was to treat intrinsic features of Personality disorder which is contrary to what NICE recommends. Only 3.8% of prescriptions were supported with written information on the efficacy of antipsychotics in personality disorder.

To assess compliance with the standards set in the Royal College of Psychiatrists (2021) Position Statement PS05/21: Stopping the overprescribing of people with ASC and Intellectual disability (STOMP) within the Child and Adolescent Mental Health Services (CAMHS) in Warrington, and Mersey Care Consent to Examination and Treatment Policy SD06

A retrospective analysis of the electronic record of children and young persons (CYPs) having a diagnosis of either ASC, attention-deficit/hyperactivity disorder (ADHD), or both, and taking psychotropic medication while actively receiving care at Alders Warrington CAMHS between 1st May 2023 and 31st May 2023, was performed. The audit sample included 18 CYPs meeting the criteria, and we conducted the audit against 14 Compliance standards.

18 CYPs were included in the audit. 10 (55%) had a comorbid diagnosis of anxiety disorder, depression, or both, while eight (45%) had OCD, OCD Traits or Tic disorder. Four CYPs (22%) had challenging behaviour, including self-injurious behaviour in one of them. Although 17 (95%) of the CYPs had a mental disorder, the clinical indication for the psychotropic medication, which was documented for all patients, was also for behavioural problems viz challenging behaviour, and self-injurious behaviour, for 3 (17%) CYPs. For one patient (6%), there was no behavioural support plan (BSP), before the commencement of psychotropic medication. Three patients were prescribed psychotropic medication for behavioural problems. Two of the three patients with challenging behaviour had already commenced psychotropic medication before referral to the locality. All eligible patients had an initial multi-disciplinary team (MDT) meeting before prescription and routine 3-monthly reviews for efficacy and side effects. In all the cases, a specialist prescriber prescribed medication, and mental capacity was assessed and documented. Where necessary, a decision was taken in the patient's best interest. The service met all other requirements for compliance with standards set in the RCPsych position statement except for three criteria.

Overall compliance with STOMP guidelines at the Alders Warrington CAMHS was 98%, with Significant Assurance. Dissemination of good practices and an early re-audit is strongly recommended.

To improve the quality of care received by service users of Electroconvulsive Therapy (ECT) treatment in Lincolnshire Partnership Foundation Trust (LPFT) by measuring the compliance of the local ECT clinic in Lincolnshire in accordance with National Institute of clinical excellence guidance and ECT accreditation services standards.

Pre-audit work up includes consultations with ECT clinic lead and stake holders to ensure ethical and governance standard are met. This audit is conducted with the permission of trust quality and safety team.

Sample population is identified from ECT clinic registry, Lincoln. A total of 10 patients who received ECT treatment between January 2023 and August 2023 are included regardless whether the necessary information is available on the clinical system or not, to minimise selection bias. Retrospective data collection by using Rio electronic case records. Descriptive analysis of data using Microsoft Excel and evaluation of results is based on 3 key domains such as indication, consent process and monitoring.

A total of 10 service users, comprising 30% males and 70% females, underwent treatment in both inpatient (80%) and outpatient (20%) settings, primarily for severe depressive illness. In 70% of cases, a pre-ECT assessment was documented to evaluate potential risks and benefits. The consent procedure was completed by a psychiatrist in 70% of instances. However, ongoing consent was not consistently reviewed at each ECT treatment.

Baseline monitoring using the Clinical Global Impression and Comprehensive Psychopathological Rating Scale was conducted in 20% of cases, with no follow-up assessments performed after each treatment. The Montgomery–Åsberg Depression Rating Scale was employed at baseline for 40% of patients, yet there was no evidence of weekly monitoring. While the Montreal Cognitive Assessment was administered to all patients at baseline, it was not conducted after every four treatments.

Post-ECT follow-up data revealed that less than a quarter of patients underwent clinician reviews. Validated rating scales were utilized in no more than a fifth of patients at both one week and two months after treatment.

The findings suggest the need for improved documentation of the entire consent process and in regularly assessing the ongoing validity of consent. Moreover, there is a need for stronger monitoring at baseline, during, and after ECT treatment. It is recommended to revise the local ECT record pathway by December 2023, with a follow-up re-audit scheduled for March 2024 to evaluate the effectiveness of the implemented changes.

DVLA guidance is very clear about patients not driving during or shortly after episodes of acute mental illness. There is an obligation for patients to inform the DVLA if they are unwell. The obligation for doctors to inform the DVLA if the patient chooses not to, and continues to drive when they should not, is also well known.

This audit aims:

1. 1. To identify the number of patients whose driving status was recorded following their admission to an acute psychiatric ward.

2. 2. To identify the number of patients discharged with correct DVLA compliant advice.

3. 3. To identify the number of patients whose notes reflected correct driving status information on discharge.

Patient ward notes and discharge summary documents relating to their admission on to the PICU ward were examined retrospectively for recorded evidence of patient's driving status and any documented DVLA advice given. Patients admitted from November 2022 and April 2023 were reviewed. 68 patients were identified and systematic sampling techniques identified a sample of 30 patients.

Keyword search included “Driving”, “License”, “Car”, “Driving license”, “DVLA”.

30 patients were reviewed in total.

40% of sample patients had no driving status recorded on their notes.

Of the 60% of sample patients who were confirmed to be driving/held license, nearly half (47%) had no recorded advice documented regarding the DVLA or driving after an acute MH illness on discharge.

A third (33%) of sample patients were recorded as having been given generic advice regarding driving only.

Only 20% of sample patients recorded to be driving, were documented as having been given correct advice as per DVLA guidance on discharge.

This audit demonstrated that driving status is currently poorly recorded in patients admitted to PICU and documentation of correct DVLA-compliant driving advice being given on discharge to relevant patients is also poor. Patients may not be receiving important information that they need.

Providing correct and accurate advice to patients regarding the DVLA rules and psychiatric illness should be part of a safe and robust discharge plan, and forms part of the clinical teams obligations to the patient. Identifying patients as drivers and improved documentation of driving status and evidencing appropriate advice being given is key.

A number of interventions were implemented and a re-audit will be undertaken in Spring 2024. If successful at improving rates of DVLA compliant advice being given, it would be hoped these interventions could be shared across the trust.

According to The Medicines and Healthcare products Regulatory Agency (MHRA) Drug safety update in August 2020 regarding clozapine, monitoring blood clozapine levels for toxicity is now advised in certain clinical situations such as when a patient stops smoking or changes to e-cigarette.

Aim of this audit was to determine whether blood clozapine levels are being performed in patients on clozapine when there has been a change in patient’s smoking status from two localities, East and West Hull community mental health team.

Because there is a risk of significant blood clozapine change within 3–5 days post starting or stopping smoking which consequently increases the risk of toxicity, we also looked at whether a medical review was undertaken post change in smoking status in order to review if any adjustment was required in current clozapine dose.

A list of Hull CMHT patients on clozapine was obtained from local clozapine clinic. The data comprised patients who were on clozapine from both localities of CMHT between October 2022 to October 2023.

Data was obtained retrospectively from Trust's patient electronic record system.

Eligibility criteria was set for the patient on clozapine to be a current smoker, or have been a smoker over last 12 months. Non-smokers and the ones on clozapine without a change in smoking status over the duration period were excluded.

58 patients were identified to be smokers and taking clozapine. Change in smoking status was documented in 21 instances, and therefore included in final analysis of results.

42.86% patients had a clozapine blood level check post smoking status change.

19% of patients from our sample had a medical review after change in smoking status within the duration time of audit.

We concluded that compliance with current MHRA guidelines in relation to blood clozapine levels and change in smoking status is quite poor in Hull CMHT and measures are needed for improvement.

We recommend that every patient with a change in smoking status must have blood clozapine level checked within a week of any change in smoking status and a medical review in two weeks. We identified some scope of improving current clozapine monitoring form on electronic system and recommend changes by adding a section where change in smoking status is recorded.

Maintaining a healthy lifestyle plays a vital role in the prevention and management of many mental conditions. There is also evidence that these patients have a lesser standard of health promotion and physical care and despite national awareness and guidelines early mortality rates have not improved.

The aim of this audit cycle was to firstly establish whether lifestyle interventions are being offered to patients (in a Home Treatment Team) and secondly how could this be further improved. A patient-led lifestyle intervention was introduced whereby the aim was to help patients feel empowered by being able to select an area of lifestyle they would like to improve. A coaching style framework was used and the patient was assisted in setting a lifestyle related goal to help with their mental health recovery.

An audit was carried out on 20 Physical Health Forms in January 2023 looking at the documentation of lifestyle interventions offered in the following lifestyle domains: smoking, alcohol, substance misuse, diet, exercise and the measuring of waist circumference and weight. This is a form that is usually completed by Psychiatric nurses based in the Worcester South Home Treatment Team during initial patient assessments.

The audit showed low levels of interventions offered to patients for lifestyle domains and therefore staff education on the importance of lifestyle and the importance of measuring waist circumference was delivered within a team meeting setting. A patient led lifestyle questionnaire was also initiated. After implementing this for 3 months, a re-audit was completed of 20 physical health forms in May 2023.

The re-audit results showed an increase in lifestyle interventions offered to patients in all lifestyle domains. There was a 30% increase in patients being offered interventions in exercise, a 40% increase in patients being offered interventions in diet, 20% increase in patients having waist circumference measured, 5% increase in patients being offered substance misuse interventions, 10% increase in patients being offered interventions for alcohol misuse and a 30% increase in patients being offered interventions for smoking.

There is growing evidence that by addressing lifestyle factors we can improve overall patient care outcomes by raising awareness and including lifestyle modification to be a part of the treatment plan. Using a coaching framework can be an effective part of the management plan by helping patients to feel empowered and future focused to improve their lifestyle and therefore their own health.

Ireland's Mental Health Act 2001 (MHA) outlines the procedure and criteria for referring patients for involuntary admission. After consultant psychiatrist examination, if appropriate, a referred individual is admitted involuntarily under an admission order (AO). Involuntary admission is only appropriate if the person meets criteria for a “Mental Disorder”. It's unlawful to detain a person solely because they suffer from personality disorder, are socially deviant, or are addicted to drugs/intoxicants. AOs aren't completed if these criteria aren't met, referral forms are incorrect, or individuals agree to voluntary admission. We aimed to determine (1) the rate of unsuccessful referrals for involuntary admission to an Irish approved centre (Lakeview Unit) during 2019 and 2021, (2) the reasons AOs weren't completed, (3) the source of unsuccessful referrals and (4) the time such referrals were made.

Unsuccessful referrals for involuntary admission during 2019 and 2021 were identified. Data were collected retrospectively by chart review. We identified the documented reason AOs were not completed, and the time and source of these unsuccessful referrals. In March 2021, authors delivered teaching on appropriate use of the MHA to local Police (Gardaí) and out-of-hours General Practitioners (GPs).

Of 78 referrals for involuntary admission in 2019 and 115 in 2021, 19% and 44% respectively were unsuccessful (AO not signed). In 60% of unsuccessful referrals in 2019, the person presented with no mental disorder meeting criteria for involuntary detention. The same figure in 2021 was 27%. Individuals presented with substance misuse disorder in 73% and 27% of unsuccessful referrals in 2019 and 2021 respectively. In 2019, 93% of unsuccessful referrals came from Gardaí, 100% came from medical practitioners other than the patient's own GP and 73% came outside of normal working hours.

Unsuccessful referrals for involuntary admission are not uncommon. Audit cycle 1 highlighted that those subject to unsuccessful referrals frequently present out-of-hours, with substance misuse disorder and/or no mental disorder meeting criteria for involuntary admission. In 2021 a smaller proportion of unsuccessful referrals presented with no mental disorder and substance misuse disorder. This suggests that Gardaí/GP education offered benefit. We observed an increase in both the overall number of referrals and the percentage of unsuccessful referrals in 2021. This possibly reflects an impact of the COVID-19 pandemic. There is a need for ongoing education, discussion and feedback with Gardaí and GPs on the process of making referrals for involuntary admission. A limitation is that separate registrars completed each audit cycle.

The aim of the audit is to measure the performance of Bradford District Care Trust (BDCT) against the NICE guideline's quality standard: ‘Adults with schizophrenia that has not responded adequately to treatment with at least 2 antipsychotic drugs are offered clozapine.’

We identified the 273 patients prescribed clozapine in BDCT as of January 2023. 202 had been prescribed clozapine for more than 5 years and these were excluded. Of the remaining 71, 34 were excluded for reasons such as their diagnosis i.e. Parkinson's or personality disorder or inadequate information within the clinical record. The final sample consisted of 37 patients prescribed clozapine within the last 5 years with a diagnosis of treatment resistant schizophrenia (TRS).

To define an ‘adequate trial’ of an antipsychotic, an adequate duration and adequate dose was determined. It is widely recommended in literature that an adequate trial of antipsychotic should last at least 6 weeks and this time constraint was utilised for the audit. The Maudsley Guidelines minimum effective dose table was utilised for establishing adequate doses. For antipsychotics not included in this list the British National Formulary (BNF) maintenance doses were used. A data collection tool was then developed that allowed for retrospective collection of key information relating to the objectives outlined above.

Clozapine was offered at the appropriate time [this includes where clozapine was considered but was not felt to be suitable/was contraindicated/declined by the patient] in 13 cases (35%). In 24 cases (65%) clozapine was not offered at the appropriate time. For 21 patients there was a delay in offering clozapine after 2 adequate trials of antipsychotic medication had been given. Delays ranged between 9 days and 15 years, with the average [mean] delay being 3.7 years. There were 3 patients who were initiated on clozapine without the completion of 2 adequate trials of other antipsychotic medication.

In summary, this audit measured BDCT's adherence to the NICE guideline on clozapine for TRS. Of the 37 patients in the final sample, 35% received clozapine at the appropriate time, while 57% experienced delays with an average delay of 3.7 years. Notably, 8% commenced clozapine without completing the recommended antipsychotic trials. These results emphasize the importance of improving adherence to the guideline, as delays in offering clozapine pose potential risks for patients with TRS. Ensuring timely access to this treatment is crucial, as it has the potential to significantly enhance patient outcomes.