Aims: This audit aims to assess the prescribing practices of benzodiazepines and hypnotics within the Heddfan inpatient psychiatric unit. These medications are effective in managing acute anxiety, agitation, and insomnia; however, they carry significant risks, including dependency, cognitive impairment, and an increased likelihood of falls.

This audit seeks to identify prescribing patterns, evaluate compliance with established guidelines, and suggest recommendations to enhance clinical usage, in light of the significant prevalence of their use and misuse as indicated by recent data.

The aims are as follows:

1. Evaluate the prevalence and patterns of benzodiazepine and hypnotic prescribing in psychiatric inpatient settings.

2. Assess adherence to national guidelines, including treatment duration and dosage limits.

3. Identify factors contributing to misuse or overprescribing, such as prolonged PRN use or multiple concomitant prescriptions.

4. Provide evidence-based recommendations to enhance patient safety and prescribing practices.

Methods: The audit will involve a retrospective review of medical records over a month in the Heddfan Psychiatric Unit. Data will be collected and analysed to evaluate prescribing patterns, including:

Frequency of benzodiazepine and hypnotic prescriptions.

Duration and dosages of treatment.

Documentation of prescribing rationale and adherence to guidelines.

Data Collection: The following data points were collected:

Patient demographics (age, gender, diagnosis, and length of stay).

Type of benzodiazepine or hypnotic prescribed (e.g. lorazepam, zolpidem).

Dosage and duration of each prescription.

Indication for use (e.g. agitation, insomnia, anxiety).

Use of multiple benzodiazepines or hypnotics simultaneously.

Adverse events reported during treatment (e.g. falls, agitation).

Discharge plans, including tapering schedules or withdrawal strategies.

Results: Of the total sample observed, out of the 40 patients, 38 were prescribed PRN benzodiazepines. The indication was agitation in about 18 and anxiety in the other 20.

Most patients studied were commenced on lorazepam (35 of 38; 92%) while the rest received diazepam (3 of 38).

Out of the 38 patients, only 12 were reviewed for PRN medication in a week. Only one patient had their PRN medicines stopped while exactly half continued receiving PRN benzodiazepine for more than 3 weeks. 28 patients out of 38 were written up for a maximum dose of up to 4 mg per day. 2 patients received 8 mg and one patient received 15 mg diazepam.

50% (20) of patients received zopiclone as a secondary sedative of which 66% (8) continued for 3 weeks or more than 3 weeks.

Of the total 20 patients, 3 (15%) were on regular benzodiazepine of which 2 received diazepam and 1 received zopiclone.

The most common concurrent antidepressant prescribed was sertraline, closely followed by mirtazapine. Among antipsychotics, there was an equal prescription of regular olanzapine, quetiapine and aripiprazole.

Of the total sample, 27.5% (11 patients) were already on regular benzodiazepine, of which 4 were receiving diazepam, followed by 3 receiving temazepam and 1 was on clonazepam.

Conclusion: Our recommendations from this audit are as follows:

Enhanced training for prescribers on guideline adherence.

Increased involvement of pharmacists in monitoring and auditing prescriptions.

Development of standardized protocols for prescribing and tapering benzodiazepines and hypnotics.

Promotion of non-pharmacological alternatives to manage agitation and insomnia.

We will be liaising with the pharmacist to generate a protocol for weekly reviews during ward rounds and to make a protocol for reducing PRN medications and stopping them, both while in the inpatient unit and at discharge.

Aims: The National Institute for Health and Care Excellence (NICE) recommends that individuals aged 18–25 or those at increased risk of suicide should be reviewed within one week of initiating or increasing a selective serotonin reuptake inhibitor (SSRI) dose. This study aimed to assess compliance with these guidelines in primary care, identify barriers to timely reviews, and evaluate changes following a previous audit.

Methods: A retrospective review was conducted using SystmOne to identify patients aged 18–25 who started an SSRI between 1 December 2023 and 15 July 2024 in a Nottingham GP surgery. Data collected included the time from SSRI initiation to a booked and completed review, as well as instances of non-attendance (DNA). Findings were compared with a prior audit (1 August–24 November 2023) to assess improvements and ongoing challenges. Following the first audit cycle, results were shared and discussed within the practice, prompting greater awareness from all members of the multidisciplinary team (MDT) upon current guidance and performance.

Results: In the initial audit, none of the 21 eligible patients had a review booked within one week, with an average booking time of 20 days and 30 days to an actual review. In the re-audit, 36 eligible patients were identified, with a slight improvement in booking time (19 days) and review completion (23 days). Three patients (8.3%) had a review scheduled within the recommended one-week timeframe.

The main barrier remained appointment availability, with a shortage of GP slots limiting one-week follow-ups. High DNA rates persisted, with 14 patients missing their reviews in the re-audit. No standardised approach to DNAs was implemented, with some patients receiving multiple recall attempts and medication re-issues, while others had no further action documented.

Conclusion: Over this one-year period, noticeable improvements were observed in both booked and actual SSRI review times. However, most patients still did not receive a timely review. Limited appointment availability and inconsistent follow-up for DNAs remained significant challenges. Expanding the role of other healthcare professionals, such as pharmacists, to conduct initial medication reviews could improve guideline compliance and reduce GP workload. Establishing a standardised protocol for DNAs, ensuring a set emergency medication supply and a timely follow-up, is essential to improving patient safety and treatment outcomes.

Aims: To identify any patients on OST who have not been offered or received naloxone.

To improve documentation of naloxone provision.

To explore reasons why clients have declined naloxone.

The standard audited against was that 100% of clients prescribed OST should be offered naloxone. This is advised in the Department of Health publication “Drug misuse and dependence, UK guidelines on clinical management”, which advises services should be “offering all opiate users in the community access to a take-home supply of naloxone with instructions on its use”.

CGL is a charity which provides medical and psychosocial support for people who are affected by alcohol and drugs. As of January 2025, they prescribe Opiate Substitute Treatment (OST), typically a formulation of methadone or buprenorphine, to 748 clients in East Sussex. Naloxone is an opioid antagonist which can reverse the effects of opiate overdose, and is offered to service users to reduce mortality from overdose.

Methods: It was recorded for each of the 748 clients whether they had been offered naloxone and training, and whether they had accepted. The data were collected from the CGL County-wide Opiate report in January 2025, and cross-referenced with a manual review of notes on Criis, the electronic clinical notes platform used by CGL.

Results: Of the 748 clients prescribed OST, 65 total clients did not have naloxone (8.7%), while 60 had expired naloxone. 54 clients did not have naloxone documented in the opiate report, but on a manual review of notes it was confirmed to have been given, but the dispensing form had not been completed on Criis. Of the 65 clients without naloxone, 100% had been offered naloxone and had declined.

Conclusion: The manual review of notes showed that naloxone uptake was better than the opiate report suggested, due to a lack of coding. Most commonly, this was a result of clients already having naloxone from another service or from earlier course of treatment. A potential barrier is the data entry required – if a client was dispensed from another location, it must also be confirmed by the keyworker and manually entered into a form on Criis.

The keyworkers of those clients with expired naloxone were informed, to arrange suitable follow-up.

The most common reason for declining naloxone was that the client was no longer injecting, and had no contacts who used opiates (57%). Also mentioned was the stigma of carrying naloxone, and the fear that others would assume they had relapsed.

Aims: This audit aims to assess adherence to the ‘CRAMS’ criteria in clinical records for patients on a blended low/medium secure women’s forensic ward. In response to feedback from a CQC Mental Health Act Review that some daily entries in patient notes included insufficient detail to properly inform decisions on care (particularly with regard to qualitative information regarding leave), the service adopted the CRAMS criteria for these entries, which specify that information on 11 points relating to care plan, risk, activity, mental state, and Section 17 leave should be included.

Methods: Data were collected from daily electronic patient record entries for ten randomly selected patients on two different weeks – in total 140 entries were examined in this initial sample. Each of these entries was assessed to determine if it contained each of the 11 aspects of the CRAMS criteria.

Following the initial data collection, findings were disseminated and discussed with the team, an information sheet was produced, and CRAMS was discussed at daily team huddles with the aim of improving adherence. A further sample of 140 records was examined a year following the initial cycle, using the same methodology.

Results: The initial cycle of the audit found that from the 140 clinical note entries that were examined, a total of 814/1540 (52.9%) of CRAMS criteria were met. This included:

212/420 (50.5%) criteria pertaining to care planning.

99/140 (70.7%) criteria pertaining to risk.

153/280 (54.6%) criteria pertaining to activity undertaken.

209/420 (49.8%) criteria pertaining to mental state.

141/280 (50.3%) criteria pertaining to S17 leave.

The second cycle of the audit found that a total of 1120/1540 (71.6%) of CRAMS criteria were met. This included:

305/420 (72.6%) criteria pertaining to care planning.

105/140 (75.0%) criteria pertaining to risk.

198/280 (70.7%) criteria pertaining to activity undertaken.

296/420 (70.5%) criteria pertaining to mental state.

198/280 (70.7%) criteria pertaining to S17 leave.

Conclusion: The audit showed a significant improvement in adherence to the CRAMS criteria following the action plan enacted following the initial cycle. However, there were still numerous entries in which the full CRAMS criteria were not met. The ward team continues to discuss CRAMS as part of morning briefings to sustain and build upon this improvement, and the adoption of an electronic template to help further build on this once the Trust moves to a new electronic patient record system has been discussed.

Aims: To ensure adequate availability and stocking of benzodiazepines on the wards for management of status epilepticus.

To ensure ward staff can locate treatment for status epilepticus during a medical emergency.

To ensure current ward staff are up to date with local ALS guidelines on status epilepticus.

Methods: Three general adult wards, two old age wards, and one intensive psychiatric care unit were audited. Two cardiac arrest packs were also audited as these are part of the cardiac arrest team protocol in Woodland View Hospital. Ward and pack audits occurred at random, and wards were not informed prior. Each ward was checked for medication availability, dosage available and expiration date.

Benzodiazepines were checked for as per the ALS guidelines; this included lorazepam, diazepam, and midazolam. These preparations were intravenous lorazepam 2–4 mg, rectal diazepam 10 mg, and buccal midazolam 10 mg.

Following the first cycle of data collection, a questionnaire was distributed to the ward team to identify gaps in ward knowledge of benzodiazepine location on the ward and status epilepticus management.

The intervention was a teaching session which was held with the ward staff to help improve staff confidence with identifying status epilepticus, medications, as well as timely management of seizures on the wards.

A second cycle of data collection and questionnaires was completed.

Results: The results showed that intravenous medications (lorazepam) are not regularly supplied at Woodland View. This was due to lack of IV training amongst the nursing staff.

All wards (100%) were adequately stocked with a supply of rectal diazepam which was the correct dose and in date. Buccal midazolam was only available in two (33%) of the six wards audited. The emergency packs had two preparation options of either midazolam or diazepam which were both in date with the correct dosing.

Following the intervention of staff education, ward staff self-reported that they felt more comfortable with identifying a seizure and locating medications in a timely fashion. There was a 50% self-reported improvement in staff’s ability to identify the medications required for seizure management and a 19.5% self-reported improvement in staff’s confidence of locating medications.

Conclusion: This audit demonstrated that first-line benzodiazepines for the treatment of status epilepticus are available on all wards in at least one preparation. It highlighted the need for staff education about these preparations and their location on the wards. Staff self-reported an improvement in their confidence and knowledge of status epilepticus following the intervention.

Aims: Writing a prescription is an essential task in wards for optimal management of patients. Errors in prescription writing can lead to discrepancy in patient’s care. The aim of this audit is to identify errors in prescription writing in wards, communicate them to the staff for improving standard and quality of care, making sure the provision of adequate medication to the patient.

Methods: The study, conducted in early 2023 at a tertiary care hospital in Faisalabad, assessed prescription writing quality through a baseline audit, a faculty-led workshop intervention, and a re-audit after three months. Two team members evaluated randomly selected prescription cards using an audit tool. Results, discussed in a departmental meeting, revealed unsatisfactory standards. In response, mandatory teaching sessions addressed issues like inconsistent expectations, time management, and resident education gaps. Residents were trained on proper prescription documentation and its clinical importance. A follow-up audit showed improvements, highlighting the effectiveness of targeted educational interventions.

Results: Prescription charts of patients admitted in psychiatry ward were analysed, which included 156 charts and added up to a total of 624 drug prescriptions in the initial audit which showed severe discrepancies in writing of important parameters. A re-audit was done several months later in which inpatient charts of patients admitted in psychiatry ward were checked, including 200 charts with total 650 prescriptions which indicated positive response from staff resulting in much improvement in writing adequate prescriptions according to defined parameters.

Conclusion: This audit suggests the importance of improving prescription writing as 1st audit indicated many errors in prescription writing including missing medicine dosage, frequency or strengths and starting/ending dates of medicines. However in re-audit many improvements were noted in prescription writing in all the highlighted areas. Prescribing errors can be effectively prevented by better education and training of prescribing staff, appropriate task and role definitions, proper supervision and teamwork. After writing a prescription, success of the treatment should be reviewed and proper arrangements must be in place for future review and monitoring.

Aims: The aim of this audit was to ascertain the number of patients prescribed valproate who underwent pre-prescription evaluation and ongoing treatment monitoring was in alignment with NICE guidelines.

Methods: The study, conducted in early 2024 at a tertiary care hospital in Faisalabad, involved 18 bipolar affective disorder patients (12 male, 6 female) prescribed valproate. A baseline audit was followed by an intervention – a faculty-led presentation on monitoring guidelines – and a re-audit three months later. Data from patient files (1–30 April) was reviewed using an audit tool to assess compliance with NICE standards. Initial findings revealed unsatisfactory monitoring. Results were discussed in a departmental meeting, leading to targeted training for residents. The re-audit showed significant improvement in monitoring practices, demonstrating the effectiveness of the intervention.

Results: The initial audit revealed that only 3 out of 18 patients (16%) had baseline weight measurements, and 6 (33%) had full blood count and liver function tests during treatment. A re-audit conducted months later reviewed 25 patient charts, showing marked improvement: 20 patients (80%) had baseline weight checked, and 18 (72%) underwent recommended blood tests during treatment. These findings indicate a positive staff response and significant progress in adhering to monitoring guidelines for patients on valproate.

Conclusion: This audit underscores the critical need for comprehensive monitoring in patients prescribed valproate. The drug is associated with increased risks of insulin resistance, obesity, Type II diabetes, and cardiovascular complications. Valproate also impacts haematopoietic homeostasis, inhibiting erythroid differentiation and activating the myelo-monocytic pathway, leading to thrombocytopenia manifesting as prolonged bleeding, platelet abnormalities, or petechial bleeding. Hepatotoxicity ranges from mild ALT elevation to severe liver injury, including jaundice, hepatic dysfunction, coma, or death. Rigorous monitoring of these parameters is vital for mitigating risks, enhancing patient safety, and improving quality of care through effective primary prevention strategies.

In conclusion, this audit highlights the critical importance of adhering to NICE guidelines for valproate monitoring to ensure patient safety and minimize potential adverse effects. The significant improvement observed in the re-audit demonstrates the effectiveness of targeted educational interventions, underscoring the need for ongoing staff training and regular audits to maintain compliance and enhance patient care.

Aims: The aim of the audit was to ensure that the referral practices and assessment methods of patients who received ECT were carried out and documented as per the NICE guidelines.

Methods: Study was carried out at Allied Hospital 2, Faisalabad Medical University, Faisalabad. Data was collected from May 2023 to October 2023. Study includes all the inpatients referred for ECT during a 6-month period from May 2023 to October 2023. The data was collected by examination of the patient’s notes to establish the adherence to all 9 standards required by NICE guidance.

Results: Total number of patients was 47 (24 females and 23 males) the results show that ECT guidelines were followed and 100% compliance was achieved in all standards except one. Assessment of cognitive functions, 44 patients (86.3%) were assessed for their cognitive functions before the course of treatment but only 29 patients (56.9%) were assessed after the course.

Conclusion: The adherence to referral and consent standards was excellent; however, greater attention is needed in the implementation and documentation of cognitive assessments before, during, and after treatment. This is particularly important due to the high incidence of cognitive dysfunction observed following ECT administration.

Aims: The aim of this audit was to analyse the prescribing trends of promazine in secondary care within a psychiatry department, to evaluate adherence to current guidelines and best practices for promazine prescribing in secondary care and identify potential areas for improvement in prescribing practices to enhance patient care and safety.

Promazine is a phenothiazine-type, first generation (typical) antipsychotic with relatively weak antipsychotic activity making it less effective in treating psychotic disorders but with pronounced sedative effects. It is licensed for short term adjunctive management of psychomotor agitation, and for agitation and restlessness in the elderly. Promazine is highly sedative, has anticholinergic activity, hypotensive effect and can prolong QTc (Corrected QT Interval) at therapeutic doses. Promazine is not endorsed in any recent guidelines for management of agitation e.g. NICE (National Institute for Health and Care Excellence) or BAP (British Association for Psychopharmacology). The BNF (British National Formulary) marks it as a drug considered to be “less suitable for prescribing”.

Despite this, prescribing data suggests it is still being used widely in some areas, particularly in Bury and the North West.

Methods: A retrospective review of clinic letters from January 2024 was conducted within the psychiatry outpatient department at Irwell Unit, Fairfield General Hospital. Patients prescribed promazine were identified, and data was collected on diagnosis, indication, duration of use, dose, physical health monitoring, and treatment reviews.

Results: Fifty-three patients were prescribed promazine. Of these, 73.6% had no documented indication for its use, and only 3.8% had a documented treatment duration. No patients were on promazine for four weeks or less, the recommended treatment duration. There was no record of review of promazine in a significant proportion (81.1%) of the patients identified. 22.6% had not received any annual physical health checks. Additionally, 41.5% of patients were prescribed promazine alongside another antipsychotic.

Conclusion: The audit highlights that promazine is widely being used in the outpatient department at Irwell Unit, Fairfield General Hospital. Its use is not currently in line with local or national guidelines. The findings support the need for improved prescribing protocols, clearer documentation, and regular medication reviews. Action points include increasing awareness through education, ensuring appropriate physical health monitoring, and reviewing all identified patients at their next clinic appointment. A re-audit is planned in six months to assess the impact of these interventions.

Aims: To measure the quality of care given to diabetic patients while admitted to a secure forensic setting. Across psychiatric services, individuals with a serious mental illness have higher rates of diabetes compared with the general population. Patients in forensic inpatient services often have long lengths of stay in hospital which should allow optimisation of diabetes management. We hypothesise that despite intervention, standards in diabetic management are not met.

Methods: The first cycle of a retrospective clinical audit was conducted across 5 secure wards at Ravenswood Medium and Low Secure Hospital. Results were collected from paper drug and insulin charts and electronic patient records. Audit standards were set using NICE guideline NG28, European Association for the Study of Diabetes, and Southern Health NHS Foundation Trust Guidelines. The following parameters were audited: Frequency of normal capillary blood sugars (CBG), frequency of blood sugar monitoring, management of hyperglycaemic episodes with short-acting insulin and ketone tests, HbA1c level currently and on admission. The initial audit of September 2024 showed significant underperformance. Following this we implemented feedback sessions of the audit findings with the multidisciplinary team to identify possible areas of improvement; information sessions to highlight monitoring guidelines, and dietary posters for patient areas. January 2025 was then reaudited.

Results: Of the original 18 patients, 2 had been discharged, and 16 were identified for the re-audit. Non-compliance with diabetic monitoring improved from 19% to 9%. The average number of attempted CBG measurements per day was 1.32 (previously 1.17, audit standard 2.31). On average, 31% of the CBG readings were in the target range (down from 39%, audit standard 70%). Following an episode of hyperglycaemia, novorapid was administered 68% of the time (previously 67%) and a ketone test was offered 37% of the time (previously 7%, audit standard 100%). Between audit cycles, 56% of patients had their diabetic care plan reviewed by a doctor and 25% of cases were discussed with diabetes specialist services.

Conclusion: Our targeted interventions have improved the frequency of monitoring and reduced patient non-compliance to monitoring in a secure setting. However, diabetic control has worsened, highlighting the complexity of the management of diabetes in this patient population. Increased monitoring may have identified poor diabetic control, highlighting room for further improvement. We propose that improved access to specialist diabetes advice and availability of healthier dietary choices for patients could improve diabetic management in the future.

Aims: To assess adherence to local prescribing guidelines for clonazepam, including indication appropriateness, consultant oversight, documentation of unlicensed medicine forms, weekly review compliance, and discontinuation planning before discharge.

Methods: A retrospective audit was conducted on the electronic records of 234 patients under the care of the Enhanced Team West (ETW) between July 2023 and August 2024. Using a keyword search for “clonazepam”, 20 patients were identified, with 16 meeting inclusion criteria. Data on demographics, indications, prescribing teams, consultant involvement, documentation of unlicensed medicine forms, review frequency, and discontinuation plans were collected and analysed.

Results: Indication compliance: 94% of prescriptions were for appropriate indications, predominantly agitation (56%) and anxiety (19%). No cases were for epilepsy.

Consultant oversight: 88% of prescriptions were initiated or approved by a consultant psychiatrist.

Unlicensed medicine form usage: Only 6% of cases had a completed unlicensed medicine form, despite trust guidelines mandating its use.

Review frequency: Weekly reviews were documented in 100% of cases, primarily through multidisciplinary team (MDT) meetings.

Discontinuation planning: 47% of patients had a documented plan to taper or discontinue clonazepam before discharge. Among those continued post-discharge, 89% had documented attempts at dose reduction in the community.

Conclusion: This audit highlights high compliance with appropriate indications and consultant oversight but identifies areas for improvement in documentation of unlicensed medicine forms and structured discontinuation planning. Given the risks associated with prolonged clonazepam use, enhancing adherence to trust guidelines on discontinuation strategies is essential. Recommendations include improved training on unlicensed medicine documentation, reinforced discharge planning protocols, and regular re-audits to monitor adherence and patient outcomes.

Aims: The audit aims to ensure compliance with the new sodium valproate guidelines published in November 2023, identify areas of deviation from the guidelines, and improve patient safety and outcomes by promoting adherence to best practices.

Methods: Data was collected from various sources, including patients’ case notes, GP records, and attachments like acknowledgment forms. Out of 519 service users, 68 were selected based on age (55 years or younger). These were divided into two groups: 42 new cases (system alert created on 2024) and 26 current cases (system alert created 2023). After reviewing and excluding duplicates, 3 new cases and 10 current cases were analysed. Case notes and GP records were examined for risk acknowledgement forms, LFT (liver function tests), and FBC (full blood count) results. It was noted that no case records specifically mentioned these tests as part of valproate initiation or monitoring.

Results: New Cases: Demographics: 2 males, 1 non-binary.

Testing: LFT and FBC were conducted in 67% of cases before initiation; 100% had LFTs within six months.

Forms & Settings: All had acknowledgement forms with specialist signatures; 2 initiated in inpatient and 1 in a community setting.

Discrepancy: 67% had mismatches between alert creation and medication start dates.

Current Cases: Demographics: 8 males, 2 females.

Testing: 60% had LFT and FBC tests before initiation; only 30% had LFTs within six months.

Annual Reviews: For females, annual acknowledgement forms were completed in one of two cases; both complied with the Pregnancy Prevention Programme (PPP).

Discrepancy: All cases had alert creation mismatches.

Conclusion: Good Practices:

Reduced new sodium valproate cases in 2024 (from 10 in 2023 to 3).

Universal completion of acknowledgement forms for new cases.

Adherence to PPP for females and avoidance of valproate initiation in females under 55.

Areas for Improvement:

Documentation and completion of LFT/FBC tests before and after initiation.

Timely creation and removal of alerts.

Clear record of initiation dates, reasons, and follow-up plans.

Mitigation Strategies:

Training healthcare professionals on guidelines and the importance of acknowledgement forms for all patients.

Ensuring accurate alert management.

Proper documentation in discharge plans for female patients.

Verification of recent LFTs and acknowledgement forms during reviews.

Aims: This audit highlights the well-documented disparity in life expectancy between individuals with severe mental illnesses, such as schizophrenia, and the general population, attributed in part to inadequate access to and engagement with healthcare services. Addressing this issue aligns with the Government’s commitment to achieving parity between physical and mental healthcare standards.

The audit aims to evaluate progress in physical health monitoring for patients, identify improvement areas, and assess practices against NICE and NCAP standards.

Methods: In January 2021, the team appointed a healthcare assistant to enhance physical health monitoring for patients with severe mental health conditions. An audit of 39 patients active between January 2023 and January 2024 reviewed electronic records, focusing on physical health results, case notes, and correspondence to assess outcomes.

Results: In 2021, 83% of patients had documented monitoring for HbA1c/RPG and lipids, with four documented refusals. By 2023, these rates improved to 100% (24/24) for both measures, although 15 patients refused monitoring. Family history documentation for diabetes, hypertension, and hyperlipidaemia showed significant progress, increasing from 0% in 2021 (10/10) to 100% in 2023 (25/25). For the period from January 2023 to January 2024, 100% of patients (39/39) were offered comprehensive physical health monitoring, maintaining the 2021–2022 rate. All cases documented tobacco, alcohol, and substance use clearly. Dietary and exercise advice remained consistent at 100% across both years. Notably, in 2023, 100% (3/3) of patients with diabetes and hypertension indications received intervention offers, while no patients required intervention for dyslipidaemia. Additionally, 100% of patients were offered smoking cessation and support for reducing alcohol and substance misuse, with refusals clearly documented.

Conclusion: The 2023 audit highlighted both challenges and progress in physical health monitoring. Although 15 patients declined HbA1c/RPG and lipid monitoring – an increase from 4 in 2021, this signals a need for improved patient engagement strategies, such as rapport-building and tailored education on monitoring benefits. Positively, documentation of family history for diabetes, hypertension, and hyperlipidaemia reached 100% in 2023, indicating effective recognition of familial risk factors. To further enhance documentation consistency, adding a dedicated family history section to the annual physical health check form is recommended. Overall, the audit shows significant progress, achieving 100% rates for key metrics and aligning with national standards. However, ongoing efforts are needed to engage patients who refuse interventions, ultimately improving outcomes and reducing health disparities among individuals with severe mental illnesses.

Aims: Two patients within an Older People’s Mental Health (OPMH) unit that had been transferred to the emergency department (ED) for physical health assessment were found to have returned without a handover or discharge letter. The discharge letters, received more than 48 hours later, revealed important interventions that were consequently delayed. This audit aimed to identify compliance with NICE Quality Standard QS174: adults admitted with a medical emergency and whose care is being transferred to a different healthcare setting have information about their condition and needs passed onto their new care provider.

Methods: A retrospective audit using online records from 30 patients admitted to a Doncaster OPMH unit between January–June 2024. Records were reviewed for key terms to identify patients with ED visits and then assessed for (a) handover documentation, (b) discharge letter availability, (c) actions required for the psychiatry ward, and (d) the nature and implementation of these actions.

Results: There were 20 individual ED reviews. 35% (n=7) had a documented handover to the OPMH unit at point of return (POR). 65% (n=13) had no evidence of a handover. Discharge letters were available on average 4 days (range 1–14 days) post-discharge. 5 reviews had no handover documentation or letter in the records and were followed up separately to this audit.

8 reviews resulted in actions for the ward. 7 required medication changes (antibiotics, anticoagulants, diuretics, beta blockers), 1 required patient isolation. Only one patient had evidence of a handover and subsequently their new medication was started without delay. The remaining patients received medication no longer indicated or missed doses of new medication. Patient isolation occurred with significant delay. Two reviews had a discharge letter at POR, the remaining had discharge letters available 2–8 days post-discharge.

Conclusion: The handover process between the ED and OPMH unit requires formalization. Current ambiguity has led to reliance on delayed discharge letters for follow up.

Verbal handovers may be happening but there remains an unexplained delay in actions until the discharge letter is received. There is also evidence that discharge letters have been received and not escalated. Further discussions are required to determine whether the primary issue lies with an absence of handovers or letters from the ED or internal communication and escalation within the OPMH unit.

Collaborative work to improve patient handovers is being undertaken with the ED and awareness has been raised within the trust to ensure proactive effort to obtain and escalate handovers.

Aims: This audit aimed to increase the use of the 4AT (4 A’s Test) within the Mental Health Liaison Team (MHLT) at Southend Hospital to enhance delirium awareness and recognition, thereby facilitating early discharge and improving patient outcomes. The 4AT is a validated and sensitive delirium detection tool, specifically designed for ease of clinical use, and supported by extensive diagnostic accuracy data from over 24 studies involving more than 5,000 observations. It is particularly useful as it can be administered to patients who are too sleepy or restless for traditional cognitive testing. Despite its advantages, compliance with 4AT documentation within the MHLT was initially low.

Methods: The audit was conducted in two cycles. The first cycle retrospectively reviewed patients aged 65 and over referred to the MHLT between 1 July 2023 and 30 September 2023. Out of 79 referrals, 66 patients were assessed, but only 5 (7.5%) had a documented 4AT score. To address this, interventions were implemented, including educational sessions for MHLT staff (doctors, nurses, and psychologists) on the use and benefits of the 4AT. Additionally, laminated 4AT tools were provided to staff as lanyard prompts to encourage use during assessments.

As aforementioned, not all referred patients were assessed by the MHLT. Some patients were discharged or, sadly, passed away prior to assessment, while others experienced worsening physical health conditions and were no longer fit for assessment. Additionally, some referrals only required medication advice, which did not warrant a full assessment.

Results: The second cycle evaluated data from 1 December 2023, to 29 February, 2024. Of 79 referrals, 64 patients were assessed, with 26 (40.6%) having a documented 4AT score, representing a nearly fivefold improvement in compliance. Despite this progress, further enhancements are needed to achieve consistent adherence.

Conclusion: The findings highlight the effectiveness of educational interventions and practical prompts in improving 4AT usage. Timely delirium identification is crucial for improving patient outcomes and facilitating early discharge, underscoring the importance of sustained efforts to integrate the 4AT into routine practice.

Recommendations include further staff education, integrating the 4AT into existing assessment forms, and conducting regular audits to ensure guideline adherence. This audit demonstrates the potential for improved delirium recognition and patient care through targeted interventions and ongoing monitoring. Future work can focus on expanding the use of the 4AT across the MHLT.

Aims: Valproate is widely prescribed for psychiatric conditions, particularly bipolar disorder, but carries significant teratogenic risks. The Medicines and Healthcare products Regulatory Agency (MHRA) mandates strict prescribing guidelines, particularly for women of childbearing potential, to mitigate these risks. Additionally, emerging evidence suggests potential risks for men, including infertility and neurodevelopmental concerns.

This audit aimed to assess adherence to MHRA guidelines within a Community Mental Health Team (CMHT), focusing on the documentation of risk discussions for all patients under 55 prescribed valproate, including discussions on infertility risks for men. It also evaluated the completion of risk acknowledgement forms for eligible patients and the enrolment of women of childbearing potential in the Pregnancy Prevention Programme (PPP). A secondary aim was to implement a targeted intervention and reassess compliance in a second audit cycle.

Methods: A retrospective review of electronic patient records was conducted for all patients under 55 prescribed valproate for psychiatric conditions at the CMHT. Patients with neurology-led prescriptions or aged over 55 were excluded. The first cycle, conducted in August 2024, included 22 patients (16 male, 6 female). Compliance with MHRA standards was assessed based on documented discussions, risk acknowledgement forms, and PPP enrolment. Following the first cycle, an intervention was introduced in the form of an email sent out to prescribers, emphasizing guideline adherence and areas for improvement. A second audit cycle was conducted in December 2024 to evaluate the impact of this intervention.

Results: The first audit cycle identified suboptimal compliance, particularly for male patients. Risk discussions were documented for all 6 female patients (100%) but only for 7 out of 16 male patients (43.75%). Risk acknowledgement forms were completed for 4 out of 6 female patients (66.67%). PPP enrolment was achieved in 3 out of 5 eligible female patients (60%).Following the email intervention, the second cycle demonstrated improvements. Risk discussions were documented for 9 out of 16 male patients (56.25%). Completion of risk acknowledgement forms improved to 5 out of 6 female patients (83.33%). PPP enrolment increased to 4 out of 5 eligible female patients (80%).

Conclusion: This audit highlights gaps in adherence to MHRA guidelines, particularly in documenting risk discussions for both male and female patients. The email intervention effectively improved compliance, but further efforts are needed. Future recommendations include electronic reminders in health records, and ongoing audits to ensure sustained adherence. Continuous clinician education is essential to enhance patient safety and regulatory compliance in valproate prescribing.

Aims: This audit serves to establish the practice in recent time, if patients admitted for alcohol detoxification, were examined physically and offered a cognitive assessment prior to discharge according to NICE guidelines and trust policy, as this will help to reduce missed opportunities for clients to receive effective interventions for co-morbidities.

If not, for necessary changes to be implemented in practice and a re-audit carried out.

Methods: The audit was conducted as a retrospective study. We aimed to analyse the records of all patients with alcohol dependence, discharged from Bridge House detoxification unit between July 2024 and October 2024.

National Health Service [NHS] number of all discharged patients between the time period was obtained from our Electronic Discharge Notification [EDN] system and used to access the Rio records, to check if patient was admitted for alcohol detoxification, if physical health examination was done following admission and if cognitive assessment was conducted prior to discharge.

An audit tool was used as reference for data collection, and data was analysed using Excel. In total 59 cases were analysed in this audit.

Results: The results showed that more men than women were managed in the inpatient detox unit within the time period, where 33.9% were female, with majority of service clients within working age range.

Physical health check and examination was done for almost all patients (98%). No clear reason stated why this was not done or documented for 1 patient. Cognitive assessment was done for only a few of the clients (7%) admitted to the unit. About 30% had cognitive assessment as part of management plan on initial admission review, but this was not actioned prior to discharge. 1 of the patients declined cognitive assessment when offered.

On average, patients spent about 14 days in the unit for alcohol detoxification.

Conclusion: Good practice was upheld by carrying out physical examinations on admission for almost all patients.

Cognitive assessment was not conducted for the majority of the patients prior to discharge and although this was planned on admission for some, the plan was not followed up or actioned prior to discharge. Local best practice is to conduct cognitive assessment as soon as patient is no longer under the influence of alcohol or high doses of benzodiazepines.

Aims: Service users not attending outpatient clinics without prior notification are considered as DNA. We intended to identify the factors contributing to DNA in ID patients, with a view to mitigate the risks and safeguarding concerns associated with it and also to assess staffcompliance with the Trust’s DNA policy.

Methods: Trust DNA policy states that “Ring patient after DNA, to check if the patient was aware of the appointment, and discuss the barriers of non attendance and then document accordingly.”

Using this policy as standard, we retrospectively evaluated the electronic patient notes who did not attend their appointments over the period of 2 months. Data regarding demographic details, diagnosis, neuropsychiatric comorbidities, social circumstances, treatment modalities and post DNA actions were collected.

Results: Out of the total 117 appointments over 2-month period, 35 (29%) patients didn’t attend scheduled appointment. 69% of these patients were males, 47% live with their family, 38% in residential settings, 13% in supported living and 3% live alone. The severity (mild, moderate or severe) of intellectual disability was distributed approximately equally comprising about one-third each, with 3% needing diagnostic formulation. 51% have co-morbid autism, 14% have epilepsy and another 14% have depression. Only 3% have comorbid psychotic illness. 91% are on regular psychotropics, 6% on as-required medication and 3% are receiving psychosocial interventions only.

In terms of post DNA actions, staff contacted 34% via telephone after the DNA, however no details aligned with the policy were being documented. No contact made for 57% of the patients, and for 9% there was no documentation on electronic progress notes. 83% were offered another appointment, 17% got discharged back to the care of GP.

Conclusion: Non-attendance at appointments is most significantly influenced by male gender, living with family and having neuropsychiatric comorbidity, which appeared as the dominant contributing factors. Compliance with the trust’s policy is below standard, recommendations were suggested to adapt DNA policy for this patient group and to increase awareness among divisional staff during the Induction programme.

Aims: Long-term administration of psychotropic medications can be associated with significant side effects and physical health problems. There is evidence that people with intellectual disability have overall poorer health than their non-disabled peers. Psychotropic medication prescribed must be reviewed regularly to avoid routine continuation. NICE Challenging behaviour and learning disabilities [NG11] recommends medication should be initiated by a specialist and they should record:

The rationale for medication and the likely length of treatment.

A written strategy for reviewing and stopping the medication that must be shared with non-specialist colleagues.

The Learning disability teams within Tees, Esk and Wear Valleys NHS Trust already have a STOMP pathway and Primary care liaison nurses. The audit aims to identify a good practice with promoting STOMP in psychiatric discharge letters to primary care.

Methods: The audit looked at psychiatric discharges from 4 adult learning disability teams between October 2022 to October 2023 using a standard audit tool informing above standards by NICE (NG11). The data was collected by 2 authors using an Excel sheet and analysed by the lead author.

Results: A total of 110 of the 153 patients were prescribed psychotropics and hence included in this audit. We found 81 patients were prescribed medication for other mental health diagnoses highlighting good practice with reduced use in challenging behaviour. 102 patients (92.7%) had a documented rationale for prescribing which identifies good practice. However, only 44 (40%) and 32 (29%) patients had a strategy for review of medication and timescale for stopping medication documented. This area of concern highlighted the importance to develop recommendations to change practice.

Conclusion: Overall, the audit revealed poorer score in relation to documenting a strategy to review and stop psychotropic medication. The recommendations identified include increasing awareness of STOMP, promoting involvement of STOMP team in review of medications, and amending our standard psychiatric discharge templates to include prompts for timescale to stop or review medication. We also plan to review the STOMP pathway to incorporate guidance for general practitioners for when to seek specialist advice.

We hope our recommendations will improve standards regarding STOMP and patient care. We will re-audit in 6 months’ time to record the progress with above recommendations.

Aims: To assess the current practice of rapid tranquillisation (RT) in acute inpatient psychiatric wards and compare this to trusts’ protocols.

To evaluate the adherence to NICE guidelines in the use of RT.

To provide recommendations for improving safety and adherence to local protocols in RT practices.

Methods: A retrospective audit of medical records from 2 acute inpatient wards during a three-month period in 2024.

Sample: We had a total of 237 administrations of RT, divided in between 16 patients. This total sample was then randomized, and we selected 99 RT administrations for data collection.

Data Collection: Review of patient records from a 3-month period (July–September 2024). We requested RT administration data from the trusts’ pharmacy team.

Key Indicators: We selected 18 key indicators which broadly belong to the following categories: Incident details, documentation, RT medication, patient characteristics and legal status.

Analysis: Descriptive and comparative analysis to identify trends, areas of non-compliance, and potential areas of improvement.

Results: Our data showed that in most cases (92%) there was a clear rationale recorded for using RT.

The majority of patients were under a section of the MHA (97%).

There was a record of oral medication offered prior to administration of RT in 68%.

Choice of RT medication was in line with the local TEWV RT guidelines in 75% of the cases. Lorazepam was the drug of choice in most of the cases.

In 80% of the cases, there was not adequate recording of post-RT observations, however we noted that in 57% of these cases there was a recorded refusal to have physical observations taken.

Conclusion: The audit revealed that while the use of rapid tranquillisation in acute inpatient wards is mostly in line with local protocols and NICE guidelines, however there are areas for improvement, particularly in documentation, post-RT monitoring, and adherence to RT protocols in terms of debriefing.

Recommendations for practice improvements include:

Ensure adherence to protocols to have consistent post-RT monitoring.

Regular audits to improve adherence to clinical guidelines.

By addressing these areas, we can improve patient safety, clinical outcomes, and staff confidence in the use of rapid tranquillisation in acute settings.