Aims: In child and adolescent psychiatry, particularly within Child and Adolescent Mental Health Services (CAMHS), monitoring the physical health of patients on ADHD medications is of paramount importance. Medications such as stimulants can have significant impacts on physiological processes, including cardiovascular health. This audit aims to assess current practices in monitoring physical parameters in children and adolescents prescribed ADHD medication at St Ann’s Hospital (Haringey), identify gaps in practice, and recommend improvements based on recent research.

Methods: Study design: Retrospective audit.

Sample: Medical records of children and adolescents diagnosed with ADHD and currently on medication.

Data Collection: Frequency and documentation of weight, height, blood pressure, and heart rate measurements over the past year.

Analysis: Descriptive statistics will be used to compare current practices against established standards.

Ethical considerations: Ensured patient confidentiality throughout the audit.

Literature review.

Results: Of the 50 clients reviewed:

46 clients had their blood pressure, pulse rate, height, and weight measured at every appointment.

2 clients were referred for shared care, impacting tracking of their monitoring.

1 client’s height was not checked at appointments, though other parameters were monitored.

1 client did not have blood pressure and pulse rate monitored during follow-up.

Conclusion: The audit highlighted significant adherence to monitoring standards but identified gaps in certain areas. Implementing the recommendations and maintaining a strong commitment to regular audits will enhance the quality of care provided to children and adolescents with ADHD in CAMHS. A re-audit will be planned to evaluate the impact of changes made from this audit.

Aims: PRN (pro re nata) medications are widely used in mental health settings but are prone to misuse and prescribing errors. A serious incident involving a patient’s death linked to excessive PRN medication supply prompted an initial audit to evaluate compliance with prescribing standards. A re-audit was conducted to assess progress and identify ongoing challenges.

Methods: Two prospective audits were conducted across an inpatient acute ward and a rehabilitation centre. The initial audit (29/07/2024–06/08/2024) and re-audit (29/01/2025–06/02/2025) reviewed medication cards, Rio (electronic patient notes) and EPMA (Electronic Prescribing and Medicines Administration) for 31 patients prescribed PRN medications. Compliance was assessed against 13 predefined standards, including generic naming, dose intervals, BNF compliance, and regular reviews.

Results: Sustained Full Compliance:

Both audits demonstrated 100% compliance in key areas: generic naming, specified administration routes, separate prescriptions for multiple routes, adherence to BNF limits, clear indications for use, and rewriting altered prescriptions.

Key Improvements:

Minimum dose interval specification improved from 64.5% to 93.5%.

Maximum dose documentation increased from 96.7% to 100%.

Regular ward round reviews rose dramatically from 3.2% to 64.5%.

Discontinuation of unused PRN medications (>1 month) improved from 0% to 22.2%.

Review of PRN medications used regularly (>72 hours) increased from 0% to 28.5%.

Documentation of regular vs. PRN use improved from 33.3% to 44.4%.

Ongoing challenges:

Review of PRN medications used regularly (>72 hours) remained low at 28.5%.

Discontinuation of unused PRN medications (>1 month) was only 22.2%.

Documentation of regular vs. PRN use remained below 50%.

Conclusion: The re-audit demonstrates significant progress in dose interval specification, maximum dose documentation, and ward round reviews. However, challenges persist in the regular review and discontinuation of PRN medications, as well as in documenting regular vs. PRN use. Continued focus on these areas is essential to ensure patient safety and adherence to best prescribing practices.

Recommendations:

Key recommendations include integrating PRN standards into doctor inductions, involving pharmacists in ward rounds, and conducting regular re-audits to monitor progress and sustain improvements. Disseminating guidelines and providing feedback to medical teams are essential steps toward achieving full compliance and enhancing patient safety.

Aims: Our audit aimed to assess the quality of care received by patients undergoing Electroconvulsive Therapy (ECT) treatment in one of the largest psychiatric hospitals in Pakistan. The current practices regarding the consent process, recording of vitals during ECT, and monitoring of clinical response and cognitive side effects were assessed. Adherence to guidelines set forth by the Royal College of Psychiatrists was examined.

Methods: In a retrospective analysis, a record of 31 patients who received ECT treatment between April 2024 and September 2024 was examined.

The aspects of consent process reviewed were:

Completion of consent form by the patient or carer.

Documentation of ongoing valid consent.

Right to withdraw consent.

The aspect of ECT administration process reviewed was the documentation of pulse, blood pressure and pulse oximetry readings.

The aspects of the monitoring process reviewed were:

Assessing and recording clinical response at baseline and between sessions.

The use of validated rating scales in assessing response.

Assessing and documenting cognitive side effects.

Results: Although the consent forms were completed by 100% of the patients or carers and ongoing valid consent was checked for all the patients before each ECT treatment, none of the patients were informed about the right to withdraw consent. The vital signs including the pulse, blood pressure and pulse oximetry readings were robustly documented before, during and after the administration of ECT. Unfortunately, no validated rating scale was used for assessing the symptomatic improvement during the course of ECT treatment, and the evaluation of improvement was solely based on the clinical judgement of the psychiatrist. With this reliance on clinical judgement, the clinical status of all the patients was assessed at baseline but the clinical response between each treatment session was assessed for only 45% of the patients. Regrettably, there was a lack of documentation regarding assessment and review of the cognitive side effects and no standardised cognitive assessment tool was used for this purpose.

Conclusion: This audit highlights several areas for improvement, including the failure to inform patients about the right to withdraw consent, irregular clinical evaluations, and the neglected use of standardised assessment tools for monitoring clinical response and cognitive side effects. We suggest updating the consent forms to include the right to withdraw consent. Culturally validated assessment tools should be designed for more structured and objective monitoring of clinical response and side effects. Finally, a re-audit should be scheduled in one year’s time to assess improvement.

Aims: To assess the antipsychotic burden and adherence to the Trust policy on HDAT and physical health monitoring for patients under the Liverpool Homeless Service.

Methods: Patient records were assessed for a three-month period between July to September 2024 to look at the antipsychotic burden for patients under the Liverpool Homeless Service. Sources of information included patient electronic records, and General Practitioner summaries. A two-stage process was then carried out depending on the HDAT calculations. For patients found to be HDAT, records were checked to measure the adherence to the protocol. Trust Protocol would require bloods and ECG to be done, followed by repeat tests at 3 and 6 months. For the rest of the patients on the caseload we assessed whether physical health monitoring had been done per policy. Trust policy on this was yearly Body Mass Index, full blood count, Liver function tests, Renal profile, HBA1C level, lipid profile, serum prolactin. Compliance to these standards was set at 100%. A total of 40 patients were included in this audit

Results: We found that 2.5% of the patients in the service were receiving HDAT. HDAT protocols were not followed for these patients. With regards to physical health monitoring 62.5% of the patients had received the stipulated yearly bloods tests. 55% had Body Mass Index done. Reasons given for non-compliance to these checks included lack of engagement from service users, lack of timely reviews. 77.5% of patients assessed had ECG monitoring done, and this was on time in 60%.

Conclusion: Use of high-dose antipsychotics in the service was low, at 2.5%. There was low uptake of HDAT protocol in these patients. Physical health reviews were noted to be adherent to the policy in about half the caseload. To this end recommendations were made for a system to identify patients due for their physical health checks. Awareness was also to be raised in the team regarding HDAT.

Aims: Attention Deficit Hyperactivity Disorder (ADHD) is more prevalent in adults with an intellectual disability (ID). NHS Digital reported the prevalence of ADHD in the ID population to be 9% in 2023–2024, compared with 1.2% in those without ID. Understanding the prevalence of ADHD within our Mental Health of Learning Disabilities (MHLD) team is crucial for tailoring our services accordingly and improving patient care. We decided to complete an audit across Kent and Medway to assess the degree of service demand arising from the diagnosis and treatment of ADHD in patients already open to the MHLD service, and to assess our adherence to NICE guidance for medication monitoring for ADHD medications.

Methods: A cross-sectional study of all patients currently open to MHLD was conducted. Total numbers across MHLD were recorded, as well as the split between the East and West Kent caseloads. All case notes, clinic letters and GP records were reviewed to identify whether a diagnosis of ADHD (or possible ADHD) was present. Once identified, a deep dive of patient records took place to check medication history and GP monitoring. Information was collated about the type of medication prescribed and length of prescription and whether monitoring had been carried out over the past 6 months in accordance with NICE guidance.

Results: We found that 15% (N=97) of all MHLD patients (N=629) had a confirmed diagnosis of ADHD, with 65.5% male and 34.5% female. The mean age of these patients was 24.6. Of those with confirmed diagnoses of ADHD, 43% (N=42) were prescribed medication. The most commonly prescribed medication was methylphenidate (62%), followed by atomoxetine (14%) and lisdexamfetamine (9.5%). Most patients had been on ADHD medication for less than 1 year (31%), with only 7% of patients being prescribed ADHD medication for over 10 years. With regards to medication monitoring, for those prescribed ADHD medication, 83% had their weight measured in the last 6 months, 76.5% had their pulse measured and 64% had their blood pressure measured.

Conclusion: This audit suggests that the rate of ID and ADHD in our clinical sample is higher than the estimated population prevalence. This will have implications for service development and training requirements, meaning that clear pathways will need to be established, with available resources and adequate monitoring in place to ensure the needs of our patient group are being met, and current NICE guidance is adhered to.

Aims: Paediatric inpatients often face both physical and mental health challenges, yet the extent of their mental health needs may not always be recognised. At the Royal London Hospital (RLH), we observed a high prevalence of mental health distress among paediatric inpatients, with many scoring above the distress threshold on the Strengths and Difficulties Questionnaire (SDQ), a validated screening tool for emotional and behavioural difficulties. We aimed to assess the prevalence of undiagnosed mental health concerns in paediatric inpatients using the SDQ, hypothesising that 80% would exhibit elevated distress scores, indicating potential unmet mental health needs.

Methods: Between 25 November and 22 December 2024, SDQs were administered to all paediatric inpatients across four wards, using parent or self-rated formats (depending on the child’s age and ability). Exclusion criteria included children already receiving mental health support or those not fluent in English or Tamil. Of 62 families approached, 49 (79%) participated, with 43 included in the analysis after excluding incomplete forms. Reasons for declining participation included language barriers (5), fatigue/stress (7), and perceived irrelevance of the study (1).

Results: Of the completed SDQs, 74% of children showed elevated scores in one or more categories, with 28% having a high Total Difficulties Score. Parent-reported data identified emotional (39.3%) and peer difficulties (39.5%) as the most prevalent concerns, while self-reports revealed that 59.9% of children reported greater difficulty in prosocial behaviour. Notably, discrepancies were observed in seven children, who reported higher difficulty scores than their parents.

Conclusion: The high prevalence of elevated scores across multiple domains suggests that a significant proportion of paediatric inpatients at RLH have unmet mental health needs. Discrepancies between parent and child reports highlight the value of incorporating multiple perspectives in assessments. The proportion of families declining participation underscores barriers to engaging in mental health screening. Routine, systematic screening during admissions could help normalise assessments and improve access to timely support.

Aims: It is incumbent upon psychiatrists to manage cognitive and physical health sequelae during a course of ECT. Monitoring post-seizure orientation and the stability of Montreal Cognitive Assessments (MoCAs) over time allows for dynamic changes to modality, frequency and energy settings in order to minimise side effects. Our service hypothesised that disparate electronic forms actually hindered this process and therefore conducted an audit.

An integrated paper-based treatment booklet for use within the ECT suite, with all forms bound together, was piloted as the quality improvement intervention. A new post-seizure orientation tool was also used.

Methods: The setting was South West Healthcare (SWH), Warrnambool, Australia. Standards were set a priori according to ECT guidelines from the Victorian Office of the Chief Psychiatrist and the Royal Australian and New Zealand College of Psychiatrists, with 80% compliance targeted. At a minimum, patients needed baseline bloods (full blood count; urea/electrolytes/creatinine), electrocardiograph, physical examination and MoCA, then physical/MoCA after every third treatment. Furthermore, a comment on orientation in the recovery suite after each treatment was required to meet standard.

Files were selected by 26/06/23 (cut-off date), capturing all ECT patients in the 6 months prior. 15 patients were identified, a combination of acute/completed and acute-continuation/maintenance ECT. Records, both paper and electronic, were audited against standards over 4 consecutive weeks by the authors. After the results were reviewed, the integrated treatment booklet (designed by the lead author) and post-ECT orientation questionnaire (licensed from the University of New South Wales) were introduced into clinical practice.

The audit cycle was completed a year later, with files selected by 30/08/24, capped at 20 patients and capturing all those who had had ECT since the pilot began.

Results: The baseline standard during the initial audit was generally met: bloods (79%), ECG (86%), physical (64%), MoCA (86%). However, the standard was not achieved once ECT commenced: physicals every 3rd treatment (60%), MoCAs (49%). Orientation status was documented in 90% of treatments.

During the post-intervention re-audit, compliance had vastly improved: baseline bloods, ECG, physical and MoCAs (100%); objective orientation scores (99%); ongoing physicals (76%)/MoCAs (72%).

Conclusion: Whilst not quite reaching the 80% compliance target overall, the integrated treatment booklet, with monitoring of re-orientation, significantly improved the cognitive/physical health tracking of patients undergoing ECT at SWH. With further operational change, full compliance is anticipated in the future. Returning to paper was universally supported by psychiatrists and managers, with clinical utility demonstrated within the ECT suite.

Aims: Research from the 2000s onward reveals significant digital access disparities for people with learning disabilities (LD). These individuals often have lower rates of computer ownership, internet use, and digital skills compared with their non-disabled peers. The situation is more pronounced for those with co-existing mental health conditions, leaving them further excluded from digital rights. Few studies have explored the reasons behind this digital divide or proposed solutions to improve internet access.

The study was aimed at gaining insight into the internet access and use of social media in patients with a Learning Disability in Wandsworth.

Methods: A retrospective cohort study was conducted involving fifty clients from the Psychiatry caseload of Wandsworth Mental Health and Learning Disability Team. The clients, selected randomly, had a range of intellectual disabilities and lived in different settings (e.g. with parents, independent housing with carers, or nursing homes). Data was gathered via an accessible paper survey between August 2024 and February 2025. Doctors filled out the forms in the presence of the clients or their carers to reduce recall bias. The survey collected demographic data and explored internet access, usage, and social media habits. It also included questions on internet safety and barriers to use. Chi-square tests were used to analyse relationships between variables.

Results: The study found that a significant number of clients had internet access. Most clients used the internet to watch videos on platforms like YouTube or Google, while some played online games. A smaller number used social media platforms, including Facebook, Instagram, and TikTok. However, many clients had limited understanding on cyber-safety and were unaware of accessibility features for those with visual or hearing impairments. Concerns were raised for a small group of clients who had shared personal or vulnerable information on social media. Thematic analysis identified four main barriers to digital inclusion: lack of access to devices, insufficient support from carers, lack of training, and physical/cognitive challenges.

Conclusion: The growing use of social media among individuals with intellectual disabilities highlights the need for targeted internet safety training. Without proper guidance, clients are at risk of online exploitation. In response, a one-day workshop on internet safety was organized with input from speech therapists, psychologists, and IT professionals. Feedback from participants will help assess the effectiveness of the training. The goal is to expand the study to other teams within Southwest London Trust and explore more objective data, such as device usage logs, alongside self-reported information.

Aims: To determine the number of mental health admissions to the Paediatric Assessment Unit in the Royal Aberdeen Childrens Hospital to provide a basis for implementing improvements to our knowledge and staffing so that we can provide a higher quality service for this group of patients.

Methods: Data was collected from 1 June 2023 to 31 May 2024. This period was used as any patient notes prior to 1 June 2023 were documented on paper, thus improving accuracy and consistency in collection method. Mental health admissions also included place of safety. Each patient who was admitted to PAU under these presenting complaints was noted from the nursing staff’s admissions book and the relevant information was then collected from medical notes on the online system 'Trakcare'.

Results: There were 4898 admissions to PAU from 1 June 2023 to 31 May 2024. 98 of these admissions were due to mental health. This was 2% of the total admissions to PAU. 38% of patients had a pre-existing mental health diagnosis. The most common presentation was mixed overdose with paracetamol-only overdose being the second most common. The average time spent in PAU was 2.1 days which ranged from 1 day to 20 days. 87% of patients received a psychiatry review from either CAMHS or liaison psychiatry. Of the 98 patients who were admitted, 27% required treatment for paracetamol overdose and 7% required treatment and/or monitoring for anorexia. The remaining patients either received observation only with or without monitoring of vital signs. No patients required emergency psychiatric medications, such as antipsychotics or sedation. 75% of patients were followed up by CAMHS, 3% were admitted and 22% received no follow-up.

Conclusion: Mental health accounts for 2% of PAU admissions and can have prolonged stays – up to 20 days found in the audited year. In line with the RCPCH, paediatricians are to have a role in prevention, early recognition and holistic care of mental illness to help with the growing demand in young adults and children. This audit highlights the growing demand of mental health and why health professionals within paediatrics need to develop the experience and confidence to help manage these patients.

Aims: The aim of this study was to assess clinician compliance with DVLA guidelines regarding driving status and advice for patients in an acute female inpatient unit. Specifically, the study sought to identify the documentation of driving status in patient records, the provision of DVLA-compliant advice, and the effectiveness of implemented recommendations.

Methods: This retrospective study reviewed electronic records of 20 patients admitted to an acute inpatient female ward. Data collection focused on whether driving status was documented and if DVLA-compliant advice was provided. Following the initial data collection, interventions were introduced, including visual prompts and modifications to the discharge summary template. The records of an additional 20 patients, admitted after these interventions, were subsequently reviewed. Data analysis was conducted using Microsoft Excel.

Results: Before implementing the recommendations, 20% of patients had their driving status recorded, and 15% received relevant advice. None of the discharge summaries included information about driving status. After the recommendations, the proportion of patients with recorded driving status increased to 25%, with 20% receiving relevant advice. Additionally, 25% of discharge summaries included driving-related information. The most significant improvement was observed in the inclusion of driving status in discharge summaries, attributed to the modified template. However, overall documentation and provision of advice remained suboptimal, indicating the need for further improvements.

Conclusion: The introduction of visual prompts and discharge summary template modifications led to modest improvements in the documentation and provision of DVLA-compliant driving advice. The findings suggest that additional interventions, such as enhanced data collection at initial patient reviews and clerking, could further improve compliance. Future efforts should focus on integrating these practices into routine clinical workflows to ensure comprehensive documentation and patient safety.

Aims: This audit project aims to assess whether the Crisis Resolution and Home Treatment Team North East Kent (NEKCRHTT) is following the trust protocols for requesting blood tests, or according to clinical indication.

Methods: For the first cycle, data collection was done from 1 August to 31 October 2023 from all clients under NEKCRHTT who had undergone blood tests and were under psychotropics. Information regarding documentation of clinical indication and which investigations were requested was collated and checked for compliance with trust policy. For the re-audit cycle, data collection was done from 1 July to 31 September 2024 and results were compared for improvements in adherence to the trust policy.

Results: First cycle results showed that the trust policy was not followed in 33.3% cases, in which mostly TFT, folate and B12 levels were requested without clear documentation of clinical indication. Results were presented with following recommendations: To have the trust policy poster easily accessible in clinical areas; prescribers to be aware of the policy and follow guidelines when appropriate; if there is clinical indication that deviates from policy, for this to be clearly documented on client’s notes. The re-audit cycle results showed an improvement in adherence to the trust policy: only 13.3% cases did not follow the policy. Documentation of rationale for requesting blood tests has also improved. When deviating from policy, it is still mostly by requesting TFT, B12 and folate, although the frequency has reduced.

Conclusion: The use of blood tests in a mental health crisis can serve many purposes, such as identifying potential damage secondary to overdose, aid in the differential diagnosis when considering organic causes for current presentation, ascertain renal/liver function before prescribing a new medication, among others. Having blood tests done according to the clinical indication and following a clear protocol assures accuracy in the management of the results. The implementation of change has resulted in improvement in adherence to the trust policy and the documentation of rationale for requesting investigations. This will hopefully assure accuracy in the management of the results, as well as avoid confusion of incidental findings.

Aims: 1. To evaluate the prescribing patterns and duration of benzodiazepine use among psychiatric outpatients and their adherence to established guidelines.

2. To assess the prevalence of benzodiazepine dependence and the level of patient awareness regarding its associated risks.

3. To identify discrepancies between current prescribing practices and evidence-based guidelines, particularly in the treatment of Schizophrenia, Bipolar Affective Disorder, and Generalised Anxiety Disorder.

Methods: A retrospective review of online prescription records was conducted for 35 randomly selected patients from the outpatient department of the Punjab Institute of Mental Health, Lahore, during November 2024. The review adhered to the guidelines published by the Ministry of National Health Services, Regulations & Coordination, Pakistan (April 11, 2023), and the Maudsley Prescribing Guidelines in Psychiatry, 14th Edition.

The following parameters were analysed:

Demographic details and clinical diagnosis of the patients.

Benzodiazepine use, including the type of benzodiazepine prescribed and the duration of use.

Assessment of benzodiazepine dependence, using the Severity of Dependence Scale (SDS), with a score greater than 7 indicating dependence.

Evaluation of whether patients were informed about the potential risks of dependence prior to initiating benzodiazepine treatment.

Results: Demographics and diagnoses: Out of the 35 patients audited, 29 (82.9%) were male. Diagnoses included Schizophrenia (11 patients, 31.4%), Bipolar Affective Disorder (21 patients, 60%), and Generalized Anxiety Disorder (3 patients, 8.6%).

Benzodiazepine use: A total of 97.1% (34 patients) were prescribed benzodiazepines, with 85.7% (30 patients) on long-term use exceeding six months. Commonly prescribed benzodiazepines included clonazepam (2 mg), bromazepam (3 mg), and lorazepam (1 mg), often based on pharmacy stock availability rather than patient-specific indications.

Dependence and awareness: Dependence symptoms were identified in 25 patients (71.4%). 65.7% (23 patients) were not informed about the risks of dependence or proper duration of benzodiazepine use.

Guideline discrepancies: Contrary to established guidelines recommending benzodiazepines for short-term use (2–4 weeks), these medications were prescribed for prolonged periods without regular risk assessments for dependence.

Conclusion: The audit reveals an alarming trend of prolonged benzodiazepine use among psychiatric outpatients, predominantly males with schizophrenia and bipolar disorder. The prescribing practices observed starkly contrast with international guidelines, such as NICE and Maudsley, which emphasise short-term use (2–4 weeks) and the necessity of ongoing risk assessments for dependence.

The lack of patient education on the risks of benzodiazepines and the absence of consistent, evidence-based prescribing protocols further exacerbates the problem. This is particularly concerning given the high rates of dependence and the potential for severe withdrawal symptoms upon abrupt discontinuation.

To address these issues, it is critical to:

Develop and implement national and institutional guidelines for benzodiazepine prescribing in chronic psychiatric patients.

Regularly review patients on benzodiazepines to assess the need for continued use.

Educate both healthcare providers and patients on the risks of long-term benzodiazepine use, dependence, and withdrawal.

Encourage the use of alternative, non-pharmacological interventions for managing anxiety and agitation.

Aims: The primary aim of this audit was to evaluate the adherence to the Maudsley Prescribing Guidelines for Long-Acting Injectable (LAI) antipsychotics in the outpatient department (OPD) setting at the Punjab Institute of Mental Health, Lahore, Pakistan. Specifically, the objectives were to:

Assess prescribing practices, including the use of test doses, baseline investigations, dose adjustments, dosing intervals, and combining LAIs with oral antipsychotics.

Identify gaps in clinical practices, such as patient monitoring and safety protocols, and their alignment with guidelines.

Highlight deviations like the use of LAIs in rapid tranquillization and high rates of polypharmacy.

Inform targeted interventions to improve patient safety and promote evidence-based care.

Methods: In July 2024, a random selection of 42 OPD prescriptions for patients receiving LAIs was reviewed. A structured proforma was designed to capture:

Patient demographics (age, gender).

Diagnosis,

Prescribing patterns (test doses, polypharmacy, and rapid tranquillization).

Safety protocols (baseline investigations, post-injection monitoring).

Patient education on medication side effects.

The proforma data facilitated a systematic evaluation of adherence to the Maudsley Prescribing Guidelines (14th edition) and provided insights into clinical practices at the Punjab Institute of Mental Health, Lahore.

Results: Demographics: The majority of the patients were male (76.2%) with a mean age of 41 years.

The majority of patients taking depot antipsychotics were diagnosed with schizophrenia (75.0%), followed by bipolar affective disorder (BAD) (21%), with a smaller proportion diagnosed with schizoaffective disorder (4%).

Prescribing Practices and Safety Protocols:

LAI usage: All patients received fluphenazine decanoate (25 mg intramuscular, biweekly), a first-generation antipsychotic (FGA).

Polypharmacy: All patients were concurrently prescribed a second antipsychotic, most commonly risperidone (4 mg/day).

Patient education: 78% of patients reported being informed about the side effects of injections. However, none was placed under post-injection observation, a significant gap in safety monitoring.

Test doses: No test doses were administered to patients receiving LAIs for the first time.

Rapid tranquillization: Fluphenazine injections were used in rapid tranquillization protocols, along with haloperidol (Serenace) and promethazine (Phenergan). This practice deviates from recommended guidelines.

Baseline investigations: No baseline ECG or other physical health assessments were conducted prior to initiating LAI therapy.

Conclusion: This audit highlights several critical gaps in the prescribing and monitoring practices for LAI antipsychotics at the outpatient department of the Punjab Institute of Mental Health. Key findings include the lack of test doses, absence of baseline physical health assessments (e.g. ECG), and insufficient post-injection observation. The use of fluphenazine in rapid tranquillization and the high prevalence of polypharmacy raise additional safety concerns.

Recommendations:

Staff education: Conduct regular training sessions on the Maudsley Guidelines, emphasizing test dose administration, baseline monitoring, and post-injection observation.

Test dose feasibility: Establish protocols to ensure test doses are administered before initiating LAI therapy.

Baseline investigations: Make baseline physical health assessments, including ECGs, mandatory for all LAI prescriptions to mitigate cardiac risks.

Review of tranquillization protocols: Revise rapid tranquillization protocols to align with evidence-based guidelines.

Polypharmacy monitoring: Regularly evaluate the rationale for combining multiple antipsychotics to minimize unnecessary polypharmacy.

Continuous audits: Perform regular audits to track improvements and identify persistent gaps in adherence to guidelines.

By implementing these measures, clinical practices can align more closely with international standards, ensuring safer and more effective care for patients receiving LAI antipsychotics.

Aims: Risperidone is a commonly used antipsychotic drug in the LD population. One of its common side effects is hyperprolactinemia, which can cause a range of symptoms. Women may experience oligomenorrhoea, amenorrhoea, galactorrhoea (breast milk production), and decreased libido. Men may experience decreased libido, erectile dysfunction, gynaecomastia, infertility, decreased bone mass, and galactorrhoea. These symptoms may go unnoticed in the LD population and lead to behavioural changes.

BNF advises monitoring of prolactin at baseline, after 6 months and then annually.

Methods: Identify patients on either oral or intramuscular risperidone and those receiving intramuscular paliperidone within the psychiatry case load. Determine whether these patients have their prolactin levels checked annually. All patients assessed in the East CLDT psychiatry clinic who are on risperidone or paliperidone should have their prolactin levels monitored at least once a year.

Results: Out of 106 patients, we identified 27 patients on risperidone (25.4%). 8 out of the 27 patients did not have their prolactin levels checked within the last year (29.6%). 8 out of 19 patients (42.4%) who did have their prolactin levels checked within the last year did not have them checked annually previously. This indicates that approximately 60% of patients are not receiving regular monitoring of their prolactin levels.

Conclusion: Approximately 60% of our patients are not having their prolactin levels checked annually. To address this, we can enhance our communication by including a recommendation in our clinic letters to GPs, urging them to include prolactin testing in the annual health check blood work. Additionally, it is essential to regularly monitor symptoms of hyperprolactinaemia during our clinic visits and to educate caregivers about these issues. Symptoms such as gynaecomastia can cause discomfort and may lead to behavioural changes in individuals with intellectual disabilities. By prioritizing these measures, we can improve patient care and outcomes significantly.

Aims: The Lester Tool mandates baseline monitoring parameters for patients starting new antipsychotics or having their current antipsychotic regimen changed. These parameters include blood pressure, haemoglobin A1c (HbA1c)/fasting plasma glucose, lipids, lifestyle review, waist circumference, and weight, along with weekly weight monitoring for six weeks consecutively. This audit was initiated in response to concerns about rapid weight gain observed in many patients after starting certain antipsychotics. It aims to assess compliance with the Lester Tool to address the potential risks of metabolic syndrome in these patients. The audit seeks to understand the pattern of antipsychotic prescriptions as a secondary objective.

Methods: The audit was registered and ethically approved by the local research and audit department. A retrospective review of electronic health records and medication charts was conducted for 38 patients residing in two male and two female inpatient wards in the East Midlands between 17 June 2024 and 26 June 2024. Baseline parameters were audited to determine if they were measured within one week of antipsychotic initiation, and weekly weight checks thereafter. Waist circumference measurement at baseline was excluded due to concerns about its potential impact on patient self-esteem.

Results: Among baseline monitoring parameters, blood pressure had the highest compliance at 89.5%, followed by HbA1c/glucose (65.8%), lipids (57.9%), lifestyle review (55.3%), and weight monitoring (36.8%). Weekly weight follow-up compliance was low, with only 5.9% of patients meeting 100% compliance, and 41.2% of patients having no documented weight follow-up within six weeks. Non-compliance reasons were poorly documented. Risperidone was the most prescribed antipsychotic (N=9), followed by olanzapine (N=8), zuclopenthixol (N=7), and quetiapine (N=6). Olanzapine and risperidone were most frequently initiated in male wards, while zuclopenthixol and quetiapine were more common in female wards.

Conclusion: The audit identified significant gaps in compliance with the Lester Tool, which poses a risk to patients’ physical health due to the metabolic side effects of antipsychotic medications. The findings underscore the need for better documentation and communication regarding baseline and follow-up measures. Recommendations include increasing awareness of baseline blood requirements during admission, improving electronic health record functions (e.g. alerts for weekly weight checks and a drop-down to document weight check refusals), and enhancing coordination in monitoring patient weight following planned home leaves. A re-audit is ideal once the recommendations have been implemented.

Aims: People with learning disabilities are at a higher risk of developing epilepsy and bipolar disorder. For decades, sodium valproate has been used to treat these conditions. However, recent evidence suggests an increased risk of testicular toxicity in men and neurodevelopmental disorders in children born to men who were treated with valproate in the three months prior to conception. Sodium valproate is not recommended for male patients under 55 years of age unless no other effective or tolerated treatment is available.

Aims were:

To compare our prescribing practices with the latest guidelines.

To review the indication for sodium valproate in male patients with learning disabilities.

To explain the potential risks of infertility and testicular toxicity.

Methods: We conducted a cross-sectional study within our service, collecting data on all male patients currently taking sodium valproate, focusing on their age, diagnosis, and dosage. We then contacted these patients to complete the ‘Risk Acknowledgement Form’ which involves three steps:

1. Documentation of the prescribing decision.

2. Explanation of the risks to the patient.

3. Countersignature by both the patient and clinician.

Results: A total of 25 male patients are taking sodium valproate under our service. Of these, 16 patients are aged under 40, 6 are aged 41–50, and 3 are over 50. Ten patients have bipolar disorder, 2 have schizoaffective disorder, and 12 have epilepsy, with one patient diagnosed with both epilepsy and bipolar disorder.

Regarding dosage, 5 patients are taking less than 1000 mg per day, 18 patients are taking between 1000–2000 mg per day, and 2 are taking more than 2000 mg per day. Of the 25 patients, 10 have completed the safety questionnaires. Additionally, 11 patients receive their sodium valproate from other services, such as GPs or neurologists, while 4 patients remain pending due to reasons such as inability to contact or lack of capacity.

Conclusion: This audit highlights the ongoing use of sodium valproate in male patients in our service. Despite concerns about its risks – particularly testicular toxicity and potential impacts on fertility – sodium valproate remains one of the most effective treatments available.

The results indicate that a small number of patients are receiving doses exceeding the recommended BNF thresholds due to clinical complexity.

Moving forward, further efforts should be made to reduce sodium valproate dosages and switch to alternative mood stabilizers when possible. Additionally, services should prioritize enhancing communication and documentation of potential risks while continuing to monitor and mitigate any adverse effects.

Aims: Evaluate the utilisation frequency and outcomes of Section 17 leave in an acute adult inpatient psychiatric unit.

Improve the quality of care through evidence-based and individualised treatment plans.

Inform ward resource allocation related to Section 17 leave.

Methods: Data collection: The audit included all seven patients admitted to New Victoria Court from April to May 2024. Data were collected from electronic patient records, documented discussions with patients and carers, and direct interviews with service users to capture experiences, benefits, and challenges of leave. Nursing colleagues were also interviewed about the long-term feasibility of this initiative.

Standard: HPFT Section 17 Leave of Absence Policy.

Intervention: A leave feedback template was designed and implemented to record leave outcomes daily, completed by the safety nurse at the end of each shift.

Data analysis: Quantitative measures included the percentage of compliance with documentation standards, incidents, and what went well during leave. Qualitative data enriched the understanding of leave’s impact on recovery and ward staff capacity.

A re-audit was performed two weeks post-intervention using similar parameters.

Results: Quantitative findings: The total number of leave episodes decreased from 157 to 137, likely due to one fewer patient on the ward post-intervention.

There were no significant changes in the proportion of ground or community leave utilised.

Notably, the percentage of documented leave outcomes increased by 13.2%, and documentation of what went well during leave rose by 50.3%.

Incidents during leave decreased from 8.8% to 0%, though patient demographics and mental state changes might have confounded this.

Qualitative findings: Patient feedback revealed mixed experiences. Some patients valued leave for accessing the community, viewing it as beneficial for recovery. Others expressed frustration with restrictions, preferring discharge over limited leaves. One patient reported no need for leave at all.

Nursing colleagues supported documenting leave outcomes but highlighted concerns about additional workload. Some feedback forms were used to record general observations rather than leave-specific outcomes, requiring clarification during data analysis.

Conclusion: This audit demonstrated a significant improvement in the documentation of leave outcomes, supporting evidence-based and individualised patient care. Stable utilisation of ground and community leave aids ward resource allocation. The reduced incidents might reflect improved monitoring and risk management.

Action plan:

Implement a standardised leave feedback template for regular review during ward rounds.

Conduct training for staff on thorough documentation and utilising the template.

Ongoing discussion between the trust audit team and medical directors regarding trust-wide implementation of this initiative.

Aims: Ligature incidents in inpatient psychiatric settings represent a high-risk form of self-harm behaviour. Of all deaths that occur on psychiatric wards, 75% are caused by hanging or strangulation with a ligature. Accurate assessment and documentation of ligature incidents is essential for a comprehensive understanding of these complex incidents. A Ligature Assessment Tool was developed (Panchal et al, 2022) to improve and standardise the reporting of these incidents. Use of the tool provides a detailed source of information for the multi-disciplinary team, many of whom won’t have observed the incident first hand. These detailed reports can subsequently inform the care planning for individual patients.

The Ligature Assessment Tool was introduced in a regional women’s medium secure unit in 2020 and three audit cycles were completed assessing its use. This, the fourth and most recent audit, was conducted to further assess use of the tool.

Methods: Reports from the Eclipse incident reporting system, relating to ligature incidents between January and June 2024 (n=54), were reviewed retrospectively. Each report was reviewed and data was collected as to whether each of the Ligature Assessment Tool criteria were recorded as part of the written report. Data were collected as either “recorded” or “not recorded” for each of the 15 criteria of the Ligature Assessment Tool.

Results: There was a total of 54 reports relating to ligature incidents during the six month audit period. This audit showed further improvement in the use of the Ligature Assessment Tool, with 37% of reports recording 11 or more criteria from the tool, compared with 19% in the previous audit. 19 (35%) of the reports recorded all 15 criteria of the Ligature Assessment Tool.

Conclusion: This audit, conducted two and a half years after the previous audit, showed not only that the Ligature Assessment Tool continued to be used in the reporting of ligature incidents, but that the frequency of its use had increased. This occurred despite the fact that in the intervening period there had been no specific interventions, such as education or promotion, to improve use of the tool. This demonstrates its acceptability to staff and its ease of use, suggesting that tools such as this one could be integrated as part of normal practice in any setting. Going forward, the plan is to integrate the Ligature Assessment Tool into the incident reporting system within the Trust, meaning it will be used in all ligature incidents reports.

Aims: The audit aimed to evaluate assessment, intervention, and signposting for alcohol use problems in people with gambling disorder presenting to the Southern Gambling Service (SGS).

Methods: The study included ninety-eight patients referred to SGS between the 28 December 2023 to 2 April 2024, who completed initial assessments.

Baseline data were analysed to stratify patients’ alcohol use risk based on their extended Alcohol Use Disorder Identification Test (AUDIT-C) and Estimated Weekly Alcohol Consumption (EWAC) scores, which were collected via a digital pre-assessment tool. Clinical assessment letters were also reviewed to assess documented compliance with National Institute for Health and Care Excellence (CG115) guidelines, the Department of Health and Social Care guidance and the Royal College of Physicians regarding appropriate management according to their risk brackets. Outcomes included: (1) determining if those scoring at least 5 on the extended AUDIT-C received a full AUDIT assessment; (2) if higher risk groups (scores of 5–10) received brief interventions and (3) if those with 11 or more received advice on safe alcohol reduction and signposting to alcohol services.

Results: Forty-four full records were examined: 26 [59%] patients scored <5 (AUDIT-C, lower risk), 14 [32%] patients scored 5–10 (higher risk) and 4 [9%] scored at least 11. In the latter category, 100% of patients received a formulation discussing their alcohol use and 75% of them an alcohol-related International Classification of Diseases 11 diagnosis as part of this formulation. While 100% completed the AUDIT-C and EWAC, none completed the full AUDIT. 7% of those in the higher risk category received documented brief interventions. Of the possibly dependent patients, 1 (25%) was signposted, based on documentation, to alcohol services and no patients received documented advice on avoiding an abrupt alcohol cessation.

Conclusion: The audit highlighted strengths (such as 100% of patients being screened for alcohol use problems using AUDIT-C and EWAC) but also areas for improvement (e.g. in conducting appropriate advice interventions and signposting to alcohol services, and ensuring these steps are clinically documented). Recommendations for improvement included: (1) adding a full AUDIT screening for those scoring at least 5 in the extended AUDIT-C; (2) upskilling staff in brief intervention advice; (3) developing a regional alcohol services directory for signposting; and (4) providing psychoeducation materials on safe alcohol use. After implementation of recommendations, the audit will be repeated.

Aims: This study aims to explore the patterns of psychoactive substance use among women attending the Club Drugs Clinic. It also explores associations with demographic factors and mental health comorbidities to identify additional therapeutic needs beyond current clinical treatments. The findings will help contribute to improving service provision for this population.

Methods: This is a quantitative study of 27 female patients who attended the Club Drugs Clinic across three boroughs between May 2021 and June 2024. Data collected includes demographic information, primary, secondary, and tertiary use of Novel Psychoactive Substances (NPS), age of onset of substance misuse, age of onset of treatment, associated mental health comorbidities, and harmful alcohol use.

Results: The majority of female patients attending the Club Drugs Clinic are of White British origin, with 20% identifying as Asian, Brazilian, or African Caribbean.

The average age of onset of psychoactive substance use is 25 years, while most patients begin treatment between 25–35 years old.

The most commonly used primary substances are ketamine, methamphetamine, and GHB/GBL, with fewer patients using nitrous oxide and benzodiazepines.

60% of women are polysubstance users, with methamphetamine + GHB being the most common combination (37%).

All primary methamphetamine users struggle with dependence, with 37% identifying as transgender and 71% engaging in sex work. 37% of those who are dependent on methamphetamines had history of psychosis and been treated with antipsychotics.

66% of Ketamine users present with severe anxiety (GAD-7 score >15), and 56% experience ketamine bladder symptoms, requiring referral to Urology.

44% of women at the clinic have a diagnosis of PTSD, linked to trauma such as domestic violence, sexual abuse/assault, sex trafficking, and war-related trauma. These patients received therapy from the team psychologist or are referred to trauma-focused therapy within secondary mental health services.

Conclusion: This study identified ketamine and methamphetamine as the most commonly used primary psychoactive substances among female patients attending the Club Drugs Clinic. Methamphetamine dependence poses a significant risk for psychosis, while ketamine dependence increases the likelihood of developing ketamine-related bladder dysfunction, highlighting the importance of screening for cystitis symptoms. Additionally, the majority of patients reported a history of trauma and used substances as a coping mechanism. These findings emphasize the need for integrated care approaches, including close collaboration with trauma services, to enhance treatment outcomes and improve overall service provision for this vulnerable population.