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

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

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

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

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

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

Inclusion criteria

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

Exclusion criteria

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

All other personality disorders.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The other psychotropic medications used were antidepressants and benzodiazepines.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

This audit aims:

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

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

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

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

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

30 patients were reviewed in total.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Lithium is a mood-stabiliser with a narrow therapeutic index. Patients are known to be at risk of lithium toxicity if they are unaware of how to recognise its signs. NICE guidelines outline the information that must be relayed to these patients. Furthermore, GMC Good Medical Practice highlights the importance of clear and contemporaneous patient records that contain relevant clinical information.

The aim of this two-cycle audit was to assess the quality of documentation for patients reviewed in lithium clinic and to analyse the consistency of the notes recorded to ensure high quality care provision and communication within the department, in line with the NICE guidelines.

The inclusion criteria were patients over the age of 65, prescribed lithium and were actively reviewed in the monthly lithium clinic at the Older Person's Mental Health Service (OPMHS) at Princess of Wales Hospital in Wales.

A data collection form was created to ensure all the relevant data in line with NICE guidelines was captured including serum lithium level, lithium dose, other psychotropics, side effects, renal function, patient mood, safety netting advice provided including signs of toxicity and awareness of lithium card. A standard of 100% was set for this data to be captured for each patient.

Cycle 1 was completed in November 2023 where a total of 18 patient records were selected (N = 18). Lithium dose, lithium level and renal function were recorded in over 83.3% (n = 15) of the files audited. Details on psychotropics were recorded in 61.1% (n = 11), side effects in 50% (n = 9) and patient mood in 77.8% (n = 14). Safety netting advice was recorded in 11.1% (n = 2). Furthermore, it was noted data recorded varied between clinicians.

The results of this audit were disseminated to OPMHS team. A proforma was introduced to encourage capture of all relevant information and to ensure consistency. Feedback was collected from clinicians using the proformas and relevant changes were made.

A second cycle of this audit was carried out after the proforma was introduced to the subsequent clinic (N = 12). This showed an improvement in record-keeping including lithium dose, lithium levels, psychotropics and side effects of 100% (n = 12). Renal function and mood were recorded in 91.7% (n = 11) of files and safety netting advice provision in 75% (n = 9) of files audited.

Introduction of a proforma is a simple and effective way to ensure relevant and important details are documented. This is not only for good clinical practice, but for medico-legal reasons also.

Antipsychotic medications are commonly used in the management of psychiatric disorders, including in older adults. However, the use of these medications in older adults can be associated with a higher risk of adverse effects such as cardiovascular event and extrapyramidal symptoms.

This retrospective audit aimed to evaluate adherence to antipsychotic prescribing and monitoring guidelines in a Psychiatric Unit for Older Adult Females in Kent and Medway NHS and Social Care Partnership Trust (KMPT).

The audit criteria encompassed various aspects of documentation and medication management, including diagnosis documentation, indication, age, comorbidities, consent, baseline assessments, monitoring, review, and follow-up care. Data from two months’ records were analysed leading to an action plan with slight amendments to the user-friendly template for ward round and a physical health monitoring poster for junior doctors and ward staff. These initiatives aim to improve patient care, streamline documentation, while accommodating the rotation of junior doctors. A re-audit is planned post implementation.

This audit’s limitations included the study’s single-site nature, potential sample size constraints and reliance on accurate documentation.

The audit achieved 100% compliance in documenting patient age and MHA status, meeting legal requirements. Weight, BMI, and baseline blood pressure exhibited full compliance. Baseline ECGs had an 86.66% compliance rate, while QTc interval documentation reached 100%. Antipsychotic indication and weekly reviews were documented at 100%, with an 83.33% rate for rationale documentation for medication changes. Comorbidities were fully documented, but extrapyramidal symptom and sedation monitoring showed a 46.66% compliance rate. Baseline blood tests, including glucose, bA1c, lipid profile, electrolytes, renal and liver function, thyroid function, and prolactin levels, generally had high compliance, but lipid profile and liver function achieved 73.33%. Repeat blood tests varied, with electrolytes and renal function at 100%, while thyroid function and prolactin levels scored lower at 26.66% and 46.66%. Continued monitoring of weight, BMI, and blood pressure remained fully compliant. Compliance for repeating ECGs within recommended timeframes reached 53.33%, and recommendations to GPs for yearly ECGs and blood monitoring achieved 50%.

In summary, the audit identified areas of commendable high and medium compliance with antipsychotic prescribing guidelines in a Psychiatric Unit for Older Adult Females in KMPT. An action plan has been formulated to not only enhance patient care but also to refine the documentation process positively further, fostering continued progress in the provision of high-quality care.

The audit aimed to study missed seizure frequency, management, and restimulation rate at NHFT's ECT clinic.

We conducted a retrospective analysis of ECT treatments administered between October 1, 2021, and March 21, 2023, collecting data on stimulation frequency and doses, duration of motor seizures and EEG activity, and patients' demographics. The study compared current practice with the NHFT ECT protocol, which defines missed seizures as treatments failing to induce convulsions and EEG activity. Management entails restimulation at least once or twice according to the stimulus dosing protocol during the seizure-threshold (ST) determination phase or by increasing the dose by 10% (50 millicoulombs) during the treatment phase, alternatively recording reasons for not re-stimulating. The ratio of missed seizures to total stimulations was used to determine the missed seizure rate, and the ratio of total restimulations to missed seizures was used to calculate the restimulation rate.

The clinic provided 268 treatment sessions and 26 courses of bilateral ECT to 23 patients aged 17–84 years, primarily female (60%) and Caucasian (74%), with a 12.6% missed fit rate and a 67.5% restimulation rate. Thirty missed seizures occurred during the initial ST determination phase, with twenty-two restimulated. Four of these could not be restimulated due to the maximum limit of three stimulations per ECT session. Seven missed seizures occurred later in the treatment phase, with three restimulated. For restimulations during the seizure-threshold determination phase, only eight of the twenty-two restimulation doses matched the stimulus dosing chart, and over half of these patients were stimulated at a lower-than-recommended dose. Once a seizure was generated and the threshold was identified, suboptimal maintenance doses were chosen, with 47% of patients stimulated on the same dose and 37% on doses only marginally over the ST in consecutive sessions. During the treatment phase, two out of three restimulations were performed with a dose lower than the specified 10% increase. The reasons for deviating from the guidelines were not documented.

National audits of ECT clinics in 1981 and 1992 showed 50% and 25% missed seizure rates, respectively. Bridgend ECT Clinic maintained a missed fit rate of ≤5% over a 6-year period, which is half that of NHFT. Missed seizures have been associated with treatment failure and post-ECT adverse effects; hence, to effectively manage them, we propose that all ECT administration personnel be familiar with the NHFT ECT protocol, including the stimulus-dosing protocol, and document any clinical grounds for deviations.

This audit assesses communication practices regarding interactions between lamotrigine and oral contraceptives in North West Sussex (NWS) Specialist Perinatal Mental Health Services (SPMHS).

The predicted outcome includes increasing awareness about potential interaction between lamotrigine and contraceptives with resulting impact on patient safety.

Lamotrigine is used for epilepsy and mental health disorders but can interact with contraceptives, affecting efficacy and safety. NICE recommends it for bipolar depression, relapse prevention and recurrent depression. Interactions with hormonal contraceptives can influence effectiveness of either drug and increase the risk of side effects. Patients on lamotrigine should be counselled so they can make an informed decision about taking the medication.

Reviewed records of all patient on the caseload on 21st June 2023. Collected data for lamotrigine prescription, indication, contraceptive method, and documented counselling. Calculated percentage of patients counselled on lamotrigine-contraceptive interaction.

In 261 patient records, 11.9% were previously or currently on lamotrigine or had a discussion about starting lamotrigine. 6.1% currently and 3.1% previously on lamotrigine. Counselling on lamotrigine's interaction with oral contraceptives was documented with 3.1%, while 74.2% received none. Indications for lamotrigine use were epilepsy 9.7% and mood stabiliser 90.3%. Of 27 patients who weren't currently pregnant, 9 of them were informed of the interaction risk while 18 were not. Contraception methods were documented for 10 individuals.

Findings showed the need for increased awareness about the interaction and documentation of appropriate discussions to inform their choice.

The Royal College of Psychiatrists provides guidance regarding the experience of Foundation Doctors and Core Trainees, during their Psychiatry rotations. At The Mount, an Older Adult Mental Health unit in Leeds, it was observed by trainees that management of physical health conditions was occupying a large portion of their time.

Aims:

1. 1. Measure how much time is spent on physical health activities, between Foundation Doctors and Core Trainees at The Mount.

2. 2. Consider the impact of physical health workload on the doctors’ experience of Psychiatry.

3. 3. Explore the mental health experience of doctors during this rotation.

This Audit was conducted in three stages:

1. 1. Anonymous collection of quantitative data regarding the proportion of time spent on physical health work. This data was collected for current doctors across all wards, for a two-week period in October 2023.

2. 2. A focus group of junior and senior doctors, to consider onward actions.

3. 3. An anonymous qualitative survey regarding mental health experiences and suggestions for improvement. This was circulated to any Foundation Doctor or Core Trainee who worked at The Mount in the past 12-months, via an online survey.

The quantitative survey showed that Foundation Doctors and Core Trainees at The Mount were spending at least half their time on physical health jobs, such as: clinical reviews, skills such as blood tests and ECGs, and referrals to other clinicians or specialties. This was considered unsurprising by doctors at all levels during the focus group.

The qualitative survey explored this further, with observations that doctors were sometimes unable to attend MDT meetings, tribunals or CPAs due to the high physical health workload. It was felt that senior staff were proactive in offering support, however trainees still felt that opportunities for mental health experience were limited.

Suggestions for improvement were made during the survey, including:

1. 1. Increased input by senior medical staff, such as GPs or Geriatric Trainees.

2. 2. Additional staff to support with upkeep of equipment, or skills such as phlebotomy.

3. 3. Increased use of technology rather than paper charts.

4. 4. Greater clarity regarding minimum staffing and whether locum doctors can be arranged to cover gaps.

In summary, the physical health workload for Foundation Doctors and Core Trainees was noted to be significant and impacting their mental health experience. Following this Audit, consultants at The Mount will be meeting with Senior Leadership to discuss methods for improving the training experience.

To review the practice of management of clozapine plasma levels in Solihull CMHTs between April and September 2023. Birmingham and Solihull Mental Health Foundation Trust (BSMHFT) clozapine guidelines were issued in January 2023 and further ratified in December 2023. The standard set out in the January 2023 guideline was that service users with elevated clozapine levels >600mcg/L should be assessed for signs of toxicity and consideration given to a dose reduction. Those with levels above 1000mcg/L should be reviewed urgently.

Clozapine blood clinic diaries were reviewed in order to obtain a list of 48 service users who had attended for clozapine blood tests between April and September 2023. Blood results were reviewed for clozapine level results. For those service users whose clozapine level had been over 600mcg/L, clinical notes were reviewed to determine whether they had been screened for clozapine toxicity.

Of the 48 service users prescribed clozapine, 24 had clozapine levels over 600mcg/L and 11 had levels over 1000mcg/L. Of the service users with clozapine levels over 600mcg/L, 16 (67%) were screened for toxicity. Of those with clozapine levels over 1000mcg/L, 9 (82%) were screened for toxicity.

Between April and September 2023, Solihull CMHTs demonstrated an understanding of the need for actioning elevated plasma levels as a priority, however, this could be further improved. The risks of adverse effects and toxicity with clozapine increase with raised plasma levels, particularly with levels over 1000mcg/L. Therefore, it is important that raised plasma levels are actioned accordingly. Locally, we have implemented a flow chart which summarises the updated clozapine guidelines, to assist clinicians in interpreting and acting on high clozapine levels and to prompt clinicians to review service users for signs of toxicity. We hope to incorporate this visual aid into the updated BSMHFT guidelines.

Rapid Tranquilisation (RT) is the parenteral (intramuscular) administration of medication to calm or sedate an agitated, violent or aggressive patient in a timely and safe manner. This audit specifically looks at the clinical practice in the use of rapid tranquilisation in inpatient MHSOP against trust policy. The aim of this audit is to assess the effectiveness of RT and if other methods of de-escalation are being utilized first to provide better care for patients and utilize the least restrictive management options possible.

The audit was registered, and care was taken to uphold ethics, access patient information appropriately, and to ensure that data collected was both relevant and ensured confidentiality. All incidents of RT were identified across both wards of Auckland Park Hospital from the period of August to October 2023. DATIX numbers were identified to show incidents of RT from the specified period, these numbers were used to identify patient ID with liaison with relevant staff members. Patient ID was used to review the incident, specifically to investigate de-escalation techniques documented and effectiveness of RT. Only parenteral RT incidents were included to assess if appropriate measures were taken beforehand.

A total of six Incident reports were identified over the three-month period. In all cases the choice and dose of the medication was within the current recommendations. 33% of incidents utilised promethazine 25mg while the other 66% utilised lorazepam either 1mg or 500mcg. All patients had baseline observations recorded on NEWS chart prior to the incident, however only 33% of incidents involved full recordings of observations at appropriate intervals on the NEWS chart. The reason for this in all cases was due to patient refusing observations which was documented. There were no documented side effects but 33% of incidents involved a raised NEWS score post RT. In all cases the NEWS score resolved spontaneously within the post RT monitoring period. In 100% of incidents de-escalation techniques were utilised and documented and evidence of post RT debrief with the patient was shown. 66% of incidents involved a medication review post RT as per recommendations.

Guidelines are being followed with good effect regarding RT in MHSOP. It is important to always undertake nonpharmacological de-escalation methods prior to considering RT which is reflected in the low numbers of RT during this period. Recommendations are made to follow local guidance as well as to exhaust nonpharmacological de-escalation methods to reduce the need for RT.

Section 136 of the Mental Health Act 1983 allows for a person who appears to a constable to be suffering from a mental disorder and needing immediate care to be removed to a place of safety (POS) for their protection or the protection of others.

The legislation recommends that prior to making a decision to detain on Section 136, the constable must, if practicable, consult mental health services for information to guide decision making.

The 136 suite is the preferred POS except for patients requiring urgent medical treatment in which case the Emergency Department (ED) is preferred. If the 136 suite is unavailable, then alternatives like the ED may be used.

This audit examines the use of the Birmingham City Hospital Emergency Department as a POS following Section 136 detention, the adherence to the aforementioned legislation and the outcomes of the assessments.

The audit was approved by the clinical governance team and a list of all Birmingham City Hospital patients detained under Section 136 for a three-month period (January–March 2022) was retrospectively obtained. Clinical records were examined, and the relevant data was extracted from the clinical notes.

Information including the reason for use of the ED as a POS, police contact with mental health services prior to detaining, time taken prior to assessment, reasons for mental health act assessment (MHAA) delays, and outcomes were collected and collated using Microsoft Excel.

The ED at City Hospital was used a place of safety for 80 patients in this period. In 52.5% of cases the ED was used as a place of safety due to lack of space at the POS. Contact with mental health services prior to detention was documented in only 29% of cases. The average time for a MHAA to take place in the period under review was 11.5 hours. Only 20% of these cases ended up detained under the mental health act.

The results show poor adherence in the use of Section 136 to the recommendations of the legislation. Improvements are needed on time taken for assessments and use of ED as a place of safety due to unavailability of beds at the s136 suite. The police should be re-educated on the importance of contacting mental health services prior to detaining patients on Section 136. The audit result was presented at a clinical governance meeting and repeat audits are planned across all the emergency departments in Birmingham.

This clinical audit aimed to assess if the recording of patients seen for their diagnostic appointments in memory clinic measures up to the minimum standards required in the delivery of dementia services. This standard mandated primarily that a minimum body of key information must be promptly recorded by clinicians, in patient electronic records within 24 hours, as stipulated by Trust and NICE guidelines.

The first cycle was conducted from 16 October 2022 to 10 February 2023. In this cycle random sampling was used to select 25 patients on the caseloads of the mental health services for older people. Before the start of the second phase all diagnosing clinicians within the team were informed about the project and the expected improvements against which compliance would be audited. The second phase was conducted between 10 February 2023 to 31 March 2023 and another 25 patients on the caseloads were obtained via random sampling for the second cycle. Inclusion criteria for both phases were patients who had received a diagnostic assessment in these periods.

In the first set of records, the minimum body of information was recorded in 90–100% of cases according to the team's recommended standards namely diagnostic information, prognostic information, treatment plans, post-diagnostic contact plans and documentations being made within 24hrs of consultation. In the Set 2 the minimum body of information was recorded in 95–100% records studied. That is, diagnosis, treatment, medication treatment plans (prescription plans), and post-diagnostic contact plans were covered in the diagnostic sessions. In particular, case note documentations were made within 24 hours in all but one of the records applicable.

Given that a diagnosis of dementia can be life-changing, not discussing prognostic information would not prepare patients and carers adequately with information on how to live well with dementia following their diagnosis. This could potentially lead to poor adjustment to the condition and anxiety for some. At a trust-wide level, this means there is still room for improvement for the trust as regards dementia care ideals recommended by NICE.

In outpatient settings, depot administrations are done to a large extent by Community mental health nurses and other trained clinical personnel who are not psychiatrists. As a result of this, there is a possibility that patients who are having depot medications are not reviewed by a psychiatrist for a long duration of time which can be more than a year. The aim of this audit is to find out if patients currently taking depot medication under a General Adult Community Mental Health Service in North Norfolk are being reviewed by a psychiatrist according to the standard guidelines. The Maudsley prescribing guidelines states that all patients receiving long-term treatment with antipsychotics medication should be seen by their responsible psychiatrist at least once a year (ideally more frequently) to review their treatment and progress.

List of patients currently on depot medication were taken from the spreadsheet on the Unit's Shared drive. All 47 patients currently receiving depot medication on this list were reviewed. The review period was from Ist January 2023 to 31st December 2023. Psychiatrist Review included Reviews/Appointments by Consultant Psychiatrists, Specialty registrars, Trainee doctors and GPST doctors in psychiatry posting.

It was recorded that 28 patients on depot medication have been reviewed within the last one year which is approximately 60% of the patients currently on depot medication. 19 patients who are currently on depot medication have not been reviewed by a psychiatrist in the last one year, which is approximately 40% of the patients on depot medication. Out of the 19 patients who have not been reviewed in the last one year by a psychiatrist, only 8 of them were offered an appointment.

We can conclude only 60% of patients currently on depot medication were seen by a psychiatrist for a medication review in the last one year. This fell below the expected target of having 100% of these patients meeting with the standard that states all patients receiving long-term treatment with antipsychotic medication should be seen by their responsible psychiatrist at least once a year. A significant proportion of patients might have been deprived of an adequate assessment of their progress and response to treatment and the review of the side effects of these depot medications. These findings have been discussed with the Community Team Manager who has agreed to facilitate that these patients are reviewed promptly.

This comprehensive study seeks to evaluate the adherence of (CAMHS) service, Black Country Healthcare National Health Service (NHS) Foundation Trust to National Institute for Health and Care Excellence (NICE) guidelines in prescribing medications for children diagnosed with Autism Spectrum Disorder (ASD). Our primary objectives include identifying variations in prescribing practices across different localities within the trust and identifying specific areas that may benefit from improvement.

A meticulous retrospective analysis was conducted on 142 randomly selected cases involving children diagnosed with ASD and prescribed psychotropic or sleep medications. A comprehensive analysis of patient records, encompassing progress notes and clinic letters, facilitated the gathering of extensive data. The evaluation centred around benchmarking adherence to NICE guidelines. Throughout the process, strict adherence to ethical standards was maintained.

Within the cohort of 142 children diagnosed with ASD, 44% underwent alternative interventions before medication initiation. Notable variations were observed across localities, with 87% receiving psychological therapy as an alternative intervention. Documentation of consent for commencing medication was present in 62% of cases. Specialists consistently initiated psychotropic medications at the minimum effective dose, and 70% of cases had a follow-up within 3–4 weeks. Sleep medications were prescribed to 77% of the cohort, with 55.5% of those undergoing alternative interventions before prescription.

The study's findings underscore significant variations in adherence to NICE guidelines, emphasizing the critical importance of exploring alternative treatment modalities before resorting to medication. Furthermore, collaboration with supporting agencies is highlighted as a crucial aspect of comprehensive care. The documentation of consent forms for all patients is deemed imperative, and adherence to specified intervals for reviewing medication side effects, as outlined in the guidelines, is considered crucial for optimal and safe patient care.