Elderly patients are more vulnerable due to the higher prevalence of underlying physical health problems. Hence, it is prudent to have a baseline and regular update on the physical health assessment for all old age mental health inpatients. This paper is aimed to discuss the clinical audit findings on the physical health assessment are done in accordance to the trust policy.

The clinical audit was conducted in a local elderly inpatient mental health unit over a period of a week. The standard used was based on the local Health Board Policy on acute inpatient admission, which includes an admission clerking with details on physical health need and physical examination should be done within 12 hours of admission, blood investigations and medication chart should be completed within two hours of admission, and an ECG (electrocardiography) should be done at the point of admission.

A total of 21 elderly inpatients admission clerking were analysed. It is noted that over 95 cases admission did not adhere to the prescribed standard. Only 67% of the admission clerking was completed within 12 hours, while only 52% of the admission had physical examination done. Only 24% of the admission completed their blood investigations within two hours and 14% of them had ECG done at the point of admission. Although 90% of medication chart was completed within two hours of admission, there is still room for improvement. Feedback from the junior doctors revealed a multifactorial contribution to the failure of meeting the standards: patient being agitated during admission, lack of communication among different teams, lacking an online documentation system on handover, and the heavy workload on junior doctors on venepuncture and ECG.

The clinical audit has shown a huge area of improvement is needed in terms of the physical health assessment and documentation for elderly inpatient psychiatry unit.

We recommend having a good handover system, training more nurses and HCWs in phlebotomy and ECGs, having ward based doctor cover to improve the adherence for future.

We will be presenting this audit in post grad teaching and junior doctor forum with a plan to conduct a regional audit to compare the adherence on the three different hospital under the same health board.

In Bolton Early Intervention Team (EIT) it was noticed that patients prescribed antipsychotics frequently required a change in medication due to side effects. Similar issues had been identified in Avon and Wiltshire NHS Foundation Trust where a prescribing guideline was developed which won the NICE Shared Learning Award in 2020. This recommends prescribing Aripiprazole first line and cautions using Olanzapine or typical antipsychotics first due to their side effects. The aim of this project was to identify which antipsychotic drugs are currently prescribed in first episode of psychosis (FEP) in Bolton EIT patients and to audit adherence to National Institute of Clinical Excellence antipsychotic prescribing guideline CG178.

The sample included all adults with FEP accepted by Bolton EIT across a four-month period from 01/12/20 until 31/03/21. Fifty-two people were identified.

Measured standards were documentation of prescribing rationale, discussion regarding medication side effects and weekly weight monitoring for six weeks following initiation. Antipsychotic choice and need for a change within six months of initiation was recorded. Data were collected retrospectively from patients’ electronic records.

Thirty-eight patients had been prescribed an antipsychotic – fifteen as inpatients, seventeen by Bolton EIT and six by the Home Treatment Team.

Of the fifteen inpatients Olanzapine (8) and Zuclopenthixol (3) were the most common choice. 5/15 had a documented rationale, and side effects were discussed with 3/15 patients. Weekly weight monitoring was performed in 7/15.

Of the 17 people who started antipsychotic medication once under Bolton EIT Quetiapine (6), Olanzapine (6) and Aripiprazole (5) were the most common choices. 12/17 had a documented rationale and 13/17 were consulted regarding side effects. Weekly weight monitoring was not performed for any of these patients.

Within six months, sixteen antipsychotic prescriptions (42%) were changed due to side effects (9), inefficacy (6) and non-compliance (1). The drugs changed were Olanzapine (6) Quetiapine (6) Zuclopenthixol (2) Aripiprazole (1) and Chlorpromazine (1).

Those initiated on antipsychotics as inpatients need better involvement in decision-making and consultation about side effects. A community initiative should be introduced to offer weekly weight monitoring. Further work is required to understand the rationale for frequently prescribing Olanzapine and Zuclopenthixol in inpatient services, and to consider why Aripiprazole is infrequently used first line.

All detained patients should have a leave risk discussion carried out prior to commencement of home leave. Driving risk must be clearly discussed and captured during the assessment. Driving advice as per DVLA guidance must be documented in case notes and discharge summaries. The aim was to audit and reaudit the use and quality of the driving risk assessment during leave risk discussions within adult mental health inpatient wards at one site under the Tees, Esk and Wear Valleys NHS Foundation Trust. The authors hypothesise that compliance to local policies could be improved upon.

Standards were set based on local policies. The audit was conducted across all adult acute inpatient wards within the identified mental health hospital. All inpatients who went on a period of home leave during their admission and ultimately discharged during the period from 1 April 2021 to 30 April 2021 (initial audit) and 1 October 2021 to 31 October 2021 (reaudit) were assessed. The data were collected using an audit tool. An Excel spreadsheet was used to collate data: specifically driving status of the patient, whether a leave risk discussion which captured driving risk was carried out, and whether DVLA advice was captured on discharge letters.

48 patients (19 were drivers) during the initial audit and 27 patients (9 were drivers) during the reaudit met the inclusion criteria. For the initial audit, overall compliance for leave risk discussion (73%), specifically for driving risk assessment, did not meet target compliance. Only 5% of drivers were given written DVLA guidance on discharge letters. The reaudit showed a 100% compliance in the use and quality of leave risk discussion. 56% of patients had written confirmation of discussion on DVLA driving advice recorded on discharge summary.

There has been significant improvement in the use and quality of leave risk discussion, and documentation of DVLA driving advice on discharge summary during the reaudit.

The results were discussed at the Regional Audit meeting and the Inpatient Leadership Meeting. The following improvement plan was agreed and implemented:

1. 1. Regular communication amongst Multi-Disciplinary Team (MDT) during Leave Risk Discussion. One healthcare professional assigned to inform patient of the advice and capture conversation on case notes.

2. 2. Junior doctor induction to reiterate importance of capturing DVLA advice on discharge letters.

3. 3. MDT to discuss driving risk and advice during discharge meetings. “Driving advice discussion” to be added to discharge meeting checklist.

Women with perinatal mental illness are at increased risk for severe illness with COVID-19. Vaccination against COVID-19 is strongly recommended by JCVI (Joint Committee on Vaccination and Immunisation) and RCOG guidance. Mental health professionals should proactively inform their patients about COVID-19 vaccination and also address any concerns or misinformation, should they be raised. The aim of this audit was to evaluate the rate of uptake of the COVID-19 vaccine among patients under the West Kent community perinatal mental health team. In addition, we aimed to identify factors that deter patients from taking the COVID-19 vaccine. In patients who were hesitant to take the vaccine, we offered further information to aid their decision-making process.

We identified patients under the care of the West Kent perinatal mental health community team on 27/10/2021. We excluded patients who were discharged from the team in subsequent weeks during data collection. We collected patient demographics including highest level of education, ethnicity, religion and socio-economic status. Patients’ COVID-19 vaccine status was obtained via GP records or through telephone contact.

If patients had not had their COVID-19 vaccine, they were contacted to enquire whether they were planning to take the vaccine, if not, to ascertain reasons for refusal and whether they wanted additional information about the vaccine. Those women who requested additional information were offered the RCOG information sheet and decision aid.

Amongst 86 patients included in the audit, 59% (n = 51) had taken both dose of the COVID-19 vaccine and 12% (n = 10) had taken a single dose. 29% (n = 25) were unvaccinated.

68% (n = 17) of unvaccinated patients were pregnant and 32% (n = 8) were postnatal. All women who did not accept COVID-19 vaccine were contacted to offer further information. Following this contact, 39% (n = 9) decided to accept the vaccine, 52% (n = 12) refused the vaccine and 26% (n = 6) were uncertain but were willing to consider taking the vaccine in the future.

The reasons for hesitancy in accepting the vaccine included a lack of trust in the vaccine, concerns around its development over a short period of time, concerns around close associates experiencing illness or side effects after taking the vaccine and scepticism over efficacy of the vaccine. Few women did not wish to take the vaccine during their pregnancy, but were willing to consider it after the birth of their baby.

We identified potential areas to optimise uptake of COVID-19 vaccines by discussing the importance, safety, efficacy and providing up-to-date information regarding COVID-19 vaccine in the perinatal period.

This is a re-audit of Benzodiazepine and Z-hypnotic drugs prescriptions in two community treatment teams (CTTs) in the Cumbria Northumberland Tyne and Wear (CNTW) Trust, comparing with previous audits in 2009, 2017 and 2018 to check whether areas of good practice were maintained, and progress was made.

We reviewed caseloads of four CNTW consultants in the two CTTs which included 554 patient encounters with 60 encounters where benzodiazepines or z-drugs were prescribed. Nine missing data sets brought the total audit sample to 51. For these 51, prescribing information was gathered from RiO and assessed against standards derived from CNTW Trust Policy and BNF prescribing guidance. To be compliant, 90–100% of prescriptions needed to meet the standard.

Overall, the rate of prescribing of benzodiazepines and Z- drugs increased from previous audit (7% in 2018, now 10.8%). Good areas of practice maintained were as follows (all 100%): all teams were compliant in prescribing within BNF limits, refrained from prescribing diazepam in 10 mg formulation, and no pregnant/post-partum women were prescribed these medications.

Although non-compliant, there were clear improvements in documenting indicated use (2018: 61.65%, 2021: 80.8%), and providing prescriptions of <4 weeks in duration (2018: 58.2%, 2021: 79.2%)

Key areas of concern were as follows: poor documentation of indication, duration of treatment and plans for review/discontinuation (compliance ranged from 31.5% - 81.2% in these areas). There was poor documentation of what verbal advice was given (0–16.9%), and lack of clearly documented tapering/discontinuation plans for those on long-term prescriptions (16.1%). The provision of written advice reduced from previous audit (2018: 10.7%, 2021: 5.8%). As 41/51 encounters were via telephone or video due to COVID-19 pandemic, this may have impacted on results.

Despite improvement in some areas, there remains scope for ongoing improvement in other areas. To improve these, we plan to produce and distribute an educational email to all prescribers, including the following: information on this audit and its findings, prescribing guidelines, relevant e-links to patient information leaflets as well as the audit proforma used for this audit, to encourage prescribers to undertake self-directed practice. A poster will be distributed, highlighting prescribing guidelines and standards, to be printed and displayed in clinical areas as reminder of prescribing responsibilities and the importance of documentation. Prescribers will be encouraged to participate in a small quiz to test learning. Efficacy of these measures will be assessed with a re-audit in one years’ time.

The aim of the project was to improve the routine incorporation of driving advice based on Driver and Vehicle Licensing Agency (DVLA) guidance into discharge planning by responsible inpatient teams. This would optimize patient safety, demonstrate good clinical practice (trust and professional body values) and minimize/prevent the emergence of accidents/unfair loss of licenses/unfair attribution of driving accidents caused by people who have been under recent or ongoing inpatient care.

The following questions: “Do you have a valid license”, “Do you own/have access to a vehicle”, “Do you currently drive” were developed as a standard template for gathering patients’ driving information.

These questions were embedded within:

1. 1. Barriers to ward discharge discussions

2. 2. Trust-wide communications via screensaver and circular

Answers to these questions were to be clearly documented on patient's records to serve as prompts for the responsible discharging team to take up providing the appropriate advice.

After a specified period, the electronic discharge notification (EDN) database was searched for patients with relevant diagnosis who were discharged from all the general adult/older adult acute inpatient wards within a specified period. The patients’ records were then checked for documentation of relevant driving information evidenced by documentation of answers to the screening questions as well as recorded evidence of DVLA discussion/advice held since date of diagnosis or admission.

The standards audited against were all patients:

1. 1. should have their driving licence status recorded during their admission

2. 2. should have their access to a vehicle recorded during their admission

3. 3. with a relevant mental health diagnosis should have a record of advice regarding driving given in bespoke and DVLA informed manner during ward discharge planning by the responsible discharging team

4. 4. should have documentation of the outcome of the driving advice given by the responsible team in their records

28 patients with relevant DVLA notifiable mental health conditions were audited. 11% (n = 3) had driving licence status recorded. 14% (n = 4) had access to a vehicle recorded. 7% (n = 2) had driving advice given. Only one patient had outcome of driving advice recorded. No best practice was identified.

Documentation of driving information, DVLA signposting advice and outcome for patients with relevant mental health diagnosis is a crucial part of patient risk assessment and management as these patients are not free from posing a driving risk on discharge. The trust is implementing actions to improve the routine incorporation of driving advice based on DVLA guidance into discharge planning.

To ascertain whether current medical assessment and management of self-inflicted head injuries in an inpatient CAMHS setting conforms with current NICE guidance.

Incidents of self-inflicted head injury were identified on the incident logging system Ulysses. Incidents were matched to entries on Paris, the online clinical notes system. Data were collected from Paris on whether the incident was reviewed by a doctor, time until doctor review and which components of the NICE guidance were completed during the review. The data were collated into an Excel spreadsheet and analysed.

Inclusion criteria were CAMHS inpatients at 1 Greater Manchester hospital during November 2021 who had an incident of ‘head banging’ recorded on Ulysses. Exclusion criteria were patients on ward A as the ward was found to have its own care plans for managing head banging rather than escalating to doctors.

There were 52 incidents of head banging logged. 56% (n = 29) of incidents received a doctor review and 32% (n = 17) did not. For 10% (n = 5) of incidents a doctor review was declined and for 2% (n = 1) a review was conducted for another indication. The mean time taken until review was 4.3 hours with a range of 1 to 16 hours.

NICE guidance lists 9 components of the history that should be covered. 1 component met the 100% target and 1 component was documented in > 50% of incidents. The remaining 7 components were documented in < 50% of incidents.

NICE guidance lists 16 components of physical examination that should be completed. No components of the physical examination met the 100% target. 5 components were documented in > 50% of incidents. The remaining 11 components were documented in <50% of incidents.

NICE guidance recommends verbal and written safety netting advice is given. Advice was given in 16% (n = 5) of incidents. NICE recommends a responsible adult remains with the patient for 24 hours, this was documented in 77% (n = 22) of incidents. NICE recommends ongoing doctor concerns necessitate patient transfer to A&E. Concerns/lack of concerns were documented in 6.6% (n = 2) of incidents.

This audit has demonstrated inconsistencies between doctor's documentation of self-inflicted head injuries in an inpatient CAMHS setting. The reviews do not meet the standards outlined by NICE. There is a good emphasis on gross neurology but less awareness of the need to document more subtle pathology and ongoing monitoring requirements.

To improve the Psychiatry induction for DiTs in Fife.

The purpose of induction is to provide Doctors in Training (DiT) with a smooth, supported transition between roles. Delivered well, it will promote confidence and also provide a thorough grounding in the key requirements of the role and clarity regarding sources of help.

A recent report, commissioned by the GMC, identified the key areas which should be covered in induction. The findings demonstrated a clear link between inadequate inductions to the impact on doctors’ well-being and patient safety issues.

A questionnaire was issued to DiTs completing Psychiatry inductions in August and December 2021. Questions focused on the following key areas highlighted in the GMC report:

• • Gaining access to workplace settings and systems

• • Physical orientation of workplace

• • Team inductions

• • Daytime role and out of hours working and rotas.

• • Familiarisation with common cases/procedures that doctors may deal with in this speciality: risk management, use of the MHA

Questionnaire Results: Key Issues highlighted

August 2021

• • FY2 to ST6 inducted together: differing experience levels

• • Differences in site inductions (psychiatry is spread across 3 hospitals in Fife)

• • Issues obtaining swipe cards/keys

• • IT access for emails and various computer systems delayed

• • Computer systems training not done

December 2021

• • Lack of psychiatry experience of FY2s

• • Continued IT access issues initially

In September 2021, a working group was established comprising DiT representatives and those responsible for induction. The August 2021 results were disseminated and key improvements were identified in areas covered by the clinical induction:

• • An improved induction check list universal for all sites.

• • Induction documents for each role detailing responsibilities and useful information.

• • Integration of IT training.

Plans have been made to provide simulation events which would give DiTs practical experience in a safe environment of various topics e.g., risk management in psychiatry. Additionally, there are plans to revise induction for speciality trainees.

To assess the compliance of the clinicians in EIP team with DVLA guidelines. Objectives: To assess if there was documented evidence of: 1)Patient's diagnosis, 2)Patients’ driving status, 3)Type of vehicle driven, 4)Informing the patient that their condition may affect their ability to drive, 5)Advice regarding driving restrictions where applicable, 6)Informing the patient that they have a legal duty to inform the DVLA about their condition

We selected two-thirds of the patients(n = 40) enrolled in the EIP service in the last year by consecutive sampling. We collected the data retrospectively from the clinical documentation and analysed it using excel sheets.

The mean age of the study sample was 34 years. 95%(n = 38) had a documented diagnosis, 67.5%(n = 27) had a documented driving status. The documentation of driving status was completed by doctors in 52%(n = 14), nurses in 26%(n = 7) and by both in 22% (n = 6). The type of vehicle driven was documented for only 33%(5) of the drivers. Among the drivers identified 33%(n = 5) had been informed that their condition might affect their driving, 67%(n = 10) had received information on driving restrictions and 47%(n = 7) had received information that they have a legal duty to inform the DVLA.

One of the reasons for the low compliance may be because another team might have documented the information at the time of referral. It is possible that the professional involved did elicit the information but didn't document the same. Healthcare professionals(HCP) have to identify, discuss and document driving-related information as advised by the DVLA. In cases where the patients’ don't follow the advice, the HCP must notify the DVLA.

Assessment of driving history and the risks associated are critical. Awareness should be raised among the clinicians (through training and team meetings). This practice should be made an integral part of the structured initial assessments. Patients can be offered information leaflets. If successfully implemented, it will prevent unsafe driving and minimise the risk of harm for the patient and other road users.

The COVID-19 Pandemic has had an impact on most aspects of functioning on the world in general. We wanted to see what impact of COVID-19 Pandemic has had on a Crisis Resolution Home Treatment Team North Peterborough. The main objectives of this audit were to see changes in Crisis Resolution Home Treatment Team North number and source of referrals, average length of stay, total number of patients Home Treated during this period (Pre and during COVID-19 pandemic) and to also identify whether patients with a certain diagnosis deteriorated or presented more to services compared to others.

We retrospectively reviewed case-notes and data were collected from RiO Electronic Patient Records (EPR) covering all the factors we wanted to analyse. Data collection periods were pre-COVID-19 between 1st April 2019 and 30th September 2019 and COVID-19 pandemic (1st Lockdown) between 1st April 2020 and 30th September 2020. Total number of referrals received between April and September 2019 pre-pandemic were 844 and total number of referrals received during COVID-19 pandemic between April and September 2020 were 660. Data were exported from the electronic patient record into Microsoft Excel and quantitative analysis was performed using Microsoft Excel.

The results showed 21.8% drop in total number referrals from 844 to 660 and there were 20.89% (79) less patients Home Treated from April and September 2020 during first lockdown compared to the similar period in 2019. Significant increase observed in patients with bipolar affect illness by 32% (from 86 to 128 patients), acute stress reaction and adjustment disorder by 15% (from 68 to 80 patients) and psychotic disorder by 11.5% (from 245 to 277patients) in 1st lockdown period compared to 2019 similar period. Declining trend observed in intentional self-harm by various means by 20.75% and 4% drop in personality disorder patients. Anxiety and depression patients number remained same in both periods.

Although referral numbers dropped significantly and Crisis Resolution and Home Treatment Team caseload decreased during the COVID-19 pandemic first lockdown, the number of patients with serious mental illness presented to services increased remarkably (bipolar and psychotic illness). Overall, no major change in length of stay of patients with Crisis Team was observed when compared both periods and referral numbers remained low from all sources during COVID-19 pandemic.

In Leeds, Key Performance Indicators (KPIs) specify that patients should be offered an initial assessment within eight weeks of referral to the Memory Assessment Service (MAS) and diagnosed within 12 weeks. Additionally, post-diagnostic support (PDS) should be offered within two weeks of diagnosis. There are concerns that these targets are not being met due to the COVID-19 pandemic's impact on referrals and staff absence. This audit aims to establish whether the West Leeds MAS meets KPIs relating to the assessment and diagnosis of dementia and the provision of PDS in 80% cases.

The 67 patients who were referred to the West Leeds MAS between 1 June and 31 July 2021 were included in this audit. Data were collected retrospectively from electronic patient records using an online proforma designed a priori. All data were quantitative and analysed descriptively using Microsoft Excel.

59 patients received an initial assessment; 19 (32%) received their initial assessment within 8 weeks, 14 (24%) had a delayed assessment with a documented reason, and the remaining 26 (44%) had a delayed assessment with no clear reason. 41 patients received a diagnosis; 23 (56%) received the diagnosis within 12 weeks, 12 (29%) had a delayed diagnosis with a documented reason, and 6 (15%) had a delayed diagnosis with no clear reason. Of those diagnosed, 25 (61%) were allocated a PDS appointment. No patients were offered PDS within 2 weeks of diagnosis, with no documented reasons for these delays.

The MAS failed to meet the KPIs of interest, which may be partly explained by staffing issues and a backlog of referrals following the service's suspension in 2020. We aim to raise awareness of the KPIs, and the importance of documentation when KPIs cannot be met, by presenting at local meetings. We plan to liaise with clinical managers to identify systemic strategies to improve flow through the service while ensuring patient-centred care, and we will assess impact by repeating the audit in 12 months.

Failure to attend outpatient clinic appointments by service users without prior notification is a major contributor to waste resources. Failure to attend earlier in treatment predicts attrition later in treatment (Goode, 1997; Aubrey et al, 2003) leading to further waste of resources. The department of health figures for England show that failure to attend outpatient clinic is more in mental health clinics (19.1%) compared with overall figures for other specialties 11.7% (Department of Health, 2003). Lack of appropriate follow-up when a service user does not attend as appointment has been identified as a contributory factor in Serious Incident investigations, Domestic Homicide Reviews and Safeguarding Adults Reviews. Our aim of this study is to see if we are adherent to trust policy or not.

A questionnaire tool was designed by using trust guidelines regarding DNA appointment

1. a. Was The DNA Recorded in patient's records? YES/NO

2. b. Was the information (DNA) shared with GP? YES/NO

3. c. Was The DNA discussed in MDT meeting? YES/NO

4. d. For new referrals was the referrer involved in review and decision of next step? YES/NO

5. e. Were alternative venues considered for carrying out the assessment to support the person to engage, e.g. GP Surgery? YES/NO

Data were collected by team and analysed by Dr Saleh using electronic records.

88 outpatient appointments were flagged as DNA appointments between 1 April 2021 to 31st May 2021

1. 1. In 87.5% cases DNA was recorded in patient's records?

2. 2. In 45.45% cases the information (DNA) was shared with GP

3. 3. In 45.45% cases DNA was discussed in MDT meeting

4. 4. In 0% case the referrer was involved in review and decision of next step

5. 5. In 11.36% cases alternative venues was considered for carrying out the assessment to support the person to engage, e.g. GP Surgery.

6. 6. 25 patients DNA appointment twice

We are not adherent to trust policy.

The outbreak of COVID-19, lockdown and self-isolation has created a lot of additional pressure on the society as a whole. We aim to audit the number of patients presenting to SVUH ED since March 27th 2020 (the date at which the government imposed a stay-at-home order) with an overdose.

The cohort of cases analysed was identified using ED MAXIMS under the subheading of ‘overdose and poisoning’ presentations. Data were collected using MAXIMS and clinical portal and stored on the SVUH system and analysed using Microsoft Excel and SPSS.

There were a total of 713 cases in both years (from 27th of March – 31st December), with 353 (49.5%) admitted in 2019 and 360 (50.5%) admitted in 2020. Out of those admitted, 423 patients were females (196 and 227 in 2019 and 2020 respectively). There was a significant increase in the number of female presentations in 2020, with a p value of 0.041.

When stratifying patients based on age, the mean ages were 37.22 (SD 17.04) and 34.18 (SD17.32) in 2019 and 2020 respectively (p = 0.076). When dividing age groups in three categories (under 18, over 65 and 19–64), our data showed significant differences. There was a significant increase in numbers in the ≤18 yr and 19–64 age groups in 2020 compared with 2019. In the under 18 groups, there was an increase in numbers by 7.9% in 2020 (11.6% compared with 19.5%). When comparing numbers between Months per year, overall, there were no changes in presentations. Interestingly March 2020 had no presentations compared with March 2019, coinciding with the beginning of the pandemic in Ireland. May showed more than 50% decrease in presentations in 2020. Similar numbers were seen in the rest of the months of both years.

Between 2019 and 2020, there was a 1.9% increase of ED presentations with overdoses, which did not show any significance in increase of numbers or in age demographics. There were three main findings from our analysis:

• 1. A significant difference between the two years in a rise in female patients admitted with overdose (p = 0.041)

• 2. An increase in presentations in the age groups of under 18 and 19–64. This may allude to increase strain in the younger population with loss of jobs, financial burdens etc.

• 3. There were no presentations in March 2020, coinciding with the beginning of the pandemic in Ireland.

The aim was to investigate the proportion of patients with a previous diagnosis of learning disability or autism who later successfully underwent an annual review of their prescribed anti-psychotic or anti-depressant. This audit was prompted after Public Health England announced that a significant number of adults with a learning disability, autism or both take a prescribed antipsychotic, an antidepressant or both without appropriate clinical indications (psychosis or affective/anxiety disorder).

The sample included 23 patients from the practice who had received a diagnosis of learning disabilities, autism, or both by 12th October 2020. Of these, 12 patients had a record of at least 5 prescriptions of an anti-psychotic in the last 12 months and 20 patients had a record of at least 5 prescriptions of an anti-depressant within the last 12 months. The notes for these patients were reviewed in May 2021 in an effort to ascertain whether a medication review had been completed for these patients since May 2020. The review process included a phone call between the patient and the prescribing doctor to determine whether there any side effects were being experienced and to assess the need for the continuation of the prescription. The resulting data were recorded and analysed on Microsoft Excel.

Out of the 12 patients who had been prescribed an anti-psychotic, 10 had received a medication review within the last 12 months. From the 20 patients who had been prescribed an anti-depressant, 19 had undergone a review of their medication within the last 12 months.

Review of anti-psychotics and anti-depressants prescribed to patients with a diagnosis of learning disability, autism, or both was overall positive with the majority of these patients receiving a medication review within 12 months. As a further recommendation, another audit can be done to explore whether these patients had an annual blood test done as increased cholesterol is a known side-effect of psychotropic drugs.

Though Autism Spectrum Disorder (ASD) is a common childhood neurodevelopmental disorders, the literature on presentation of undiagnosed ASD in Consultant Child and Adolescent Mental Health Services, (CAMHS) is scarce. The aim of the study was to look at symptoms at presentation among boys and girls in CAMHS, compare the symptom profile between the two genders, establish the main referral and assessment pathways and interventions employed after diagnosis

This was a retrospective review of patients’ files referred to ASD Walsall CAHMS Clinic conducted in February 2021. A random sample size of 44 boys and girls equally distributed from the ASD database was selected randomly from the completed ASD assessment list, the equal distribution between genders was intentional. We looked at presenting symptoms reported on the referral letters, assessments in CAMHS, and interventions outlined from ASD outcome letters of all subjects with completed ASD assessment, in age groups 7–18 years.

Across genders, most patients presented in the teenage years with common age of presentation seen at ages 15 and 17, both at 15.9% and mean age being 13 years. Ninety-five percent of patients were in school at the time of referral. Only 4.5% of patient were referred through crisis and the rest through local GP. A variety of presenting symptoms were seen, with the majority of the patients presenting with social and communication difficulties (77.3%), under /overreaction to sensory stimuli (63.6%) and anxiety (61.4%). 9.1% of patients had a family history of ASD. 100% of assessments included ADOS, SALT and neurodevelopmental assessment. 77.3% of patients were referred to support groups like living with ASD parent support groups. Along with CAMHS, education (97.7%) was the main agency involved in the care of these patients. In 44.2% of patients, EHCP was requested or already in place. The in between gender comparison also showed that although most symptoms were similar in both groups, some such as self-harm were higher among girls (27.3%) as compared to boys (13.6%) as well as obsessional symptoms which were more common in boys (63.3%) as compared to girls (27.3%).

Undiagnosed ASD presents with a wide variety of symptoms amongst boys and girls. Previous UK studies have shown an earlier presentation of ASD and which is contrary to our findings demonstrating a much later presentation. Therefore, we recommend referrers to be aware of the varied presentations and have a lower threshold for referral to secondary services to aid quicker ASD diagnosis and management.

Liaison psychiatry provides psychiatric care to medical patients. Patients include those attending emergency departments, general hospital inpatients and outpatients. Liaison teams work hand in hand with several general hospital teams to offer advice, review and manage these patients. Over the last few months, the Liaison service in City Hospital have been receiving many inappropriate referrals. Inappropriate referrals are defined as patients who are referred to services, with one of the following reasons:

1. 1. Insufficient presenting complaint

2. 2. No documented Past psychiatric history

3. 3. Insufficient Mental state Examination (MSE)

4. 4. No risk assessment

5. 5. No documented Drug/alcohol history

6. 6. Patients having not consented to referral.

7. 7. If one or more of the above criteria is not met

Our aim was to evaluate the appropriateness of the referrals received from D15, D17, D27 inpatients wards in City Hospital over a 3-month period from July to September 2021. These wards were chosen as they commonly refer patients to liaison services.

We collated data retrospectively on the nature of all referrals from D15, D17 and D27 ward over a 3-month period. The patient referral portal was used, and referral content of each patient was analysed. An audit tool was devised to assess whether the referrals followed the liaison referral pathway and guidelines set by NHS England for referral structure to liaison services.

18 patients were referred to the Liaison psychiatry from the three wards over the three-month period. We observed 77.8% (n = 14) of the referrals having insufficient information for the presenting complaints, whilst 22.2% (n = 4) of them did not state past psychiatric history. Approximately 94.4%(n = 17) did not state sufficient details of MSE. In 83.3% (n = 15) of referrals appropriate detailed risk assessment was not done, 27.8% (n = 5) of them did not have alcohol/ drug use stated and 22.2% (n = 4) of patients referred did not consent to the referral being made.

The results demonstrated that ward referrals lack quality and contain inadequate information to allow for safe screening of patients and for the implementation of appropriate actions by the liaison team. A possible reason for inappropriate referrals may be due an existing knowledge gap and lack of confidence taking detailed psychiatric histories, assessing risk, and performing MSE in non-psychiatric trainees making referrals to liaison services.

To ensure that psychotropic prescribing and monitoring in the Crisis Team is compliant with NICE guidelines and to provide excellent patient care and to practice medicine safely.

Medication prescribing should be a collaborative decision by the service user and the prescriber. This allows patients to have autonomy to decide their treatment plan. NICE provides guidelines for prescribing medication which includes baseline investigations, reviews of treatment including side effects, and physical health monitoring.

We selected 50 admitted patients for the audit from April 2021 until September 2021, who were prescribed psychotropic medications. We used medication cards and electronic patients’ records (System One). Our exclusion criteria were the 72-hour post-discharge follow-up from the inpatient ward.

The audit standards included as follows: age, gender, the indication, the start of medications, dose, within BNF limits, discussion, consent from the patient, comorbidities, physical health monitoring, response to treatment, monitoring of side effects, and other important information.

100% results for indication, dosage, discussion with the patient, and side effects monitoring.

We had promising results for benefits from the treatment (46 out of 50 patients responded to treatment) and 4/50 did not respond to treatment. Unfortunately, one patient died from an overdose of illicit drugs, not with prescribed medication and one was admitted, and one felt worse, and one did not have any response.

However, 22 out of 50 patients were prescribed antipsychotic medication.11 out of 22 patients had ECG and blood done by the Crisis Team and 4 done by other parties (hospital and primary care).3 had recent blood tests but no ECG.2 patients did not have physical health monitoring and the reason was not documented.2 patients were started on antipsychotic by the Crisis Team, but the dose was not changed.

In terms of side effects, 8 out of 50 reported some side effects.

6 of them were prescribed antidepressants. They reported difficulty in sleeping and palpitations with Venlafaxine, nausea with Fluoxetine, nonspecific side effects with Citalopram, and sedation with Trazadone. 2 patients felt dizziness, diarrhoea, and muscle spasms with Mirtazapine. One patient had a metallic taste with Zopiclone. For side effects with antipsychotics, only one patient reported side effects with Olanzapine.

• • The Crisis Team is working at excellent standards on most areas of psychotropic prescribing and monitoring

• • The Crisis Team needs to improve physical health monitoring of their patients.

Lithium is a useful drug and is of particular benefit in patients with chronic mood disorders like bipolar affective disorder and recurrent depression. Lithium requires careful monitoring and dose adjustment for safe use due to its narrow therapeutic index and high potential for toxicity. Monitoring must carry on even when mental health patients taking Lithium are admitted to acute hospital. Therefore, the main aim of this clinical audit was to evaluate the level of awareness of the lithium safety guidance amongst medical staff working within the Acute Hospital, James Cook University Hospital. Ideally 100% of staff should have the appropriate knowledge.

Questionnaire consisted of 6 items which were derived from key points within the Trust guidelines for Lithium. It was designed to highlight the key points in the document and check the level of awareness of the respondents. Respondents were drawn from James Cook University Hospital and South Tees Liaison Psychiatry team. A total of 25 respondents were included in the study.

96% (24/25) of the respondents were aware that renal and thyroid function should be checked for patients on Lithium. 84% (21/25) were aware of the potential impact of Lithium on Kidney function (eGFR) and 68% (17/25) were aware of signs of Lithium toxicity.

60% (15/25) of acute staff were aware about referring patients with deranged Lithium levels to the Liaison Psychiatry team. 40% (10/25) were aware of the drugs that could potentially increase lithium levels like Diuretics, Non-steroidal anti-inflammatory drugs, ACE (angiotensin converting enzyme) inhibitors. Only 24% (6/25) of acute trust staff were aware about checking lithium levels on admission.

Ideally, a 100% compliance and positive response rate should be achieved as these relate to completion of expected safety checks. Lithium is a potentially high-risk drug with a narrow therapeutic index. Possibility of its acute and chronic side effects, including lithium toxicity, makes it essential to follow safety guidelines on lithium prescribing and hence ensure patient safety.

In view of this, the clinical audit results clearly show that there is significant room for improvement to achieve a 100% positive response rate for awareness of safety guidelines on Lithium prescribing.

Overall, there were an average of 57% positive responses and 42% negative responses for awareness of various aspects of the safety guidelines for Lithium.

A robust action plan which included teaching sessions on creating awareness about lithium monitoring was planned because of this audit.

On 11th February 2020 a novel coronavirus was named SARS-CoV-2, with the World Health Organisation announcing that the associate disease would be known as COVID-19. As doctors providing an inpatient psychiatric service, there were various changes in our daily practice secondary to the pandemic. These included reduced staffing levels due to illness, the need to wear personal protective equipment during all patient contact and high levels of anxiety surrounding transmission. We hypothesised that the resultant pressure on our service might impact the quality of admission clerkings to our ward, (a 17 bed functional Old Age Psychiatry ward), and therefore resolved to audit the data. We determined that “quality” of the clerking should be equated to completeness, i.e. the degree to which all desired information is included.

Admission clerkings to the ward are to be completed on a pro forma built within the electronic patient record system (“Paris”). This pro forma is based on guidelines for the admission of patients to psychiatric inpatient units produced by the Royal College of Psychiatrists. The standard for the audit was set as 90% compliance with each individual section of the pro forma.

All admissions across three periods were extracted from the electronic record using the inbuilt reporting function. The periods were 1st April to 1st July in 2019 (pre-pandemic, n = 15), 2020 (early pandemic, n = 29) and 2021 (late pandemic, n = 22). Data were extracted manually from each admission clerking and recording anonymously on an excel spreadsheet, with either “yes” or “no” confirming or denying compliance with each domain (e.g. presenting complaint).

All domains showed improved compliance from 2019 to 2021 other than recording of the mental state examination which saw a 9.09% decrease (which is not statistically significant). Comparing the pandemic years, performance was better in the early pandemic in 4 domains, better in the late pandemic in 10 domains and equal in 6 domains. 4 domains demonstrated a statistically significant improvement compared to pre-pandemic, however 9 domains still fell below the 90% standard set.

Despite the challenges posed by the COVID-19 pandemic the quality of inpatient admission clerkings has not only remained unharmed but in some domains significantly improved. Admission numbers increased during the pandemic periods, so it may represent greater familiarity with the clerking process, or perhaps a desire to make more comprehensive notes during a time of crisis. Repetition of the study post pandemic may be of value.

To clarify if MHRA guidance regarding valproate prescription in women of childbearing potential is being followed by psychiatrists in Cwm Taf Morgannwg University Health Board.

Women of childbearing potential who were prescribed valproate for mental health conditions were identified by contacting GP practice pharmacists. The notes of these patients were reviewed to see if the ARAF (Annual Risk Acknowledgement Form) had been completed. The GP records were cross-checked to see if highly effective contraception was prescribed for women who were on valproate. The first audit was done in November 2018, while the second audit was completed in December 2020. The main intervention after the first audit was general awareness raising amongst psychiatrists in secondary care about the MHRA guidance and the need for annual reviews, through email reminders and posters. The 2020 audit gathered detailed clinical information, including the reasons for prescribing valproate and the doses prescribed.

2018 – out of 53 women on valproate, 1 had a completed ARAF, and 15 were on highly effective contraception.

2020 – out of 48 women on valproate, none had a completed ARAF, and 13 were on highly effective contraception.

Concerningly, only half (46%) of these women were prescribed valproate for bipolar disorder. The rest were prescribed valproate for a variety of diagnoses including schizophrenia, cyclothymia, emotionally unstable personality disorder, and complex PTSD.

Raising general awareness about MHRA guidance failed as an intervention in this audit. Hence, after the second audit, specific targeted emails are being sent to each sector's consultant psychiatrists, with a list of female patients of childbearing potential in their sector who are prescribed valproate. A valproate register was created for the Merthyr/Cynon and Rhondda/Taff Ely localities – to our knowledge, this is the first time this has been developed in Wales. The impact of these interventions is being evaluated with a third audit which is being done in March 2022. This audit cycle highlighted significant challenges in sharing information across primary and secondary care. Detailed information about patients on valproate, with information on prescribed contraception, was available only for the 2020 audit, due to the appointment of a pharmacist working across primary and secondary care.