Rampton Hospital is the High Secure Hospital of Nottinghamshire Healthcare NHS Foundation Trust's Forensic Service. It is one of three such hospitals in England, following Security Directions set out by the Department of Health. Patient management occurs through the implementation of strict policies and procedures. Policy requirements highlight the need for MDT post-incident discussion of restrictive interventions, and in particular, of Rapid Tranquilisation (RT). This primary audit aimed to ascertain current practice and if necessary, suggest interventions to ensure that patient-care remains safe, effective, and well-led.

To establish current practice with regards to the discussion of individual cases of RT in MDT settings, specifically in Ward Round, we commenced a retrospective data collection from electronic notes covering all directorates within the High Secure estate between May and June 2022.

From these notes, we tried to ascertain whether the following policy standards were being met:

• • A de-brief with the patient should take place as soon after the incident as is practicable and reasonable, ideally within 72 hours.

• • The MDT meeting post RT episode should explicitly discuss the episode, and consider medication and any triggers of periods of acutely disturbed behaviour.

• • There were 81 data sets to explore.

Not all data sets were viable. Out of those analysed, less than 10% were found to have met the aforementioned ideal policy standards of having had a reflective discussion within 72 hours with both the patient and as an MDT, exploring the episode itself and its antecedents.

There are several interesting factors to consider from the results obtained. We postulate that the frequency of episodes of RT makes meeting the policy standard problematic; pragmatically, there is a significant time barrier to exploring these incidents in detail and the various teams, operating in dynamic and high-risk environments, may find it difficult to coalesce in order to debrief appropriately.

Furthermore, the reflections may actually be happening, but the burden of documentation mean that these are not being recorded formally in a way that can be measured.

There are limitations to the searches of electronic notes and we did not have access to Incident Reports, often completed at the time of these episodes; further information may have been uncovered if they were available.

Despite this, there is room for interventions that inform staff of this need and to provoke improvements in current practice.