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.

Inpatient admissions during the COVID-19 pandemic went up in the regional unit by 18%. This included a 50% increase in Eating Disorder Presentations and more complex SMI requiring admission to Beechcroft. Beechcroft is the regional inpatient unit for CAMHS in Northern Ireland. This project aimed to improve staff joy in work by 30% by June 2021, following what was one of the most difficult years to be a health professional with the COVID-19 pandemic.

We used the IHI Joy in Work methodology along with our own rating scales in the inpatient unit.

Several PDSA cycles were carried out including focus groups, gathering baseline data from different wards, and our change ideas- Beechcroft stars nominations, Virtual Quizzes and Staff recognition certificates.

Baseline data on our run chart demonstrated a bad day median in Beechcroft with 4.3 being the score.

With the PSDA cycle we demonstrated a 33% improvement in good day scores with a median of 1.4.

We have learnt that Joy in work comes from recognising the work already being done and rewarding the efforts our staff go to.

Spread and scale with Beechcroft stars now part of fortnightly MDT meeting and management meeting. Also rolled out to a community mental health team.

Joy in Work comes from the team. Recognising the efforts of the team is central to this. In particular during a pandemic.

The aim of this study was to assess the legibility as well as components of a prescription prescribed by doctors in tertiary care hospitals of Rawalpindi, Pakistan.

An analytical cross-sectional study was conducted in pharmacies of two allied hospitals of Rawalpindi Medical University. Data were collected using stratified randomized sampling. A total of 661 prescriptions were selected and analysed for legibility by three experts. SPSS version 26.00 and Graph Pad Prism were used to enter and analyze the data. Descriptive statistics, correlational model and multinomial logistic regression were applied.

A total of 1982 drugs were prescribed in 661 prescriptions. A total of 46.0% prescriptions were classified in grade 2 and 32.1% in grade 3. On average, 55.74% prescriptions were found to be complete. On average, prescriber's information, patient's information and medication details were present in 72.64%, 57.25%, and 36.73% prescriptions, respectively. Grade 1 (AOR = 0.62), grade 2 (AOR = 0.83), and grade 3 (AOR = 0.85) prescriptions had less odds of being complete compared to grade 4 prescriptions.

Majority of the prescriptions prescribed at tertiary care hospitals were barely legible and also quite a number of prescriptions were incomplete.

Hackney is home to the largest Charedi Orthodox Jewish community in Europe. According to the Census 2011, 7% of the population of Hackney are Charedi. Hatzola is a non-profit, volunteer organisation established in 1979 to provide pre-hospital emergency medical response and transportation to acute hospitals at no cost, to those living in and around the North London Charedi community. Given the large Charedi population served by Homerton University Hospital it is a common occurrence for psychiatry liaison staff to work side by side with Hatzola in delivering care to those in mental health crisis. Our aim was to create and nurture a professional relationship between Homerton University Hospital Psychiatry Liaison Service and Hatzola ambulance. We wanted to gain an understanding of the perception of mental illness within the Charedi community, and identify issues faced by members of Hatzola when working with those with mental illness. We wanted to identify the learning needs of Hatzola around psychiatric illness as well as increasing confidence within team members when called to manage mental health crises.

We scheduled an initial meeting with Hatzola to gain an understanding of their service. We used questionnaires to ascertain their level of knowledge on managing mental health patients. We set out to provide teaching sessions to address Hatzola's learning needs.

We designed interactive teaching sessions based on providing mental health first aid, discussing case studies, considering the legal framework around emergency mental health. We ensured coverage of working with both adults and children with mental health difficulties. We delivered these teaching sessions in person over four consecutive weekly meetings, with the sessions being recorded to serve as an educational resource.

We gathered qualitative evidence reflecting the impact of our intervention. We were able to compare levels of confidence among Hatzola members before and after our teaching programme.

Our training programme was well received by Hatzola, and it was an excellent opportunity to develop links with members of the community.

We have learned that mental health is a taboo subject for members of the Charedi community, and have identified a need for more support to Hatzola in coping with the emotional toll working with mental health patients can take. There may be scope for providing further training on developing reflective practice and more emotional support for Hatzola members in future.

Following a Serious Incident (SI) on a mixed sex ward; it was important to investigate whether this is a widespread problem in Psychiatry. The acute care group standard is that patients with known risk to the opposite sex should not be admitted to mixed sex wards. A comprehensive risk assessment should take place when a patient is admitted to a mixed sex ward. Furthermore, if any risks are identified, these should be escalated to the multidisciplinary team (MDT), including the nurse-in-charge and on-call Consultant Psychiatrist.

We conducted a literature search to establish how different Trusts consider risk when arranging for admission, as well as to identify whether single-sex wards have helped to reduce the incidence of serious incidents. We then retrospectively collected data from 10 inpatients present on mixed sex wards throughout Kent and Medway in May 2021. This involved searching electronic notes at the point of admission, including progress notes and risk assessments to identify whether information is present to suggest that an admission to a mixed sex ward is unsuitable, and if so, whether this has been appropriately escalated.

When patient notes were surveyed, only 50% of patients had a full risk assessment documented. Historical risks were documented in 40% of patients notes at admission. Junior doctors are required to complete an admission clerking for new patients, which should include a risk assessment; 70% of these contained a risk assessment, and 60% discussed risks towards others. 30% of patients had identifiable risks to the opposite sex but were admitted to a mixed sex ward. However, none of these cases were escalated to the MDT for discussion regarding the most suitable ward for the patient.

When patients are admitted to any inpatient psychiatric ward it is important to document a full risk assessment including historical risks. Unfortunately, full risk assessments were not always carried out at the point of admission, meaning that patients who had been admitted to mixed sex wards remained there despite previously documented risks. In general, junior doctors included risk assessments in their admission clerkings, but there is evidently room for improvement from all healthcare professionals. Recommendations for improvement are to generate specific guidance for documenting risk assessments and to offer teaching to healthcare professionals on ensuring they have completed a comprehensive risk assessment and when it is appropriate to escalate this to ensure further serious incidents do not occur. Re-audit is scheduled for March 2022.

Letters between secondary and primary care are an integral part of continuity of patient care. It is crucial letters are comprehensible, focused and useful. The quality of letters can be of a variable standard, we aim to see if the letters sent from Cherrywood clinic are in line with the Royal College guidance.

Data were collected manually by 2 doctors using dictated clinic letters and patient notes, from the 3 community teams. 20 outpatient letters were sequentially selected from each team from the 1st to 31st of March 2017; 60 letters in total. The letters were divided equally between consultants and junior doctors. In the team where there were 2 Consultants; 5 letters of each were taken, and in the team where there was a junior doctor and a specialist registrar, 5 letters from each were taken. The data were collated onto an Excel spread sheet and analysed.

1. 1. Demographic Details including Name, Date of Birth, Address and the Date of Appointment

2. 2. Who was the patient been seen by; Consultant or Junior doctor (FY/GPST/CT/SPR)

3. 3. Current diagnosis

4. 4. Current medication including doses

5. 5. Mental State Examination (MSE) findings

6. 6. An update of the current problem(s)

7. 7. Current/relevant Risks

8. 8. Plan/recommendations

9. 9. Follow-up plans

Of the Consultant letters the diagnosis, medication and dosage was mentioned in 93%, 93% and 90% respectively. Mental state was found in 66%, risks in 83% and follow-up plans in 96%.

Most of the content derived from the registrar letters were unremarkable; with 80% in MSE in the 5 audited letters.

In the Junior doctor letters; the diagnosis was mentioned in 88% of letters, medication and dosage 76%, mental state 100%, risks 80%, follow-up 100%.

Our letters are largely meeting the Royal College standards, more than 85% of the data were up to the standard. The main area's to improve are;

• – Documentation of the MSE.

• – The medication and the dosages.

• – Diagnosis.

• – Risks should always be present.

Job interviews are the platform for employers to identify suitable candidates for vacant posts, i.e. those who are able to demonstrate a certain set of competencies specified in the job description. In the recent psychiatry specialty training (ST) application process, candidates are required to propose a management plan for two complex scenarios. This interview can be stressful given the high-stakes nature of the outcome, i.e. the successful enrolment into a training programme of a preferred deanery. Candidates who are unable to have an organised approach to problem-solving will likely have an unfavourable result. To overcome this difficulty, a simplified “I AM” approach is being proposed to assist applicants to organise their thoughts during their ST application interview.

The “I AM” approach stands for “Issues, Assessments, and Management”, which is adapted from the “Handbook of Psychiatry: Surviving Consultation Viva Examination of Malaysian Conjoint Board”. The “Issues” are the problems identified in a scenario, “Assessments” are the investigation required to get a clearer picture of the problems, and “Management” is the action plan to solve the problems. This approach was piloted with five applicants of ST in psychiatry prior to their interview practices.

For a complex clinical case scenario, the “I AM” approach can be put into the matrix of 3 × 3 tables together with a biopsychosocial model to ensure the issues in different domains are explored thoroughly. Further sub-classification into necessary subheadings, including ideas, concerns, and expectations from different parties, can be included in the assessment matrix. Lastly, a management plan using a multidisciplinary team and collaborative decision-making model with the patient and family can be proposed. For a complex managerial scenario, the seven pillars of the National Health Service's clinical governance model involving different stakeholders can be incorporated into the “I AM” approach to explore problem-solving strategies from different angles. Positive reactions had been received from all five trainees (Kirkpatrick's Evaluation Model Level One).

The “I AM” approach can be flexibly applied in different problem-solving scenarios and it works well with other models. The approach may be limited by inadequate information and a failure to prioritise. Further systematic evaluation of the effectiveness and generalisability of the “I AM” approach to other disciplines is required.

Clozapine is an atypical antipsychotic primarily used in the management of individuals with schizophrenia and schizoaffective disorders, prescribed to those with symptoms unresponsive to alternate antipsychotic medications. Clozapine is known to have cardiovascular side effects and is associated with an increased risk of significant cardiac events including myocarditis, cardiomyopathy, and sudden cardiac death. Regular electrocardiogram (ECG) monitoring is recommended to facilitate early detection of cardiac complications. This study aimed to identify the prevalence and evaluate the nature of ECG changes, assessing for tachycardia and corrected QT (QTc) interval prolongation, in patients prescribed Clozapine, and to determine whether the appropriate action was taken following identification of these changes.

We conducted retrospective data collection examining consecutive ECGs of 50 adult patients prescribed Clozapine within the East sector of the Cherrywood Outpatient Psychiatry Department at The Royal Oldham Hospital. Patients were identified using the clinic's Clozapine database. The PARIS electronic record system and patient written notes were utilised to obtain patient demographics, diagnoses, and ECGs. We assessed rate, rhythm and QTc intervals amongst the ECGs taken and compared the most recent ECG findings with those from previous ECGs.

Of the 50 patients prescribed Clozapine, 34 were identified as having 2 consecutive ECGs in their notes, enabling ECG comparison and assessment for changes. Amongst these 34 patients, 11 (32.35%) demonstrated new-onset ECG changes; 8 with new sinus tachycardia, 1 with new QTc prolongation and 2 with additional rhythm strip abnormalities. Based on these new findings, 50% were then referred for a repeat ECG. No plan had been made for the other 50%. ECGs of 8 (23.53%) individuals demonstrated changes which remained present across the consecutive ECGs. Plans for these patients included referral for cardiology opinion (25%), repeat ECG (25%) and dose reduction (50%). A further 8 patients demonstrated an improvement in findings on their most recent ECG. In 3 (37.50%) of these cases, Clozapine had been reduced during the period between ECG recordings. 7 (20.59%) individuals demonstrated no ECG changes.

Our findings suggest many individuals prescribed Clozapine develop ECG abnormalities, with the largest proportion developing sinus tachycardia. Regular monitoring remains beneficial within the outpatient department to determine the nature of ECG changes, and further methods may be required to ensure appropriate management plans are in place should these changes arise.

Physician associates (PAs) are becoming more commonplace in psychiatric services in the UK to help address long term workforce difficulties. The 2019 NHS Long Term Plan detailed a commitment to transforming mental health care in England recognising that services were not meeting current or future increase in demand. Health Education England's (HEE) report, Stepping Forward to 2020/21: The Mental Health Workforce Plan for England, described a longer-term strategy to expand the mental health workforce, including recruiting 5,000 people into ‘new roles’ including physician associates. The NHS Mental Health Implementation Plan 2019/20–2023/243 stated an aim of recruiting 140 PAs to the workforce over five years in addition to the requirements specified in the HEE report. A curriculum for PAs working in mental health would set out the competencies required to work in mental health services.

The curriculum was developed by the National Collaborating Centre for Mental Health (NCCMH). The work was overseen by an expert reference group, comprising experts in training PAs in mental health, PAs, researchers and experts by experience, all selected for their expertise in research, training and service delivery.

The overarching aims and objectives of the curriculum was to convey a practical understanding of the attitudes, knowledge and skills that underpin the role, thus enabling PAs to offer effective and value-driven support to patients.

The completed curriculum has been arranged into seven modules: Knowledge, Professional/Legal Issues, Engagement and Communication, Diagnostic Assessment and Treatment Planning, Interventions, Managing the Interface of Mental and Physical Health and Team Working. This reflects the expected roles and responsibilities of PAs working in mental health.

HEE and the Royal College of Psychiatrist have recommended all mental health organisations implement an educational programme for new PAs. The curriculum will inform the training requirements for PAs and standardise the training they receive from mental health organisations. It should support the work of PA supervisors and peer coordinators, and those delivering education and training to them. The curriculum will be a dynamic document and work will be needed to adapt it as the role changes, for example with incoming regulation and potential prescribing rights that follow.

High Dose Antipsychotic Therapy (HDAT) prescriptions and combinations of antipsychotic agents are not currently recommended as standard practice by the RCPsych. College guidance (RCPsych, CR 190) advises that there is “little convincing evidence that off-label prescription of doses of antipsychotic medication above the licensed dosage range has any therapeutic advantage in any clinical setting” and that “any prescription of high-dose antipsychotic medication should be seen as an explicit, time-limited individual trial with a distinct treatment target”. Despite this, both national and local data demonstrate that HDAT has continued to be used regularly across psychiatric inpatient settings, often out of hours and often secondary to the use of PRN Antipsychotics, without a clear treatment plan or rationale. My aim was to create a simple, accessible, online tool that would allow prescribers to quickly and efficiently calculate the BNF percentage of any antipsychotic prescription and that this will enable safer prescribing.

With the support of a web-developer, I developed an online tool quickly and easily calculate antipsychotic BNF percentages. The tool can be found here: www.hdat.co.uk

The HDAT Helper has been well received at local presentations and I have recently gained the support of senior management at Southern Health NHS Foundation Trust to develop an education programme on HDAT and the HDAT Helper to expand use of the tool across Southern Health.

The current expert guidance, clinical research and my own audit work demonstrates that there are ongoing issues with the prescription of high dose antipsychotics and that at times this occurs inadvertently when different agents are combined.

I believe that the HDAT Helper can make prescribing of antipsychotic agents clearer and more efficient and as a result significantly improve patient safety.

Once refugees and migrants have accessed mental health services, there are a number of potential barriers to establishing a positive therapeutic relationship with clinicians and engaging patients in treatment. WHO recommend that training programmes can help clinicians to understand and assess mental health difficulties according to different cultural explanatory models of psychological symptoms. This audit aims to explore current training of those who work with asylum seekers and migrant patients, within the Merseycare Early Intervention in Psychosis teams.

A survey of 11 questions was sent out to all assessors, team managers, care co-ordinators, psychologists and doctors within the Early Intervention in Psychosis teams. Questions were asked regarding demographics of participants, their views of the difficulties and barriers of working with asylum seekers, their current level of training to work with this particular cohort of patients and their willingness to attend such training.

33 results were collected and consisted of a broad range of team members. Only 4 out of the 33 participants had any form of training prior to or during their time working with this cohort of patients and 3 of the 4 who had, stated that it was not specific training. Difficulties highlighted included; language barriers, cultural differences, a lack of understanding of the asylum process and a lack of knowledge for local support. All participants said they would be willing to attend training specific to working with the asylum seeker patient population.

This audit demonstrates that we are far from reaching the World Health Organisation recommendations of cultural training for all who work with asylum seeker and migrant patients. It also demonstrates a felt need amongst staff for training to be provided. Recommendations from this audit is to consider mandatory training for all staff, including; cultural training, guidance on use of interpreters and awareness of external support agencies.

The aim of this study was to ascertain the correlations between patients’ views of their recovery and clinicians’ views of patients recovery, symptoms and risk, in a cohort of patients in the National Forensic Service Dundrum (NFMHS).

A cross sectional study was performed of all inpatients in the NFMHS Dundrum. The self-rated Dundrum tool was offered to all 96 in-patients and completed by 64. Clinican rated measures of violence risk (HCR-20), programme completion (Dundrum-3), recovery (Dundrum-4), symptoms (PANSS) and functioning (GAF MIRECC) were rated. ANOVA and concordance ratings were calculated using SPSS

A total of 64 patients agreed to participate, of whom 10 were female. The self-rated Dundrum-3 correlated with the staff rated Dundrum-3 (0.471, p < 0.001). The self-rated Dundrum-4 correlated with the staff rated Dundrum-4 (0.373, p = 0.003). The self-rated Dundrum-3 correlated with the HCR-20 total (0.0352, p = 0.005), HCR-C (0.3677, p = 0.004), and HCR-R (0.301, p = 0.018). The self-rated Dundrum-3 correlated significantly with GAF occupational (-0.273, p = 0.48), symptomatic (-0.299, p = 0.03). The self-rated Dundrum-4 correlated only with the GAF symptomatic (-0.333, p = 0.05). The self-rated Dundrum-3 correlated with PANSS positive (0.457, p = 0.001), PANSS negative (0.514, p < 0.001), PANSS general (0.395, p = 0.004) and PANSS total (0.352, p = 0.005). The self-rated Dundrum-4 correlated with PANSS positive (0.356, p = 0.01) and PANSS negative (0.413, p = 0.002).

There was good correlation between patient and clinician ratings of programme completion and recovery. Patient self-ratings of programme completion and recovery correlated with staff ratings of functioning and symptoms. The directions of agreement were correct

The Enhanced Trauma Pathway (ETP) at Berkshire Healthcare NHS Foundation Trust was established in 2018 to manage high demand on a highly specialist psychology team called the Berkshire Traumatic Stress Service (BTSS). The ETP is used to treat complicated cases of Post-Traumatic Stress Disorder (PTSD) within the IAPT service. However, because of the ETP there is now a cohort of Service Users (SUs) presenting to IAPT with a higher complexity than has been typical, presenting new challenges for the service. We aim to evaluate and redesign the ETP within IAPT to meet the needs of the changing population.

Clinically Led workforcE and Activity Redesign (CLEAR) is a workforce transformation methodology with four unique stages: i) Clinical Engagement: in-depth qualitative analysis of interview data from staff ii) Data Interrogation: cohort analysis using clinical and workforce data visualisations and analysis, iii) Innovation: developing novel solutions with insights from triangulated qualitative and quantitative data, iv) Recommendations: formulation of new models of care (NMOC) and smaller quick high impact service innovations. Thematic analysis was used for the qualitative data. Quantitative data analysis was conducted using the IAPT dataset.

27 semi-structured interviews were conducted with staff. SUs on the ETP had longer waiting times, their treatment took longer (18 sessions for ETP Vs 12 for core step 3) and they had lower recovery rates: 32.9% for ETP, 49.9% for core step 3 in IAPT and 57.3% for the whole IAPT service. SUs on the ETP presented with increased risk concerns, often not mitigated by stabilisation work offered. Thematic analysis also identified challenges with recruitment, a lack of qualified staff and inefficient use of skills across the pathway. Staff well-being was found to be paramount, however supporting staff was found to be challenging due to national constraints placed upon IAPT and the targets the service is asked to achieve. A series of recommendations were made including three options for a NMOC. The options suggested different ways to redesign the pathway including an option where there would be a trauma only team within IAPT working exclusively on the ETP.

This evaluation highlights the challenges for the ETP and identifies NMOC to reduce their impact on the service. Further work is required to assess the NMOC once it has been implemented and to further evaluate the needs of the SUs presenting to this service.

This study analyses the progression of psychiatric symptoms over time of young people with special educational needs (SEN). The aims of this study were: 1) To examine whether the presence of psychiatric symptoms in earlier life are more likely to impact functional outcomes in later life in those with SEN; 2) Whether the presence of psychiatric symptoms in adolescence predicts functional outcomes in early adult life.

Data were obtained from the Edinburgh Study of Comorbidity (ESC) which was a longitudinal follow-up study of adolescents with SEN. This study had ethical approval from the Multicentre Research Ethics Committee for Scotland. It involved head teachers of 99 schools around Scotland identifying pupils aged 13–22 years whom they would estimate as functioning in the borderline to mild intellectual disability range (estimated IQ between 50–80) and were therefore receiving special educational assistance.

Adolescents with SEN were assessed with the Clinical Interview Schedule (CIS) to evaluate the presence of psychiatric symptoms. A total of 247 individuals with SEN were recruited to the study. They completed the CIS at baseline (T1), 1–2 years later (T2) and 6 years later (T3). At T3, the participants also completed the World Health Organisation Disability Assessment Schedule 2.0 (WHO-DAS) to measure the degree of functional impairment. Correlation statistical analyses were carried out to find whether there was a significant relationship between CIS and total WHO-DAS scores.

There was a statistically significant correlation between total WHO-DAS score with slowness and anxiety symptoms (p values 0.008 and 0.024 respectively) measured on the CIS at T1. None of the symptoms measured on CIS at T2 had a statistically significant correlation with total WHO-DAS score. With the symptoms that were significant, after application of a Bonferroni correction, none of the symptoms measured on CIS had a statistically significant correlation at any time point with total WHO-DAS score.

Our results show that there is some evidence that anxiety and slowness in adolescence are associated with greater functional impairment in young adulthood. However, further research is required to confirm this relationship. Our data highlight the potential value of identification and treatment of psychiatric symptoms in early adolescence.

The traditional ‘one size fits all’ model within secondary care mental health (MH) settings of regular appointments scheduled by a clinician at defined intervals isn't always responsive to an individual's changing needs. Previous reviews have shown significant levels of patient and clinician satisfaction with Patient initiated models of review in a variety of healthcare settings but its use within secondary care MH settings has been relatively limited. We describe the development and implementation of a Patient initiated follow-up (PIFU) pathway within MH services in NHS Greater Glasgow and Clyde (GG&C).

The pathway was developed by a small working group of clinicians with input from local management and eHealth colleagues with an emphasis on the principles of Realistic Medicine. There was input from peer support workers and the Mental Health network, a local service user organisation, into the development of the pathway. The pathway underwent a ‘test of implementation’ within three adult CMHT's with support from the development group. Feedback from the test sites was used to modify the pathway and ultimately support the wider rollout of the model across all seventeen CMHTs within NHS GG&C over the course of 2021. Formal evaluation of the pathway, including patient and clinician satisfaction, service utilisation as well as safety measures, is due to be undertaken at 12 months after full implementation.

The tests of implementation identified a range of factors that needed to be considered as part of the introduction of a PIFU model into MH settings.

Patient choice and shared decision making along with other clinical factors such as level of insight, availability of other supports, shared risk assessments and current clinical need were identified as relevant patient related factors. Clinician related factors included concerns about applicability within MH settings, perception of risk, increase in workload and appropriate identification of suitable patients. Regular meetings between the clinicians in the test sites and members of the development group as part of the implementation process helped address clinicians concerns and ultimately supported uptake of the model.

Our experience highlighted the potential for a personalised approach to care planning in empowering patients have a more active role in the way they access services as part of their recovery journey. It also highlighted patient and clinician related factors that need to be considered for a successful adoption of the model.

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.

There are concerns following the Winterbourne view investigation and from the Learning Disabilities Census that psychotropic medications are being inappropriately given to people with learning disability as a means of managing difficult behaviours. Stopping Overuse of Medication in People with Learning Disability (STOMP) is a key area which has been identified as needing improvement for the Transforming Care Programme which is being supported by the Royal College of Psychiatrists. Members are encouraged include STOMP in their local audits. It is for this reason that the topic has been chosen. The overall aim of this project is to capture the snapshot of prescribing of psychotropic medications for people under SST care. This information has been used for establishing baseline of current practice as they are happening and to develop SST base response to support STOMP agenda.

The population audited was patients open to the SST LANCS/GM. Patients had to be between 18 and 65 years old, have a diagnosis of a learning disability and be known to have challenging behaviour. Patients were excluded from the audit if they had no challenging behaviour, had been discharged from services. The sample size was 20 (10 from GM and 10 from LANCS). Data were collected using the proforma and then entered into Microsoft excel for analysis.

Four overall standards were audited, each with key lines of enquiry within the standard audited to help determine compliance. Overall compliance for standard one, the indication and rationale should be clearly stated, was 50%. For standard 2, consent to treatment procedure, the third standard, regular monitoring of the treatment response and side effects, and the final standard, review and evaluation of the need for continuation or discontinuation of the psychotropic drug, the compliance was less than 10%. It should be noted that the audit erred on the side of counting in any information that suggested that the theme had been thought about at all: an in depth capturing of any of the themes did not feature in the sample.

This audit highlights important issues for improvement within the SST both in relation to better supporting STOMP and good psychotropic medication management practice, and in relation to its documentation. It also serves as a springboard to a number of initiatives that would help to turn that situation around. In the light of concerns, an early re-audit of practice is recommended.

Lithium is an effective mood stabiliser for the treatment of the bipolar disorder. Its utility is not restricted to acute mania and prophylactic treatment of the bipolar disorder. Another well-known indication for its use is the treatment of refractory depression. Lithium can cause several adverse effects, and typically the side effects are dose-related. Unlike antipsychotic medications, lithium is rarely associated with drug-induced Parkinsonism.

We present a case of 78 years old gentleman who was assessed due to complaints suggestive of cognitive impairment. His past psychiatric history revealed that he was admitted to a psychiatric inpatient unit with a diagnosis of treatment-resistant depression in 1991. Lithium therapy was commenced during this admission, and he remained on lithium for 27 years. The patient was clinically stable in terms of the symptoms of depression; however, he reported bilateral postural tremors 20 years after the initiation of lithium therapy. Initially, he was diagnosed with lithium-induced tremor; however, in the following months, his symptoms had worsened, and he developed new motor disturbances, although the serum levels of lithium were within the therapeutic range. On examination, he had classic parkinsonian signs of shuffling gait, muscle rigidity in all four limbs and freezing of gait. DaT-SPECT imaging clarified the diagnosis as drug-induced Parkinsonism. As the daily lithium dosage was stopped, the patient's motor symptoms improved significantly; nevertheless, some of the symptoms persisted.

The pathophysiological mechanism behind lithium-induced Parkinsonism is unclear. The condition may develop with or without frank lithium toxicity and have diverse presentations. Literature suggests that the risk factors for lithium-induced Parkinsonism appear to be the patients' age, duration of lithium therapy, and serum lithium levels. It has been suggested that older patients have a more permeable blood-brain barrier and decreased renal clearance; hence, serum lithium levels can appear therapeutic, but brain lithium levels may be much higher. Pharmacokinetic drug-drug interactions might also contribute; thus, careful monitoring is essential.

Drug-induced Parkinsonism improves with discontinuation of the offending medication; however, 10% of patients will develop a persistent and progressive parkinsonian syndrome.

This report aims to emphasise the need to consider lithium-induced Parkinsonism when Parkinson Disease symptoms appear in chronic lithium users and close monitoring of lithium levels in geriatric populations. It is essential to recognise the condition, avoid misdiagnosis and prevent inappropriate use of anti-dopaminergic medications.

Antipsychotic polypharmacy is a relatively common practice, despite a lack of robust evidence. In 2018, the National Clinical Audit of Psychosis evaluated the treatment of 8000 patients with a diagnosis of schizophrenia or schizoaffective disorder, and found 10% were receiving non-clozapine antipsychotic polypharmacy. This included 432 patients receiving one oral & one long acting injectable (LAI) antipsychotic and 2 patients receiving two LAI antipsychotics. An audit within our service, found that 24 of 88 (27%) inpatients were receiving non-clozapine antipsychotic polypharmacy. Of these, 3 were prescribed two LAI antipsychotics. A literature review found very limited evidence supporting the use of combined LAI antipsychotics, with publications relating to a total of 18 cases. Presented here is a case series, reviewing the use of LAI antipsychotic polypharmacy in three patients within Devon Partnership Trust.

The case series reports on three male inpatients, who are under the care of secure services within Devon Partnership Trust. All are currently prescribed two LAI antipsychotics. Two have a diagnosis of treatment resistant schizophrenia and one of schizoaffective disorder. All are complex, necessitating recurrent or lengthy admissions, and present with significant risk to others when unwell. In each case, there have been trials of multiple antipsychotics, but only one has had a previous trial of clozapine.

Published case reports highlight the positive effects of LAI polypharmacy, noting an improvement in mental state and lack of adverse effects. The cases presented here show significant variability, with one patient improving significantly, the second to a lesser extent, and the third remaining under high level observations.

All cases are complex with decisions taken on a background of high risk, after multiple failed trials of medication.

Although no specific adverse effects were reported, none of the patients regained sufficient insight to engage in treatment decisions and physical health monitoring. It is therefore difficult to quantify the adverse effect burden and weigh this against perceived efficacy.

Combined LAI antipsychotic medication is a possible treatment option in complex individual cases. Prescribing decisions are based on perceived clinical benefit, and the evidence base remains limited, with little understanding of long-term effects or consequences.

Unlike high dose antipsychotics, there is no formalised guidance for prescribing combined LAI antipsychotics. Treatment targets and review processes were not always explicit. A more robust approach, would provide greater clarity around the practice and aid with future decision making.

To reduce monthly bed days for children and young people (CYP) aged under 18 years admitted to adult psychiatric beds by 50%

QI tools used included driver diagram, stakeholder analyses, process mapping, ishikawa diagram, pareto chart and interviews with CYP and carers to gather qualitative data. Monthly data were collected on all admissions of CYP to adult mental health beds. Change ideas/ process changes included:

• • Early senior psychiatric CAMHS review for all CYP admitted to adult psychiatric beds (same or next working day)

• • Increased access to CAMHS medical records for out of hours staff

• • Admission of all appropriate under 16's to paediatric beds instead of adult mental health beds

• • Short test of change of staffing CAMHS specialist nurses over a weekend

• • Develop alternative non-health crisis support/bed for CYP

• • Develop Personality Disorder (PD) pathway

• • Early senior CAMHS psychiatric review was associated with a reduction in CYP admitted to adult mental health beds from a median of 20 days a month to 2 days a month without an associated increase in CAMHS inpatient admissions

• • Pareto chart showed that Personality Disorder (PD) was the commonest diagnosis

• • Access to CAMHS medical records for all out of hours psychiatric medical staff was increased from 13% to 100%

• • Routine admission to paediatrics for all under 16's was agreed with paediatric medical and nursing managers but not sustainably implemented

• • There were no acute referrals to the CAMHS specialist nurses over the single weekend short test of change

• • Development of an alternative non-health crisis support/bed and development of a Personality Disorder (PD) pathway is still in process

The primary outcome measure was successfully met with the median bed days of CYP admitted to adult mental health beds sustainably reduced from a median of 20 days to 2 days. This was associated with the implementation of routine early senior psychiatric CAMHS review and increased access to CAMHS health records for all medical staff providing psychiatric out of hours assessments. The change ideas including development of different admission pathways (paediatrics and non-health crisis bed), weekend CAMHS specialist nurses service and development of a personality disorder pathway were not implemented sustainably. The pathways of care around CYP presenting in crisis are complex. Making sustainable improvements in complex adaptive systems is complex and challenging but not impossible.