The Central Mental Hospital is the Republic of Ireland's only secure forensic hospital and the seat of its National Forensic Mental Health Service (NFMHS). We scrutinised admission patterns in the NFMHS during the period 01/01/2018–01/10/2023; before and after relocating from the historic 1850 site in Dundrum to a modern facility in Portrane on 13/11/2022.

This prospective longitudinal cohort study included all patients admitted during the above period. The study initially commenced in Dundrum and continued afterwards in Portrane. Data gathered included demographics, diagnoses, capacity to consent to treatment, and the need for intramuscular medication (IM) after admission. Therapeutic security needs and urgency of need for admission were collated from DUNDRUM-1 and DUNDRUM-2 scores rated pre-admission. Hours spent in seclusion during the first day, week, and month after admission were calculated. Data were collected as part of the Dundrum Forensic Redevelopment Evaluation Study (D-FOREST).

There were 117 admissions during the 69-month period. The majority were male (n = 98). Most were admitted from prisons (87%). Schizophrenia was the most common diagnosis (55.8%). Mean DUNDRUM-1 triage security scores were in the medium-security range (2.84–3.15) during this period. At the time of admission, 53.8% required seclusion, 25.6% required IM medication, and 79.5% lacked capacity to consent to treatment. Those who required seclusion on admission had worse scores on the DUNDRUM-2 triage urgency scale (F = 20.9, p < 0.001). On linear logistic regression, the most parsimonious model resolved with five predictors of hours in seclusion during the first day and week, which were: D1 item 8 – Victim sensitivity/public confidence issues, D1 item 10 – Institutional behaviour, D2 item 2 – Mental health, D2 item 4 – Humanitarian, and D2 item 6 – Legal urgency. 50% required IM medication during their first week of admission and these patients had significantly worse scores on: D1 item 8 – Victim sensitivity/public confidence issues, D1 item 10 – Institutional behaviour, D2 item 2 – Mental health, and D2 item 4 – Humanitarian (all p < 0.05).

There was an increase in the frequency of admissions since relocating to Portrane. The results suggest that there was no change in overall triage security and urgency needs during the time period in question. Major mental illness related factors impacted the need for seclusion early in the admission, whereas factors linked to prison behaviour or personality-related factors were more associated with an ongoing need for seclusion at month one.

Forensic psychiatric services address the therapeutic needs of mentally disordered offenders in a secure setting. Clinical, ethical, and legal considerations underpinning treatment emphasize that the Quality of Life (QOL) of patients admitted to forensic hospitals should be optimised. This study aims to examine changes in the QOL in Ireland's National Forensic Mental Health Service (NFMHS) following its relocation from the historic 1850 site in Dundrum to a new campus in Portrane, Dublin.

This multisite prospective longitudinal study is part of the Dundrum Forensic Redevelopment Evaluation Study (D-FOREST). Repeated measures were taken for all inpatients in the service at regular 6 monthly intervals. The WHOQOL-BREF questionnaire was offered to all inpatients. An anonymised EssenCES questionnaire was used to measure atmosphere in wards. Data were obtained at 5 time points for each individual patient and ward. WHOQOL-BREF ratings were obtained across 5 time points with comparisons available for 4 time intervals, including immediately before and after relocation. For 101 subjects across 4 time intervals, 215 sets of data were obtained; 140 before and 65 after relocation with 10 community patients who did not move. Using Generalised Estimating Equations (GEE) to correct for multiple comparisons over time, the effect of relocation, with community patients as a control, was analysed by ward cluster and whether patients moved between wards. Observations were categorised according to security level – high dependency, medium secure, rehabilitation, or community – and trichotomised based on positive moves to less secure wards, negative moves to more secure wards, or no moves.

Relocation of the NFMHS was associated with a significant increase in environmental QOL (Wald X2 = 15.9, df = 1, p < 0.001), even when controlling for cluster location, positive and negative moves. When controlling for ward atmosphere, environmental QOL remained significantly increased after the move (Wald X2 = 10.0, df = 1, p = 0.002). EssenCES scores were obtained within the hospital for 3 time points before relocation and 2 time points afterwards. No significant differences were found on the three subscales before and after the move. All three EssenCES subscales progressively improved with decreasing security level (Patient Cohesion: Wald X2 = 958.3, df = 1, p < 0.001; Experiencing Safety: Wald X2 = 152.9, df = 5, p < 0.001; Therapeutic Hold: Wald X2 = 33.6, df = 3, p < 0.001).

The GEE model demonstrated that the move of the NFMHS improved self-reported environmental QOL. The cluster location made significant differences, as expected for a system of stratified therapeutic security, with a steady improvement in scores on all three atmosphere subscales.

Excellence is that quality that drives continuously improving outcomes for patients. Excellence must be measurable. We set out to measure excellence in forensic mental health services according to four levels of organisation and complexity (basic, standard, progressive and excellent) across seven domains: values and rights; clinical organisation; consistency; timescale; specialisation; routine outcome measures; research and development.

To validate the psychometric properties of a measurement scale to test which objective features of forensic services might relate to excellence: for example, university linkages, service size and integrated patient pathways across levels of therapeutic security.

A survey instrument was devised by a modified Delphi process. Forensic leads, either clinical or academic, in 48 forensic services across 5 jurisdictions completed the questionnaire.

Regression analysis found that the number of security levels, linked patient pathways, number of in-patient teams and joint university appointments predicted total excellence score.

Larger services organised according to stratified therapeutic security and with strong university and research links scored higher on this measure of excellence. A weakness is that these were self-ratings. Reliability could be improved with peer review and with objective measures such as quality and quantity of research output. For the future, studies are needed of the determinants of other objective measures of better outcomes for patients, including shorter lengths of stay, reduced recidivism and readmission, and improved physical and mental health and quality of life.

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

There has been a notable increase in requests for psychiatric reports from District Courts for persons remanded to Ireland’s main remand prison, Cloverhill. We aimed to identify if reports were prepared for persons with severe mental illness and if they led to therapeutic benefits such as diversion to healthcare. Measures of equitability between Cloverhill and other District Courts were explored.

For District Court-requested reports completed by the Prison Inreach and Court Liaison Service (PICLS) at Cloverhill Prison from 2015 to 2017, we recorded clinical variables and therapeutic outcomes such as diversion to inpatient psychiatric settings.

Of 236 cases, over half were diverted to inpatient or outpatient psychiatric care. One-third of remand episodes were admitted to a psychiatric hospital, mainly in non-forensic settings. Nearly two-thirds had major mental illness, mainly schizophrenia and related conditions. Almost half had active psychosis. Cases in Cloverhill District Court and other District Courts were similarly likely to have active psychosis (47% overall) and hospital admission (33% overall). Voluntary reports were more likely to identify active psychosis, with over 90% diverted to inpatient or outpatient community treatment settings.

This is the first large scale study of diversion outcomes following requests for psychiatric advice from District Courts in Ireland. Requests were mainly appropriate. Over half led to diversion from the criminal justice system to healthcare settings. There is a need for a complementary network of diversion initiatives at every stage of the criminal justice system to effectively divert mentally ill individuals to appropriate settings at the earliest possible stage.

Secure forensic mental health services treat patients with high rates of treatment-resistant psychoses. High rates of obesity and medical comorbidities are common. Population-based studies have identified high-risk groups in the event of SARS-CoV-2 infection, including those with problems such as obesity, lung disease and immune-compromising conditions. Structured assessment tools exist to ascertain the risk of adverse outcome in the event of SARS-CoV-2 infection.

To assess risk of adverse outcome in the event of SARS-CoV-2 infection in a complete population of forensic psychiatry patients using structured assessment tools.

All patients of a national forensic mental health service (n = 141) were rated for risk of adverse outcome in the event of SARS-CoV-2 infection, using two structured tools, the COVID-Age tool and the COVID-Risk tool.

We found high rates of relevant physical comorbidities. Mean chronological age was 45.5 years (s.d. = 11.4, median 44.1), mean score on the COVID-Age tool was 59.1 years (s.d. = 19.4, median 58.0), mean difference was 13.6 years (s.d. = 15.6), paired t = 10.9, d.f. = 140, P < 0.001. Three patients (2.1%) were chronologically over 70 years of age, compared with 43 (30.5%) with a COVID-Age over 70 (χ2 = 6.99, d.f. = 1, P = 0.008, Fisher's exact test P = 0.027).

Patients in secure forensic psychiatric services represent a high-risk group for adverse outcomes in the event of SARS-COV-2 infection. Population-based guidance on self-isolation and other precautions based on chronological age may not be sufficient. There is an urgent need for better physical health research and treatment in this group.