To evaluate the Institute of Mental Health's (IMH) clinical governance and quality processes following an independent review of systems related to care lapses, and to implement standardised root cause analysis (RCA) processes to improve patient safety outcomes.

An independent review of IMH's clinical service delivery model and governance processes was conducted, examining Serious Reportable Events (SRE) and Sentinel Events (SE) from January 2017 to October 2023. A two-pronged approach was employed: an independent-led review by the National Healthcare Group and an internal self-review. Further in-depth analyses of selected incidents were conducted by subject matter experts using selection criteria based on recency, incident type, severity of harm, and findings. Root causes and recommendations were assessed using the New South Wales Root Cause AnalysisReview Committee's Classification of Recommendations. Following identification of governance deficiencies, a comprehensive change management process was implemented incorporating six key strategies: educate, engage, empower, evaluate, encourage, and escalate. A standardised RCA process utilising the Human Factors Analysis and Classification System (HFACS) framework was adopted, with establishment of the SRE-SE Oversight Panel in October 2024 to ensure oversight and consistent quality of the RCAs.

The review identified inadequately robust clinical and quality governance processes. Previous RCA investigations were sub-optimal, resulting in weak recommendations and reactive responses that missed opportunities for systems-level improvement. Prior to HFACS implementation, majority of recommendations in 2022 and 2023 were classified as 'weak', relying heavily on memory and vigilance. Post-implementation, there was an increase in robust, system-level recommendations requiring greater senior management involvement. However, approval processes initially extended to 373 days, failing to meet the 60-day requirement stipulated by the Ministry of Health. Following establishment of the SRE-SE Oversight Panel, approval times reduced from an average of 145 days to 50 days by April 2025. Despite improved recommendation quality, there was a decrease in the percentage of recommendations implemented within stipulated timeframes, attributed to the increased complexity of system-level interventions.

The implementation of standardised RCA processes using HFACS successfully improved the quality and robustness of safety recommendations at IMH. However, stronger system-level recommendations require greater resources and extended implementation timelines. Continuous improvement through iterative Plan–Do–Study–Act cycles, stakeholder engagement, and appropriate escalation processes are essential for drivingsustainable change in psychiatric healthcare quality and safety initiatives.

Adolescent depression often presents with somatic complaints, and its clinical manifestation is strongly shaped by cultural context. In non-western districts, psychological distress is frequently expressed through physical symptoms; a tendency that, combined with mental health stigma and culturally influenced health beliefs, complicates accurate detection, diagnosis and treatment. Standardised diagnostic tools developed in Western populations may overlook culturally specific symptom patterns, contributing to under-recognition and inadequate care. Despite the global impact of adolescent depression, cross-cultural symptom-level studies remain limited, hindering the development of culturally responsive mental health strategies.

This study aims to compare somatic-depressive symptom networks in Chinese and Rwandan adolescents using symptom-level network analysis, to identify culturally distinct central and bridge symptoms, and to assess structural differences between symptom networks across groups.

A cross-sectional sample of 3830 adolescents (China: n = 2017, mean age 15.35 ± 1.56; Rwanda: n = 1813, mean age 15.80 ± 1.90) completed culturally adapted versions of the Patient Health Questionnaires for somatic symptoms (PHQ-15) and depression (PHQ-9). Gaussian Graphical Models were estimated in R to construct symptom networks. Centrality measures (expected influence and bridge expected influence) were used to identify influential symptoms within each group. Network Comparison Tests were conducted to examine differences in global strength and network structure, and bootstrapping was employed to assess network stability.

Depressive symptoms were more prevalent among Rwandan adolescents (54.6%) than among Chinese adolescents (29.2%), whereas somatic symptoms were more commonly reported by Chinese participants (71.0% v. 64.0%). Low energy and sleep problems emerged as key bridge symptoms in both groups. Cultural differences were observed in central symptoms: psychomotor impairment and chest pain were central symptoms in Rwanda, whereas dizziness and headaches were central in China. Network structure differed significantly between groups (S = 0.99, p < 0.05), with culturally specific symptom connections.

The findings revealed distinct central and bridge symptoms in Chinese and Rwandan adolescents, reflecting culturally patterned architectures of symptom expression and distress reporting. These results highlight the need for culturally adapted screening tools and symptom-level interventions that target culture-specific symptoms to improve adolescent mental health care globally.

Maternal mental health strongly influences child development and depression risk. This study investigated how positive and negative dimensions of prenatal maternal mental health differentially shape childhood depressive symptoms through cognitive mediators.

Participants were drawn from the Growing Up in Singapore Towards Healthy Outcomes (GUSTO) cohort. Of the 1198 mother–child dyads enrolled, 523 (52.6% boys) had sufficient data for the mediation analysis. Maternal mental health at 26 weeks’ gestation was assessed using a bifactor model derived from the Beck Depression Inventory-II, State–Trait Anxiety Inventory, and Edinburgh Postnatal Depression Scale. Child language ability was measured at age 2 years with the Bayley Scales of Infant Development, executive function at age 7 years with the Behaviour Rating Inventory of Executive Function, and depressive symptoms at age 9 years with the Children’s Depression Inventory-2. Serial mediation models tested hypothesized pathways.

Distinct mediation pathways emerged. Positive maternal mental health was associated with enhanced early language ability, which in turn was associated with fewer depressive symptoms in later childhood (β = −0.017, 95% CI: −0.042, −0.003). Conversely, negative maternal mental health was associated with poorer executive functioning, which in turn was associated with more depressive symptoms (β = 0.040, 95% CI: 0.016–0.077).

Positive and negative maternal mental health are linked to childhood depressive symptoms through distinct neurocognitive pathways. By identifying language and executive function as specific developmental mediators, our findings point to targeted and developmentally sensitive intervention opportunities to disrupt intergenerational pathways of depression.

A 26-year-old male patient presented to the Emergency Department with chemical burns sustained at his workplace, reportedly from 4% Sodium Hydroxide exposure. Despite wearing full personal protective equipment (PPE), including a body suit, goggles, boots, gloves, and a hood, the patient experienced contact burns on his forehead. Immediately following the exposure, he initiated workplace decontamination procedures, rinsing his suit and irrigating the affected area before seeking medical attention.

He presented with persistent forehead pain without visual symptoms. Initial examination was conducted, there was an erythematous area of 4x2 cm over the central forehead, two smaller sub-centimetre brown spots above his left eyebrow, and the glabella. The eye examination was normal. The patient received continuous irrigation with normal saline until pH normalization, and the burns team was consulted. During treatment, physicians recognized a pattern consistent with prior cases involving similar injuries, which prompted further inquiry. Upon subsequent questioning, it was revealed that the chemical spill incident involved multiple index casualties, who had presented separately to the emergency department throughout the day. Both the patient and his coworker, involved in the chemical spill cleanup, were unaware of additional casualties and had chosen not to disclose specific details, including the company’s name. The link was made through address correlation. All patients were treated conservatively, discharged without complications, and had uneventful follow-ups.

This case underscores the crucial management of early decontamination and burns management. Proper workplace protocols for PPE use are also paramount. The coordination of responses via a safety manager and proper communication through national networks is also key to ensuring a timely response and appropriation of resources. Finally, the critical need for clinicians to maintain a high index of suspicion in potential mass workplace incidents, particularly when patients may withhold details due to confidentiality concerns or limited awareness.

Disaster Medicine training can be resource-intensive and difficult to reproduce on a large scale. This study explored the use of an online open-source platform, GatherTown, in Disaster Medicine training for medical students. The maps provided were modified to recreate a disaster zone with multiple casualties and hazardous elements. The hypothesis was that this platform would be an effective teaching method and help in knowledge application.

Medical students from all three medical schools in Singapore were recruited. Those who consented to participate were sent a pre-test questionnaire. Students watched a standardized, prerecorded Introduction to Disaster Medicine video. They then worked together in teams with facilitators to triage and treat 30 casualties in a virtual mass casualty setting. A post-test questionnaire was then sent; this included 10 questions that assessed the students’ knowledge of key elements of disaster management. Pre- and post-test results were matched and analyzed.

A total of 43 medical students participated across 2 sessions in 2024. 17 (39.5%) were Year 1 students, 5 (11.6%) Year 2, 8 (18.6%) Year 3, 12 (27.9%) Year 4, and 1 (2.3%) was a Year 5 student. The average pre- and post-test scores were 52.3% and 66.5%, respectively, with an average increase of 14.2% (0.89-1.94 95% Confidence Interval), p < 0.001. 29 (67%) students improved, while 3 had lower scores and 11 had the same score. Students felt that the scenario-based virtual game helped facilitate learning of Mass Casualty Incident principles (4.88/5), was interactive and informative (4.91/5), and improved their understanding of disaster triage (4.91/5).

The virtual platform Disaster-Town shows promise and may have future applications in training medical students in Disaster Medicine.

In a mass casualty incident, adult medicine-trained emergency physicians and nurses may need to treat pediatric casualties, as part of Field Medical Teams (FMTs) deployed to pre-hospital First Aid Posts. These healthcare professionals are often unaccustomed to managing pediatric patients, who present relatively infrequently to adult general hospital emergency departments in Singapore. A pediatric pre-hospital trauma module was developed to address this gap in knowledge and skills, potentially improving the survival of pediatric casualties in a disaster scenario.

The pediatric module was embedded in the National Disaster Medical Responders’ Course (DMRC) to ensure all emergency medicine medical and nursing staff would progressively benefit from this training. The learning objectives included: 1) effective clinical management of pediatric trauma in a pre-hospital environment with limited medical resources; 2) efficient management of team dynamics in organizing the FMT’s response to pediatric trauma management in a pre-hospital environment; and 3) accurate prioritization during pediatric trauma triaging and evacuation to hospital in a pediatric-predominant mass casualty incident. The curriculum included the following aspects: triage; initial assessment and primary survey; airway, breathing, circulation, and disability considerations focusing on differences between adult and pediatric patients; and team dynamics. Course content was delivered via pre-recorded lectures (given the ongoing COVID-19 pandemic) and hands-on skill stations in small groups.

From April 2022-August 2024, 50 courses with 1144 participants from public healthcare institutions were conducted. Of the participants, 246/1144 (21.5%) were doctors, 787/1144 (68.8%) were nurses, 65/1144 (5.7%) were allied health, and 46/1144 (4.0%) were administrative staff.

Medical responders in a mass casualty incident need to be prepared for managing pediatric casualties, which are infrequently encountered in daily clinical practice. This module is an important component of Singapore’s disaster medical curriculum and will contribute to disaster preparedness for the vulnerable pediatric population.

While statistically uncommon, aircraft-related MCIs pose a wicked challenge for disaster response systems because the sudden surge of numerous critically injured patients can quickly overwhelm local healthcare resources. Aircraft disasters present unique and specific considerations like jet fuel fires, debris, and multi-agency involvement. No study thus far has systematically examined current literature to consolidate best practices for an optimal field medical response to an aircraft-related MCI. This narrative scoping review aims to analyze lessons learned from previous incidents and exercises to guide future preparedness efforts.

Following the PRISMA-ScR guidelines, the authors systematically searched PubMed and Cochrane using MeSH keywords. A total of 29 out of 518 retrieved articles were eventually included in the qualitative synthesis.

This review utilized the CSC-ATT/ETHANE framework advocated by Major Incident Medical Management and Support. Command and control is the most critical element to ensure coordinated responses across various agencies. In the SQ006 crash, the airport fire department was designated as the lead agency but focused solely on fire suppression and failed to establish incident command. Safety concerns include hazards like spilled aviation fuel, toxic gases, live ammunition (e.g. the Pope Air Force Base crash), and environmental factors (hypothermia, lightning, heat exhaustion). Maintaining communications can be challenging due to ambient noise and radio-traffic congestion (e.g. the 2015 TransAsia crash), worse since crash sites typically span large search areas and may have scant cellular reception. Efficient triage, treatment, and transport systems can improve outcomes for survivors, who often suffer from spinal injuries, head trauma, and extremity fractures. Conveyance with spinal immobilization should be considered, as a significant proportion (18% in the TK1951 crash) may sustain spinal injuries.

By analyzing experiences learned from previous incidents, this scoping review provides actionable insights to better optimize the field medical response in the chaotic aftermath of an aircraft MCI.

Mass casualty incidents (MCI) stress systems. Research shows the critical role laypersons play in saving lives and reducing morbidity by providing time-sensitive interventions at a disaster scene. While many first-aid and basic life support courses exist, training for laypersons to respond to disasters is few. A course, “Ground Zero,” was developed by Disaster Volunteer Corps, Singapore General Hospital, for laypersons focusing on basic disaster management and simple lifesaving interventions. This review aims to detail the methods of course development and challenges faced in this pilot program. Kern’s 6-step approach was undertaken for curriculum development. Core content for Ground Zero included scene safety, triage, emergency communications, and principles for basic lifesaving procedures. Emergency physicians supervised Emergency Medicine residents and trained students who conducted the sessions. Course feedback was sought through online forms. Pre- and post-session quizzes were undertaken to assess the learning and confidence of the participants. (Key challenges faced)

• Implementation: Phase 1 was delivered online with breakout sessions, due to COVID-19 pandemic restrictions. Phase 2 was delivered in person, with sessions centering around hands-on practice, and culminating with a simulated MCI, with scene safety, assessment and intervention, and evacuation of casualties undertaken by participants.

• Understanding: the course needed to address disaster response from the layperson’s perspective. MCI principles needed to be simplified, and the limitations of life-saving measures in MCIs had to be addressed sensitively. Citizens have differing levels of baseline medical understanding and willingness to intervene. Focus stayed on empowering and not endangering them in their efforts. The importance of alignment with emergency systems was also taught.

Previous studies demonstrate the willingness of laypersons to respond to disaster scenarios. However, there is a lack of training in this area. Education remains a cornerstone in disaster readiness. Further training and research need to be conducted.

The loss of the Indonesian submarine KRI Nanggala in 2021 and the commercial Titan Submersible in 2023 highlight the importance of preparedness for Submarine disasters. As a Submarine operating navy with Submarine Rescue (SR) capabilities, the Republic of Singapore Navy (RSN) regularly exercises its SR capabilities to maintain this edge. The Medical Flotilla (MedFlot) is tasked with the medical response component of RSN’s SR capability.

Quarterly component training is conducted for all medical personnel. However, there was no opportunity for the entire 37-member medical team to exercise a Submarine Disaster Mass Casualty Scenario (SMASHEX) between 2020 and 2023 due to COVID-19 restrictions. This paper focuses on the lessons learned from conducting MedFlot’s first SMASHEX since 2019.

Conduct of Exercise:

SMASHEX was conducted over a single day in April 2024. Two serials of 10 casualties each were simulated; The first serial simulated casualties rescued directly from the Submarine via a submersible rescue vehicle, while the second serial simulated casualties who had escaped from the distressed submarine in Submarine Escape Immersion Equipment (SEIE) suits.

After-Action Reviews (AARs) were initially conducted in small groups before being held in a larger group setting that involved the conducting team, simulated casualties, and participants. Feedback was initially wholly qualitative in nature.

Feedback highlighted that existing processes were robust. However, a proactive approach surfaced several areas for improvement: i) Triage processes; ii) casualty tracking; iii) medical team communications; iv) familiarity with equipment and processes for casualty movement.

As with other areas of disaster preparedness, the onus falls on organisations with SR capabilities to regularly exercise, evaluate, and improve their Submarine disaster response processes. Future efforts to improve training and evaluation in this realm should involve the use of quantitative markers for benchmarking and tracking.

Screen time in infancy is linked to changes in social-emotional development but the pathway underlying this association remains unknown. We aim to provide mechanistic insights into this association using brain network topology and to examine the potential role of parent–child reading in mitigating the effects of screen time.

We examined the association of screen time on brain network topology using linear regression analysis and tested if the network topology mediated the association between screen time and later socio-emotional competence. Lastly, we tested if parent–child reading time was a moderator of the link between screen time and brain network topology.

Infant screen time was significantly associated with the emotion processing-cognitive control network integration (p = 0.005). This network integration also significantly mediated the association between screen time and both measures of socio-emotional competence (BRIEF-2 Emotion Regulation Index, p = 0.04; SEARS total score, p = 0.04). Parent–child reading time significantly moderated the association between screen time and emotion processing-cognitive control network integration (β = −0.640, p = 0.005).

Our study identified emotion processing-cognitive control network integration as a plausible biological pathway linking screen time in infancy and later socio-emotional competence. We also provided novel evidence for the role of parent–child reading in moderating the association between screen time and topological brain restructuring in early childhood.