The aim of this audit is to assess compliance with physical health monitoring for patients admitted in an acute inpatient setting including weight, height, BMI, waist circumference. Also to assess if metabolic risk factors have been identified and whether appropriate risk mitigation measures were taken.

This is a retrospective audit design where electronic patient records of patients admitted in an acute inpatient unit between November 2024 and August 2025 were reviewed. Information was extracted to determine whether physical health monitoring including weight, height, BMI, waist circumference was completed at baseline (on admission), at 4 weeks, 8 weeks, 12 weeks and subsequently every 3 months. Data was only collected for the duration of the inpatient stay.

Drug charts were reviewed to see whether any changes were made to the treatment regime while inpatient. Discharge summaries were also reviewed specifically the section titled “Plan and Requested Actions” to determine any advice and follow up recommendation were made.

100 patients were admitted in the ward between November 2024 and August 2025. Waist circumference was not measured during the whole length of stay for any patient.

Base line weight was not recorded in 12 patients, height was not recorded in 14 patients. BMI was not calculated for 15 patients.4 patients were not on any psychotropic. Unclear documentation about medication for 3 patients.

37 patients were discharged/transferred before 4 week review.Among the remaining 63 patients, weight was not recorded in 21 (33.33%) patients, height was not recorded in 22 (34.9%) patients. BMI was not calculated in 23 (36.5%) patients. 2 patients didn’t have any psychotropics prescribed.

By 8 weeks, 30 patients were discharged/ transferred. Among the remaining 33 patients,weight was not recorded in 13 (39.39%) patients, height and BMI was not recorded in 14 (42.42%)patients. No psychotropics were prescribed for 1 patient

By 12 weeks, 15 patients were discharged/transferred. Among the remaining 18 patients, weight, height and BMI were not measured in 7 (38.8%) patients.

Before 3 monthly monitoring review point, 13 patients were discharged. Among the remaining 5 patients, weight was not monitored for 1 (20%) patients. 2 (40%) patients didn’t have their height and weight measured.

35 patients had documentation regarding their metabolic risk factor. No patient had clear documentation regarding action taken to mitigate these risks.

This audit shows the need for consistent weight monitoring and implementing a structured traffic-light risk category system to enable early identification and management of antipsychotic-induced weight gain.

Seclusion is highly restrictive and is a last resort to manage immediate risk of harm towards others. Therefore it requires high quality medical reviews and clear documentation to ensure patient safety.

• • To assess compliance with local trust standards for medical seclusion reviews in a inpatient mental health unit (Meadowbrook Unit, Salford, Manchester)

• • Evaluate the impact of quality improvement measures through an re-audit.

Trust policy outlines eight core review criteria: assessment of physical and psychiatric health, medication and adverse effects, observations, risks to others and to self, and the ongoing need for seclusion. This is alongside two best-practice criteria addressing harms of seclusion and steps required to end it/patient awareness.

Quality improvement measures(local teaching/presentations, communication to line managers, and a poster of trust standards in clinical areas) were implemented after an initial audit in July 2024. The re-audit was conducted in March 2025.

A retrospective audit of medical seclusion reviews was conducted using electronic clinical records within an inpatient mental health unit. Forty seclusion reviews from July–August 2024 were analysed against local trust seclusion review criteria. A re-audit of 56 seclusion reviews conducted between March and June 2025 was then undertaken to assess changes in practice.

The re-audit demonstrated higher quality seclusion reviews. No reviews met all eight criteria in 2024, but seven reviews did in 2025. The most common number of criteria met for each review increased from one criterion in 2024 (n=9) to four or five criteria in 2025 (n=12).

Documentation improved overall, including physical health (70% to 82%), psychiatric health (40% to 66%), and medication side effects (0% to 19%). Also, assessment of harms associated with ongoing seclusion improved (2% to 14%). Small declines were found in documentation of the decision to continue seclusion (97% to 91%) and steps to end seclusion or patient awareness (25% to 23%).

Limitations:

The 2024 audit had a smaller sample size (n=40) which was increased in the re-audit (n=56). The 2024 audit was also conducted shortly after a new doctors rotation. Patient sleep status(n=12), senior-led reviews (n=10), and undocumented reviews (n=3) in 2025 may have influenced findings however all reviews were included in the analysis.

The re-audit demonstrated improvement in patient safety through higher quality of documented medical seclusion reviews. There was an improvement in assessment of physical and psychiatric health, medication, and risk assessment. Minor reductions were observed in documentation of decisions to continue seclusion and steps to end seclusion/patient awareness.

Further re-audit across other trust sites should occur with measures to address undocumented reviews and asleep reviews. There should be continued integration of seclusion standards into doctor induction programmes and regular local teaching.

This re-audit shows low-cost, targeted interventions can improve patient safety and seclusion review quality which is transferable to other inpatient mental health settings.

This study evaluated the efficacy of an immersive Acceptance and Commitment Therapy (ACT)-based intervention in reducing subclinical depressive, anxiety, and obsessive–compulsive symptoms in medical students at Cardiff University.

A quantitative within-subjects repeated-measures design was employed using a single-group pretest–post-test approach. Participants completed baseline measures of obsessive–compulsive (OCI-R), anxiety (GAD-7), and depressive (PHQ-9) symptoms prior to engaging with the immersive ACT intervention, and the same measures were repeated post-intervention. Participants were recruited via the medical school’s student support unit and through advertising across all years of the undergraduate medical programme.

Seventeen participants completed all study components. No significant pre–postdifferences were observed on the total OCI-R, GAD-7, or PHQ-9 scores. However, subscale analyses revealed a significant reduction in the neutralising dimension of the OCI-R following the intervention (z=−1.941, p <0.05). Post-intervention differences were also identified between participants with high versus low depressive symptoms (PHQ-9), specifically in obsessional symptoms (z=−2.298, p <0.05). In addition, participants with high versus low anxiety scores (GAD-7) demonstrated a significant reduction in ordering symptoms post-intervention (z=−2.179, p=0.029).

Although no significant changes were observed on overall measures of obsessive–compulsive, anxiety, or depressive symptoms, targeted reductions were evident in specific symptom dimensions following the immersive ACT-based intervention. These findings suggest potential symptom-specific benefits for medical students with elevated obsessive–compulsive, depressive, and anxiety traits. While limited by a small, subclinical sample, the results support further investigation of immersive ACT interventions in larger and clinical populations.

This audit aimed to review patterns of psychotropic prescribing within a community LD psychiatry service in Caerphilly, focusing on medication type, dosage, documented clinical indication, and trends in medication change over time.

Psychotropic medications play a central role in the management of mental health conditions among individuals with Learning Disability. However, their use in this population requires careful consideration due to increased vulnerability to adverse effects, polypharmacy, and challenges in monitoring efficacy and safety. National guidelines, including those from NICE and the Royal College of Psychiatrists, emphasize the importance of regular review, clear documentation of indications, and adherence to best practice standards to minimize inappropriate prescribing.

A retrospective review of clinic and home visit letters for all patients seen by the community LD psychiatry service during the audit period was undertaken. Data were collected by 3 doctors on level of LD, presence of autism spectrum disorder (ASD) or attention deficit hyperactivity disorder (ADHD), psychiatric diagnoses, psychotropic medications prescribed, antipsychotic dose expressed as a percentage of the British National Formulary (BNF) maximum, and medication changes over the audit period.

A total of 117 patients were included. 114 (97.4%) were prescribed at least one psychotropic medication. 77 patients (65.8%) were prescribed antipsychotics, mostcommonly risperidone (n=37). Antipsychotic doses ranged from 1.5% to 100% of the BNF maximum, with 47 patients (61.0%) prescribed doses at or below 25% of the maximum.

A clear mental health diagnosis supporting antipsychotic use was documented in 23 of 77 patients (29.9%), while behaviours that challenge were documented in a further 15 patients (19.5%). No clear indication for antipsychotic prescribing was recorded in the remaining 39 patients (50.6%). Antidepressants were prescribed to 44 patients; anxiety or depressive disorders were documented in 16 patients (36.4%), while 8 patients (18.2%) had no documented indication.

Over the audit period, psychotropic medication remained unchanged in 57 patients (48.7%), increased in 27 patients (23.1%), reduced in 23 patients (19.7%), and switched or cross-titrated in 6 patients (5.1%).

This audit demonstrates high rates of psychotropic prescribing within a community LD caseload, with substantial gaps in documentation of clinical indication, particularly for antipsychotic and antidepressant use. Although some medication reduction occurred, increases were more common than reductions. Improved documentation, structured medication review processes, and multidisciplinary approaches are required to support safe prescribing and align practice with national guidance.

Tier 4 CAMHS general adolescent inpatient services are required to monitor clinical outcomes using measures including CGAS, collected on admission and at discharge. This audit aims to evaluate the completeness of CGAS recording at admission and discharge, and describe CGAS distribution for young people admitted to a general adolescent inpatient unit over a nine-month period.

Data was collected over a nine-month period (30/01/2025 to 30/09/2025), giving n=50 admissions for analysis. Inclusion criteria was all completed admissions within the audit period, and exclusion criteria was any entries where the episode was incomplete or duplicated. For each admission, presence/absence of CGAS at admission, presence/absence of CGAS at discharge, CGAS score at admission (banded into 10-point ranges), and CGAS score at discharge (similarly banded) were extracted from patients’ admission forms and discharge summaries on MORSE healthcare electronic data.

CGAS was recorded on admission for 39/50 admissions. The admission CGAS completion rate of 78.0% did not meet the local target of ≥90%. CGAS was recorded on discharge for 29/50 admissions. The discharge CGAS completion rate of 58.0% was well below the local target of ≥90%. 56% had admission CGAS scores in the 31–40 band, indicating marked impairment in functioning. 16% scored 21–30, and 4% scored 11–20, reflecting very severe impairment. By discharge, a greater proportion of young people had scores in the 41–50 and 51–60 bands, and a small number reached 61–70 and 71–80, suggesting improvement in functioning for those with recorded scores. However, because discharge CGAS was missing or “TBD” for almost half of the sample, these figures may over-represent young people whose episodes were more complete or stable at discharge.

Where recorded, CGAS distributions indicate clinically meaningful improvement in functioning from admission to discharge, but missing discharge data in 21/50 cases weakens the ability to demonstrate outcomes for the whole cohort. Going forward, the Information Officer will routinely check discharge summaries (where no CGAS score is included, the author will be contacted) and the Medical Secretary will only accept discharge summaries that include a completed CGAS, querying any summaries where this is missing. A re-audit will be undertaken for all eligible admissions from 10/2025 to 02/26, using the same criteria and targets to assess whether CGAS completion at admission and discharge has improved towards or beyond the ≥90% threshold.

To improve the accuracy and efficiency of NEWS monitoring by assessing flexibility for parameter recalibration and standardising documentation practices by March 2026.

To ensure NEWS parameters are safely and accurately adjusted for patients with atypical baselines (e.g. on psychotropics), in line with TEWV policy.

PDSA Cycle 1 – Completed November 2025

Plan: To understand current NEWS monitoring practice and identify gaps related to accuracy, recalibration flexibility, and efficiency. This was following discussion with colleagues currently working with the secure inpatient services.

Specific objectives:

• • Assess how frequently NEWS scores are documented electronically and on paper.

• • Determine whether ward systems allow recalibration of NEWS parameters.

• • Identify whether NEWS charts are being used for non-NEWS purposes.

• • Compare practice against TEWV NEWS Policy and NICE guidance.

The expected outcome was to highlight inconsistencies and identify initial improvement opportunities.

Do:

• • Collected data from five forensic wards using a structured yes/no/na audit tool.

Obtained data on:

1. Electronic NEWS recording.

2. Paper NEWS recording.

3. Ability to adjust/recalibrate parameters.

4. Misuse of charts.

• Converted findings to percentage compliance to allow cross-ward comparison.

Study: Key findings from Cycle 1:

• • 72% of wards recorded NEWS electronically.

• • 80% recorded NEWS on paper, showing duplication.

• • 0% electronic recalibration available.

• • 100% of paper charts allowed manual parameter adjustment.

• • 28% of wards used paper charts for non-NEWS tasks.

• • 0% misused electronic charts.

Interpretation:

• • There is a reliance on paper charts for flexibility.

• • The electronic system is inflexible, which may affect clinical accuracy.

• • Documentation duplication results in inefficiency and possible errors.

• • Paper misuse indicates lack of standardisation.

Act: Based on Cycle 1, the project team decided to:

• • Present and disseminate findings to the ward teams and managers.

• • Develop guidance on when and how to adjust NEWS parameters for atypical baselines.

• • Explore options with digital teams for electronic NEWS customisation.

• • Plan staff education on appropriate chart use.

• • Prepare tests of change for Cycle 2.

These findings shaped the next phase of improvement work.

• • 72% of wards recorded NEWS electronically.

• • 80% recorded NEWS on paper, showing duplication.

• • 0% electronic recalibration available.

• • 100% of paper charts allowed manual parameter adjustment.

• • 28% of wards used paper charts for non-NEWS tasks.

• • 0% misused electronic charts.

Summary of Wastes: Duplication of documentation, inability to recalibrate electronically, misuse of paper charts, risk of inaccurate scoring, and reliance on inefficient workarounds all contribute to waste in time, motion, accuracy, and staff expertise.

The data show good overall compliance with NEWS recording but significant limitations in electronic flexibility and non-standardisation of paper chart use.

To align with TEWV policy and NICE guidance, a structured recalibration approach and system improvements are required.

The ADHD service in the London Borough of Redbridge has a waiting list over nearly 600 patients. However, it was noticed that many patients were being booked in for assessments inappropriately, including patients who lived out of borough, who already had a diagnosis or who were seeking a medication review. It was decided to audit the waiting list to see if all remaining patients were suitable to be booked for assessment.

The entire waiting list of 559 patients was screened manually and compared with our electronic patient record system Rio. Client demographics were checked to ensure they currently reside in Redbridge. Referral information was screened to ensure clients were referred for a diagnostic assessment. The list was also screened for duplicate patients. Theexpected standard was that 100% of patients on the waiting list were suitable for an ADHD assessment.

408/559 patients (73%) were deemed as suitable for assessment based on the criteria of living in Redbridge and requiring an ADHD assessment. 151 patients (27%) were unsuitable for a variety of reasons, including residing outside the borough, having moved since being referred, patients who were referred for medication review and patients who had not returned screening questionnaires. There were a significant number of duplicates, with 37 patients being on the list twice, and one patient three times. After removal of these 151 patients, the remaining 408 patients were reaudited to the same standard, with 398/408 (98%) of patients being suitable for assessment. The remaining 10 were subsequently removed. The removal of so many patients had the effect of reducing the waiting time for ADHD assessment in Redbridge by approximately 5–6 months.

The audit revealed flaws with the waiting list and the screening system. Many patients were referred multiple times without this being noticed. There was no screening of the referral to assess which intervention the patient required (i.e. medication review, yearly review or new assessment), with all patients being added to the same list. Patient addresses were not scrutinised and there was no means of being alerted when patients had moved out of borough. These flaws resulted in an increased waiting time for ADHD assessment, and many patients being booked erroneously, wasting clinical and patient time. Measures to prevent this have been implemented, including cross-referencing of new referrals with the waiting list, regular screening of the waiting list by the consultant, and administrative staff checking patient addresses before offering appointments.

During a routine presentation of a ‘mental state examination’ (MSE) within clinical supervision, we noted a hesitancy to describe a patient’s appearance with regards to their race and ethnicity, in a manner routinely taught during training. Our aim was to critically engage with relevant literature to inform our understanding of whether teaching the routine inclusion of race and ethnic descriptors within the MSE should be challenged.

We conducted a review of relevant literature. Six articles were included (full references available).

Limitations within diagnostic formulation: Race, associated with physical characteristics, and ethnicity, associated with descent and cultural factors, are poorly defined, Racial categories do not robustly represent biological predisposition to mental illness. Ethnicity might be considered a ‘shortcut’ to understanding an individual’s sociocultural predisposition to mental illness, however this is shaped by broader societal influences across the lifespan.

Risks of stereotyping: Despite a decline in stereotyping of patients by psychiatrists, racial stereotyping, whether arising from conscious or unconscious biases, remains an issue. Such stereotyping can lead to inaccurate assumptions which may contribute to disparities in diagnosis and healthcare delivery.

Impact of racial/ethnic mis-assignment: Visual assessments of race/ethnicity, based on offhand observations, risk mis-assignment. There is evidence from non-clinical settings that this has a negative impact on sense of identity and mental health. In a specialty where patients often have a complex sense of their own identity, this may cause additional unintended harm. A positive view of one’s ‘self’ is important to recovery; conversely invalidation of a patient’s ‘knowledge of self’ may contribute to epistemic injustice. Being mis-labelled by professionals may also reinforce mistrust of mental health services by some ethnic minorities, contributing to perpetuation of inequalities in accessing care.

Risks of ‘colour blind’ practice: Recognising and understanding an individual’s ethnicity may validate a patient’s sense of identity and is vital for providing holistic care. Recording, recognising and researching race and ethnicity is crucial to better understand and address health disparities within mental health.

Understanding patients’ ethnic and cultural identities is crucial to appreciate and respond to their mental health difficulties. However, we challenge teaching the routine inclusion of race and ethnic descriptors within the ‘mental state examination’. It has little value in supporting formulation and treatment planning, and may contribute towards damaging stereotyping and mis-assignment. Teaching psychiatric trainees to engage in conversations around patients’ heritage and to incorporate relevant aspects within their formulation and treatment is crucial.

Working with carers alongside service users improves clinical outcomes, service user experience, and reduces risks of suicide and self-harm. Caring significantly impacts carers' physical and mental health, yet carers often feel unsupported. This project was conducted in a specialist community rehabilitation team in Sheffield supporting 50 service users with significant support needs. The aims of the project were to improve carer engagement and support, and to identify gaps in carer recording.

A survey based on the Royal College of Psychiatrists standards for community rehabilitation services was distributed electronically to a total of 58 friends, families and carers of current service users. Alongside this an audit of Electronic Patient Records (EPR) was conducted to identify formally recorded carers. This took place in March 2025. The results of this survey and audit were then used to implement changes within the service.

The audit revealed that only 3 out of 50 service users (6%) had formally identified carers recorded, totalling 6 carers. Many more friends and family were recorded without carer status identified.

The response rate of the survey was 24% (14/58). All 14 respondents identified as carers when presented with a definition of a carer as described by Carers UK, suggesting significant under-recording of carers. Carer feedback was generally positive: 93% had emergency contact information, 78% felt well supported by the team, 71% had been offered individual time with team members, and 64% felt involved in care decisions. Areas for development included information around available carers groups, with only 50% being aware these existed, and only 14% of carers being provided with written information about the team.

A bimonthly family, friends, and carers support group was established jointly with the inpatient rehabilitation service. Attendees have given positive feedback regarding this. The written carers pack was reviewed. The team’s view of who constituted a carer was broadened–due to limitations with the EPR carer status wasn’t easily formally recorded, but any family and friends involved in care were considered carers.

This project highlighted gaps in the identification and recording of carers under the community team, despite good levels of carer engagement. The major implemented change was that of a carers group, which was well-received.

The national recruitment process for higher psychiatry training in the UK includes a self-assessment section that recognises applicants’ experience and achievements outside of their usual work. Evidence is uploaded by applicants then reviewed by verifiers using a standardised scoring system. The total awarded score ultimately influences applicants’ priority ranking when training offers are allocated. The aim of this study is to identify trends in self-assessment scoring inaccuracies and explore the reasons for these. This will inform future improvements to the self-assessment process and scoring guidance.

Anonymised data was provided by the National Psychiatry Recruitment Office for all applicants to higher psychiatry training in February and August 2025. Counts were summarised overall and by group using descriptive statistics. Thematic analysis was conducted to explore reasons for scoring adjustments and appeals across the ten assessed domains. Coding was cross-checked by a second researcher to enhance validity.

There were 1,025 applicants across the two recruitment rounds, with 76% having completed core psychiatry training or being in their final year of training. Fifty-nine per cent of applicants were non-UK graduates. The findings highlighted frequent errors in both applicants’ evidence submissions and in verifiers’ reviews. Common applicant error themes included submitting inappropriate, excessive, or incomplete evidence, misunderstanding current guidance, and incorrect domain allocation. Upheld appeals highlighted several instances of incorrect verifier scoring due to misinterpretation of submitted evidence and verification guidance. This resulted in frequent misalignment between candidates’ self-assessments and verifiers’ scoring, with 16% of applicants appealing their scores. Most scoring errors were identified in domains 6 (Clinical Governance, Audit and Quality Improvement as a postgraduate), 8 (Teaching), and 10 (Presentations and Poster Presentations). Scoring errors disproportionately affected applicants with non-UK qualifications and those submitting evidence obtained abroad as documents often did not conform to UK formats, contributing to scoring misalignment.

These findings highlight several challenges in translating applicants’ achievements into standardised scores in the current Higher Psychiatry Training recruitment process. Frequent scoring errors by both applicants and verifiers indicate that the current guidance may lack sufficient clarity, particularly regarding evidence requirements, domain boundaries and scoring thresholds. There is a need to develop the applicant and verifier guidance to include clearer definitions, descriptions, and examples to reduce error rates and improve equity and consistency in portfolio scoring.

High dose antipsychotic therapy (HDAT) is associated with an increased incidence of physical health complications, typically cardiac and metabolic, due to the dose dependent side effect profile of antipsychotic medication.

Since the migration to a fully electronic health record (EHR), Epic, in November 2024 there has not been a streamlined or consistent approach to the completion of physical health monitoring within this patient cohort in our Community Mental Health Team.

This project aimed to evaluate and improve adherence to HDAT monitoring guidelines to reduce the risk of HDAT-related physical health complications.

We screened our caseload of 896 patients and conducted a baseline audit in January 2026 against National Institute for Clinical Excellence (NICE) Clinical KnowledgeSummary (CKS) standards for antipsychotic monitoring (revised January 2026), with a target of 100% compliance.

We also measured the use of two functions of Epic, the ‘FYI Flag’ which is visible on the opening screen of each patient’s electronic chart and the ‘Therapy Plan’ which creates orders for appointments and specified investigations at defined intervals.

We then implemented change by ensuring all patients had an ‘FYI Flag’ for HDAT and an active HDAT ‘Therapy Plan’.

19 patients (2% of the caseload) were currently prescribed HDAT.

At baseline (January 2026), compliance with monitoring was 26%. 21% of patients had an FYI flag on their chart and 26% had HDAT therapy plans in place.

On reaudit (February 2026), compliance with monitoring was 58%. 100% of patients had an FYI flag on their chart and 100% had HDAT therapy plans in place.

Of the 42% of patients who had incomplete or outdated monitoring, 100% had an appointment scheduled for investigations to be completed. The majority of appointments were generated from the recently implemented therapy plans.

The most common reason for incomplete monitoring was investigations falling outside the recommended timeframe. The most commonly omitted components of an otherwise up-to-date set were prolactin and ECG completion.

Adherence to HDAT monitoring guidelines was initially poor but improved substantially over a short period following targeted digital interventions.

This project demonstrates how the use of EHR functionality can efficiently improve patient care. We are optimistic that the rate of monitoring will continue to rise through the implementation of ‘Therapy Plans’ which electronically generate prompts for investigation completion and appointment booking.

We plan to continue this project with ongoing Plan–Do–Study–Act cycles to reach our target of 100% and demonstrate sustained improvement.

This service evaluation aimed to assess how consistently overdose risk factors are recorded in routine outpatient clinical records, identify gaps in documentation, and explore patient characteristics associated with missing or incomplete risk assessments.

A retrospective service evaluation was conducted in an addictions psychiatry outpatient clinic. Adults aged ≥18 years receiving methadone or buprenorphine during a six-month period were included. Patients were excluded if they had transferred care during this period or had incomplete medical records. Clinical notes and pharmacy records were reviewed to extract information on overdose risk factors, including polysubstance use, previous overdose, co-prescribed benzodiazepines, psychiatric comorbidities, and naloxone provision. Demographic information and substance use patterns were also collected. Data were analysed descriptively to summarise documentation rates, and exploratory comparisons were made between patients with and without recorded overdose risk factors

A total of 110 patients were included (methadone n=68, buprenorphine n=42). Overdose risk factors were documented in 61 patients (55%), leaving 45% without recorded risk assessment. Naloxone provision was documented in only 44 patients (40% of total), including 12 patients with known polysubstance use who had no recorded naloxone offer. Polysubstance use was present in 48 patients (44%), and these individuals were more likely to have risk factors documented (65% vs 48%), although a substantial proportion remained undocumented. Patients with co-occurring psychiatric diagnoses were also more likely to have documented overdose risk, but documentation consistency varied widely. The review demonstrated that systematic evaluation of overdose risk documentation is feasible within routine outpatient records and can identify gaps that may compromise patient safety.

Overdose risk is inconsistently documented in OST outpatient settings, despite high prevalence of polysubstance use and psychiatric comorbidity. Gaps in documentation, including missed naloxone provision, highlight the need for structured protocols and staff training to ensure that high-risk patients are identified and receive appropriate harm reduction interventions. Implementing routine overdose risk assessments within clinical workflows is feasible and may improve safety, patient outcomes, and overall quality of care.

In pharmacokinetic studies of xanomeline and trospium chloride (KarXT), dosing with food reduced trospium bioavailability, potentially impacting tolerability. This study was designed to demonstrate taking KarXT with food after a slow up-titration is safe and tolerable.

In pharmacokinetic studies of xanomeline and trospium chloride (KarXT), dosing with food reduced trospium bioavailability, potentially impacting tolerability. This study was designed to demonstrate taking KarXT with food after a slow up-titration is safe and tolerable.

During periods 1 and 2, 64.2% and 39.0% of participants reported ≥1 treatment-emergent adverse event (TEAE), respectively. The most common TEAEs (≥5%) in period 1 were nausea (22.5%), dyspepsia (15.6%), headache (15.0%), constipation (12.7%), and vomiting (11.6%); the incidence of all new onset TEAEs was less in period 2 when taken with food. All TEAEs were mild or moderate in intensity; none were serious. PANSS total score decreased over periods 1 and 2; Clinical Global Impression-Severity score decreased over period 1 with no further change over period 2. Dose-normalized area under the curve and maximum plasma concentration of trospium pooled from cohorts 1 and 2 decreased by 36% and 43%, respectively, when taken with food versus fasting. No clinically significant differences were observed in xanomeline exposure.

After slow uptitration on an empty stomach, there was no increase in the incidence or severity of TEAEs when taking KarXT with food; efficacy was maintained.

Consistent and comprehensive documentation is essential for patient safety, continuity and appropriateness of care, and effective communication on psychiatric inpatient wards. The Mental State Examination (MSE) remains the cornerstone of psychiatric assessment; however, routine nursing documentation often varies in structure, emphasis, and completeness. In other clinical settings, structured documentation tools have shown improved consistency and adherence to best-practice standards. Within psychiatric services, there is limited evidence examining whether routine nursing notes consistently capture the breadth of the MSE.

This case-note review focuses on documentation quality using MINDY, a structured mental state framework developed to support systematic inpatient assessment.

We aimed to compare the completeness and consistency of routine nursing inpatient psychiatric documentation with contemporaneous assessments completed using the MINDY framework.

We hypothesised that the former do not consistently show all core domains of the MSE and that MINDY provides a more comprehensive representation of the patient’s overall mental state.

We designed this as a service evaluation and case-note review on an acute adult psychiatric inpatient unit. During a two-week period, selected randomly, three different resident doctors assessed all patients under a single consultant using the MINDY tool. We obtained corresponding nursing documentation for this period and compared these sources of information, only including days when both were available.

An independent medical student, not involved in patient care, performed the comparative analysis.

All records were anonymised prior to analysis. Local NHS information-governance procedures and General Data Protection Regulation (GDPR) were followed.

Routine nursing documentation demonstrated a median MSE-domain completeness of 40% across patients, with consistent focus on behaviour, activity, mood and cognition but near-complete omission of speech, thought process and insight.

In contrast, the MINDY framework structurally mandates assessment of nine of ten classical MSE domains, yielding a median completeness of 90% per assessment. The median difference in domain coverage was therefore 50 percentage-points. The magnitude of this effect was very large (Cohen’s h=1.13), and the difference was highly statistically significant on two-proportion testing (p < 0.001).

Compared with routine narrative nursing documentation, MINDY more than doubled the breadth of mental-state recording, increasing median MSE-domain coverage from 40% to 90%. The size of this improvement was extremely large and statistically robust, supporting MINDY’s role as a powerful standardisation intervention rather than merely a symptom-rating scale.

These findings indicate that structured daily use of MINDY could enhance multidisciplinary communication and reduce systematic omission of key psychopathological domains on acute wards.

Medical Emergencies in Eating Disorders (MEED) guidelines provide essential recommendations for identifying and managinghigh-risk eating disorder presentations in acute hospital settings. Local audit data showed inconsistent referral pathways and incomplete documentation of MEED aligned risk assessments, indicating gaps in clinician confidence and understanding. This project aimed to improve the knowledge and confidence of resident doctors, consultant psychiatrists, nurses and allied health professionals (AHPs) in applying MEED guidance, with an emphasis on risk assessment, safe refeeding, legal frameworks, and multidisciplinary collaboration.

A series of interactive teaching sessions were delivered to diverse clinical groups, including foundation doctors, psychiatry residents, consultant psychiatrists and multidisciplinary liaison psychiatry teams. Teaching was case-based, using real patient scenarios to illustrate MEED risk stratification, indicators for urgent medical admission, safe refeeding principles, decision-making under the Mental Capacity Act (MCA) and Mental Health Act (MHA), and best-practice multidisciplinary management. Participants completed structured pre- and post-session questionnaires evaluating confidence, the relevance of case examples, the likelihood of applying learning, and suggestions for improvement.

A total of 50 clinicians completed the pre-session questionnaire, and 67 completed the post-session questionnaire. At baseline, 68% reported low confidence. There was wide variation in clinical experience, with 32% having never encountered patients with eating disorders.

Following the teaching, most participants reported improvements in confidence, with 76% reporting “significant” or “quite a bit” of improvement, frequently citing clearer understanding of MEED principles, including “MEED guidelines and applying it to patients”, as well as practical skills such as “give thiamine before glucose”. 97% of participants indicated that they are “very likely” or “somewhat likely” to implement the learning in their practice. Post-session, clinicians expressed a stronger grasp of legal frameworks, noting improved confidence in “treatment under MCA” and recognising the need to “always assess for capacity in patients refusing treatment”. The importance of coordinated multidisciplinary practice was repeatedly highlighted by clinicians, noting that “managing patients jointly with physicians will produce the best result” and that effective care relies on close “interaction between medical team, PLT and dieticians”.

Interactive, case-based MEED teaching is an effective educational approach that improves clinicians’ confidence and readiness to manage eating-disorder emergencies. Embedding MEED teaching within routine induction and MDT training, alongside accessible reference materials, may strengthen clinical practice and patient safety across acute care settings. The next steps involve training physicians in accident and emergency departments and in acute medical wards.

Academic performance in medical school is shaped by socio-demographic and psychological determinants, yet evidence from Emirati cohorts remains scarce. This study examined associations between socio-demographic characteristics, psychological resilience and academic performance among Emirati undergraduate medical students, with a focus on family structure.

We conducted a cross-sectional, questionnaire-based study among Emirati Medical students enrolled at the United Arab Emirates University. Undergraduate medical students were invited via institutional channels. The online survey captured self-reported cumulative Grade Point Average (GPA), socio-demographic data (age, gender, academic year, school type, high-school tutoring, family structure, curriculum type) and psychological resilience using the Brief Resilience Scale (BRS). Descriptive statistics summarised the sample. Group differences in GPA were tested using independent-samples t-tests and one-way ANOVA, and the association between GPA and resilience was examined with Spearman correlation, withsignificance set at p<0.05. A total of 115 complete responses were analysed.

Respondents had a mean age of 20.3 years (SD 1.23); 75.7% were female. Slightly more attended public than private UAE schools (52.2% vs 47.8%); 71.3% had not received private tutoring. Most were in years 3–4 (64.4%). The majority lived in nuclear families (82.6%), with 12.2% in extended families and 5.2% in single-parent/own-household arrangements; 48.7% followed a UAE high-school curriculum and 51.3% non-UAE curricula. Mean cumulative GPA was 3.45 (SD 0.37). Resilience scores indicated moderate resilience (mean total 19.1, SD 3.66; mean item score 3.18, SD 0.61) and were not associated with GPA (Spearman r=0.022, p=0.814). There were no significant GPA differences by gender, tutoring, school type or curriculum (all p>0.05). Family structure showed a significant effect (F(2,112)=3.14, p=0.047), with students in single-parent/own-household arrangements having a lower GPA (M=3.09, SD 0.45) than those in nuclear families (M=3.46, SD 0.37), while those in extended families had a similarly high GPA.

In this cohort of Emirati medical students, academic performance was generally high and similar across gender, resilience, school type, tutoring, or curriculum. However, lower GPA among students living in single-parent or independent households suggests that reduced or disrupted family support may affect outcomes. Routine screening for social and family stressors, along with targeted support for students with less stable family arrangements, may help mitigate emerging inequalities.

No financial sponsorship has been received for this study.

Background

Armed conflict and political instability are major determinants of population mental health, disrupting service delivery, workforce sustainability, and prevention systems. Following the 2021 military coup in Myanmar, formal psychiatric training pathways and national mental health services were severely fragmented or collapsed. In response, the Myanmar Board of Psychiatry (M.B.Psych) was reconstituted in 2025 to support a population-oriented, task-shared mental health system operating under complex humanitarian conditions.

Aims

To describe a national public mental health model integrating workforce development, service delivery, prevention, and community-based interventions in a protracted conflict setting.

A descriptive programme analysis was conducted using routine training, service delivery, and supervision data from M.B.Psych activities between January and December 2025. Interventions were mapped across core public mental health domains, including promotion, prevention, treatment, capacity building, and system governance.

M.B.Psych implemented a multi-layered mental health system spanning community, primary, and specialist care. Workforce capacity was strengthened through postgraduate psychiatric training, undergraduate teaching, medical education programmes, and international global mental health certification, with seven psychiatrists qualifying during the study period, supporting continuity of specialist care despite widespread displacement.

Population-level preventive and promotive interventions included nationwide Psychological First Aid, Mental Health and Psychosocial Support (MHPSS), mhGAP training, suicide prevention services, and school-based mental health programmes. Task-sharing enabled trained volunteers, lay counsellors, and primary care clinicians to deliver frontline care with structured psychiatric supervision.

Clinical services were delivered through an integrated hybrid model combining tele-mental health, primary mental health clinics, suicide prevention hotlines, and targeted on-ground psychiatric deployment in conflict-affected regions. Diaspora psychiatrists provided sustained supervision, psychotherapy training, and clinical governance support. Contextually adapted resources, including a Myanmar-language WHO Group PM+ manual and military-focused MHPSS materials, supported scalable and culturally appropriate interventions.

This public mental health model demonstrates that equitable, population-based mental health systems can be sustained during armed conflict through task-sharing, digital delivery, diaspora engagement, and integrated education–service frameworks. The Myanmar experience offers transferable lessons for global mental health system strengthening in fragile and conflict-affected settings.

Acknowledgements

The authors acknowledge the commitment and resilience of all Civil Disobedience Movement (CDM) mental health professionals, psychiatrists, psychologists, trainees, volunteers, and the Myanmar psychiatrist diaspora who contributed to service delivery, training, supervision, and community mental health support under extremely challenging conditions.

Congenital insensitivity to pain (CIP) is a rare neurogenetic condition characterised by lifelong absence of nociception, removing a fundamental biological deterrent to injury. Psychiatric risk-assessment frameworks implicitly rely on pain perception, distress cues, and behavioural feedback to signal escalation. We describe a case of severe self-harm escalation in a young adult with genetically confirmed CIP, emotionally unstable personality disorder (EUPD) highlighting critical limitations of standard inpatient risk-management approaches and the need for pain-independent safeguarding strategies.

We describe a female in her early twenties admitted to an acute psychiatric ward under the Mental Health Act following overdose and repeated self-harm. She has a childhood diagnosis of genetically confirmed congenital insensitivity to pain due to a homozygous SCN9A mutation, with lifelong absence of pain perception and a history of significant injuries without reported pain. She also has longstanding neurodevelopmental and personality vulnerabilities, including autism spectrum traits and emotionally unstable personality disorder, with self-harm beginning in early life. During admission, she described persistent internal voices and intrusive phenomena consistent with pseudo-hallucinations associated with EUPD and autism, rather than primary psychotic illness. Despite prior minor self-harm episodes, environmental access to hazards such as sharps and boiling water continued. This culminated in a severe self-inflicted scald injury requiring admission to a specialist burns unit and intravenous antibiotics, with minimal behavioural or verbal pain response observed during injury assessment and wound care.

This case demonstrates how self-harm can escalate rapidly and silently when nociceptive feedback is absent. The absence of pain and distress cues rendered conventional observation levels and harm-minimisation strategies ineffective, delaying recognition of injury severity. Risk could not be reliably inferred from reported experience, expressed intent, or diagnostic category. Even in the absence of primary psychosis, self-harm associated with EUPD and autism progressed to life-threatening physical injury without typical warning signals, exposing a critical blind spot in inpatient psychiatric risk frameworks that rely on pain-dependent deterrence and behavioural escalation markers.

In patients with congenital insensitivity to pain, self-harm risk must be assessed independently of pain perception and expressed distress. Psychiatry services should implement pain-independent safeguards, including early and sustained environmental restriction, routine body mapping, scheduled wound and physical observations, and prioritisation of psychotic symptom control. This case highlights the need for integrated neuropsychiatric approaches and revised inpatient risk frameworks when biological pain deterrents are absent.

The use of seclusion in intellectual disability services presents significant ethical and emotional challenges for staff. While the impact of restrictive practices on patients has been widely explored, there is limited literature examining the potential for moral injury among staff involved in delivering seclusion. This service evaluation aimed to explore the nature of moral injury experienced by staff involved in seclusion within an intellectual disability assessment and treatment unit (ATU), alongside perceived contributing factors, available support, and coping strategies.

An exploratory mixed-methods service evaluation was conducted in an intellectual disability assessment and treatment unit. Anonymous staff surveys were used to collect both quantitative and qualitative data. Quantitative data were gathered using a modified moral injury rating scale to explore levels of moral distress and wellbeing. Qualitative data were obtained through free text responses exploring staff experiences of seclusion, including ethical dilemmas and emotional responses. Quantitative data were analyzed descriptively, and qualitative data were analyzed using thematic analysis.

Findings suggest that staff involved in the use of seclusion may experience features consistent with moral injury. Key themes included the emotional impact of enforcing restrictive practices, perceived lack of autonomy within organisational systems, repeated or prolonged use of seclusion, and limited opportunities for structured debriefing and reflective practice. Staff described tensions between professional values and organisational demands, alongside variable access to psychological and supervisory support.

This service evaluation highlights moral injury as a potential occupational risk for staff involved in seclusion within intellectual disability services. Addressing moral injury through reflective spaces, supervision and organisational support may be important in promoting staff wellbeing, reducing burnout, and maintaining standards of patient care. Further work is warranted to better understand moral injury in restrictive practices and to evaluate interventions aimed at mitigating its impact.