Drug resistant first episode psychosis in a 17-year-old adolescent male with autism spectrum disorder presents with a significant diagnostic and therapeutic challenge especially with associated physical comorbidities. Medication intolerance, persistently low white cell count, partial response and early relapse after discharge remain the prominent risks. This case highlights the complex nature of therapeutic decision making and discharge planning in a high-risk young person.

A 17-year-old adolescent male who was admitted to the in-patient CAMHS unit with a 14-month history of progressive psychotic symptoms characterised by chronic auditory and visual hallucinations, paranoid delusions; alleging his parents to be impostors; depressed mood, anhedonia, and social withdrawal. With a diagnosis of autism spectrum disorder, history of significant trauma, years of school bullying and street robbery. He has a past medical history of cardiac arrest with unknown aetiology and on treatment with implantable cardioverter defibrillator.

During initial admission, he was polite, compliant with treatment although with partial insight. Family support was robust, and leave was utilized with no significant adverse incidents. Despite participation in ward activities his affect remained predominantly flat with persisting psychotic symptoms albeit with less intensity. Pharmacological management remained challenging, initially commenced on aripiprazole, titrated to 15mg which was discontinued due to significant restless legs symptoms requiring procyclidine. Olanzapine was initiated and gradually increased to a maximum of 12.5 mg with partial stabilization necessitating discharge to the community.

Weeks following discharge, worsening complex delusions and commanding hallucinations and high-risk behaviours in the community was noted. These include fire-setting and possession of weapons.

This led to re-admission and risperidone was trialled and gradually titrated to 5 mg with marked elevation of prolactin with minimal improvement.

Giving treatment resistance, clozapine was considered and is being approached cautiously due to his history of cardiac arrest, persistently low white cell counts and hyperprolactinemia with close psychiatric and cardiology consultation followed with gradual risperidone taper.

This case illustrates the complexity in managing treatment resistant first-episode psychosis in autistic adolescent with significant physical comorbidities.

Careful antipsychotic selection, robust discharge planning, and intensive multidisciplinary follow-up are essential to reduce relapse and serious harm.

Suicidal and homicidal behaviors are typically assessed as distinct risk domains, despite overlapping psychopathology in psychosis and severe mood disorder. We introduce the new concept Suicide by Proxy as a psychodynamic formulation in which homicide (or attempted homicide) represents a displaced enactment of suicidal intent when direct self-destruction is inhibited. Drawing on Freudian models of internalized aggression, persecutory superego dynamics, and object-related conflict (Oedipal/Electra configurations), we aim to illustrate how self-directed destructive drive may be externalized toward a symbolic other.

Three retrospective forensic psychiatric case reports were analyzed using a psychodynamic framework. All cases involved severe mental disorder (schizophrenia-spectrum or major depressive episode with psychotic features), documented suicidal ideation and/or attempts, and a homicide or attempted homicide. Data sources included clinical interviews, collateral histories, medical/legal records, and psychological testing (including MMPI and SIMS). Identifying details were removed or altered to preserve confidentiality without changing clinical meaning.

Case 1:A 26-year-old man with paranoid schizophrenia and persecutory delusions purchased a firearm intending suicide but reported inability to act. He subsequently killed an unknown man in a mosque, then left the weapon beside the body. The act is conceptualized as displacement of self-destruction onto an authority-linked symbolic target, enabling rebellion against a persecutory superego without direct suicide or parricide.

Case 2:A 39-year-old woman with psychotic depression and intense suicidal communications stabbed her sleeping father after planning to kill herself in his presence, then attempted self-stabbing. This is formulated as a negative Electra configuration: ambivalent attachment and rage toward a passive betrayer father, with psychosis collapsing boundaries between self-attack and object-attack.

Case 3:A 36-year-old woman with schizophrenia, shaming maternal criticism, and relapsed hallucinations broke a mirror and attempted to attack her mother with glass while concealing suicidal intent. The mother is conceptualized as a proxy self-representing the rejected, humiliated part of the patient targeted for annihilation.

Across cases, homicidal acts functioned as symbolic self-attacks emerging from internalized aggression, persecutory superego pressures, and unresolved parental-object conflict. Suicide by Proxy may help forensic clinicians integrate suicidality into violence formulations, prompting dual-screening for suicidal and displaced homicidal risk in severe mental disorder. Further empirical work is needed to test the model beyond case-series evidence.

To evaluate the effectiveness of case management for children and young people (CYP) with mental disorders, substance use, or neurodevelopmental conditions, and to identify components and contextual factors associated with improved outcomes.

This was a systematic review and multi-level meta-analysis of randomised controlled trials (RCTs). Databases were searched from inception to June 2025. Reference lists and prior reviews were hand-searched for additional studies. Eligibility criteria: RCTs involving participants aged 5–18 years with mental health, substance use, or neurodevelopmental conditions, comparing case management (or equivalent) to treatment as usual, waiting list, or a less intensive model in community/outpatient settings. Outcomes extracted were clinical and social outcomes (which included any outcomes related to symptoms and functioning), service use (which included any outcomes related to the numberof service contacts or treatments given, excluding differences in treatments offered due to the experimental conditions), satisfaction, and cost-effectiveness. Two reviewers independently screened studies, extracted data, and assessed risk of bias using the Cochrane RoB 2 tool. Effect sizes (Hedges’ g) were pooled and meta-analyses were conducted for clinical and social outcomes and service use, applying a multilevel model to account for effect-size clustering within and between studies. Narrative review was conducted for satisfaction and cost-effectiveness. The certainty of evidence was rated using GRADE.

Fourteen studies were included, comprising 16 comparisons, most of which were conducted in the United States. Case management was associated with a small improvement in clinical and social outcomes (Hedges’ g=0.15; 95% CI 0.02 to 0.28) and a moderate increase in service use (g=0.68; 95% CI 0.20 to 1.17). Heterogeneity was high. Economic analyses suggested potential cost-effectiveness through reduced out-of-home placement and treatment dropout. Evidence for satisfaction was mixed. There were some concerns or high risk of bias in 10 out of 14 studies. The certainty of evidence using GRADE was very low for clinical and social outcomes and low for service use.

The review indicates that case management can improve engagement and service use among CYP with complex mental health needs, though clinical benefits are modest, and evidence quality is limited.

Acute inpatient services are experiencing increasing pressure on bed capacity, alongside a growing need for efficient and sustainable use of resources. As services transition towards the NHS ‘Home First’ approach, there is a need to critically review existing practices to further optimise patient flow and reduce discharge delays.

This service evaluation looked at how three acute general adult psychiatric wards in Sheffield utilised brief daily board meetings referred to as ‘Purposeful Inpatient Admissions’ (PIPA) meetings, and weekly multidisciplinary team (MDT) meetings. Phase 1 of the project aimed to gain an understanding of staff views on the existing daily PIPA/weekly MDT model. These findings will inform the development of the new ‘Daily Planning Meeting’ model and provide a meaningful comparator for phase 2 of the service evaluation following implementation.

An anonymised baseline survey was distributed via Microsoft Forms to staff across the three wards to capture multidisciplinary perspectives. The 21-question survey included Likert-scale and free-text items exploring views on the current model, including workload, communication, service user experience and suggestions for improvement. It remained open for three weeks between November and December 2025. Data were exported to Excel for quantitative and qualitative analysis.

Forty-six staff members responded, with nurses and medics comprising 63%, reflecting ward workforce composition. 52% of respondents found the current PIPA/MDT model ‘somewhat helpful’. 70% reported that PIPA/MDT ‘sometimes’ identified clear care goals. 57% thought that the current model ‘sometimes’ improved relationships with patients whilst 67% felt that it ‘sometimes’ enabled patient and family involvement. 9% of respondents felt the current model ‘never’ supported enthusiasm or engagement in patient-centred care. Most respondents agreed all professional roles should attend MDTs regularly.

Thematic analysis highlighted perceived benefits of the current model which included structured multidisciplinary collaboration, task prioritisation and shared decision making. However, significant challenges were identified. Both meetings were frequently described as time consuming. Communication gaps within and across teams, limited community team involvement and inconsistent patient and family engagement were recurrent themes. Staff advocated for clearer documentation processes, enhanced patient involvement and streamlined meeting structures as ways to improve the current model.

Phase 1 identified key strengths and limitations of the PIPA/MDT model. Recommendations include defining professional roles and responsibilities, improving task allocation and documentation as well as protecting time for meaningful patient engagement. Early involvement of community teams and encouraging patient and family participation are central to supporting the NHS Home First approach and improving patient flow.

Chronic alcohol dependence increases the risk of alcohol withdrawal syndrome, requiring prompt identification. Despite this, no locally endorsed clinical guidelines currently exist to support clinicians. This audit aims to evaluate the adequacy of alcohol screening and initial clinical assessment at admission to an acute psychiatric inpatient service, focusing on the identification and management of AUD, alcohol dependence, and alcohol withdrawal, and compares current practice with international standards.

A retrospective audit of all acute psychiatric admissions in March 2025 was conducted. Data were extracted in line with the American Society of Addiction Medicine Clinical Practice Guideline for Alcohol Withdrawal Management, including documentation of alcohol use, clinical history, withdrawal features, and relevant investigations. All data were anonymized following ethical approval.

Of the 217 total admissions, 190 patients were included in the final analysis. Among the analyzed cohort, alcohol use was documented in 132 patients (70%), with 36 individuals (27.3%) confirming regular consumption.

Notably, medical and surgical comorbidities were recorded in 100% of cases (n=36), followed by age at 95.6% (n=35), and suicide risk assessments at 91.7% (n=33). Clinicians also frequently screened for other substance use (100%) and history of mental illness (88.9%). Regarding consumption patterns, while the quantity of alcohol was frequently noted (88.9%), details regarding the duration of dependency and the specific time of last consumption were documented in only 8.3% of files.

Despite the use of CIWA-A scoring in 66.7% of regular users, documentation for previous withdrawal delirium, history of withdrawal seizures, and observed autonomic activation during the initial interview all stood at 0%.

Furthermore, urine toxicology was performed for 63.9% of patients. Metabolic and infectious screening was inconsistently and were documented as following; LFTs 52.8% (n=19), Albumen 41.67% (n=15), INR 27.8% (n=10), Ethanol 36.11% (n=13), Pregnancy test 10% (n=1 out of females in the cohort) and HIV and Hepatitis Screen within 5 years 55.56% (n=20).

In this retrospective audit, significant shortcomings were identified. These findings indicate incomplete adherence to internationally recommended assessment standards and may limit the early identification of alcohol withdrawal risk. Implementation of a locally adapted alcohol assessment guideline consistent with international best practice is therefore warranted. Re-audit is recommended to assess changes in clinical practice and to evaluate associations with patient-related outcomes. No financial support was received for this study.

This quality improvement project was aimed at enhancing the clinical discussion and documentation of side effects of psychotropic medications in psychiatry community settings to 100% over a span of 12 months.

This quality improvement project was carried out at the early intervention service Limbrick Centre. Sample included looking at 20 patients' first medical review under the EIS. The selection process was randomly done. Patients with a primary diagnosis of first-episode psychosis were selected using their hospital number. The audit included all patients who were referred to the EIS from 1 July to 31 December 2024. Anonymised patient data were used in line with the quality improvement initiative of this project and therefore informed consent was not applicable. Data was retrospectively obtained from outpatient electronic records over six months on patients who were newly prescribed psychotropic medications. The key standard for the baseline measurement was whether the communication of at least one side effect of a newly prescribed medication was documented by the doctor in the patient's electronic records. If electronic entries stated that side effects were 'discussed', these entries were not considered as objective evidence of discussions. The criterion for appropriate documentation was clear descriptions of specific side effects discussed and the minimum number of side effects that a doctor should discuss was set at one.

A random sampling method for data extraction was used, using the random number function in Microsoft Excel. Psychotropic medications included antidepressants, antipsychotics, benzodiazepines, mood stabilizers and hypnotics. Data was analysed using Microsoft Excel.

Forty percent of service users’ medical reviews had documentation of side effects of psychotropic medications. Sixty percent of service users’ medical reviews did not have documentation of side effects of psychotropic medications. Although out of this 60%, some doctors had written side effects discussed but the actual side effect discussed was not documented which therefore excluded these data.

This project served as a reminder that robust documentation of patient communication is at the very core of good clinical practice. Shared decision making involving patient in treatment decisions and embedding robust documentation into practice, in addition to enhancing care, confers added benefits to both individual healthcare providers and their employers through the potential diminution of medico-legal risks.

Dementia commonly affects older adults, with over 944,000 affected and one in eleven adults aged over 65 in the UK diagnosed. Due to the increasing number of referrals to memory clinics (MC), the recognition and management of reversible causes of cognitive impairment in primary care is essential. During the first cycle, missing information and blood tests were found to delay patient care and reduce efficiency. The National Institute for Health and Care Excellence (NICE) recommends the following: full blood count (FBC), urea and electrolytes (U&Es), liver function tests (LFTs), thyroid function tests (TFTs), glycated haemoglobin (Hbs-352c), serum calcium (Ca), erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP), and serum vitamin B12 and folate (B12/folate). The second cycle assessed whether a specialised proforma and education leaflets for primary care clinicians increased the availability of blood tests within two months of referral.

Patient information was extracted from referrals received over two twelve-week time periods, one and a half years apart. Cycle one was conducted between 10/10/2023 and 20/11/2023, and cycle two between 07/08/2025 and 28/10/2025. Data on referrals and blood tests, completed within two months of referral, were obtained from RiO and ICE West and analysed in Excel, with data anonymised. Patients with an existing dementia diagnosis or those referred directly by secondary care were excluded. After the first cycle, focus groups were held with the multi-disciplinary MC team, followed by the distribution of an information update letter and updated proforma to all primary care clinicians.

A total of 101 referrals were included. In Cycle one, only 11.9% of patient referrals had all recommended blood tests completed within two months prior to referral. 27.1% hadnone of the recommended tests. In Cycle two, 85.7% of referrals used the distributed proforma. The proportion of patients with all recommended blood tests completed increased to 23.8%. Of the referrals utilising the proforma, 80% included all relevant blood tests two months prior to the referral receival.

Overall, 85.7% of referrals used the MC proforma. Using the proforma improved referral quality by prompting inclusion of relevant information and blood tests, enhancing service efficiency. Notably, around 75% of referrals lacked vital blood tests, affecting the efficiency of MC services. Focus group discussions highlighted that MC staff should now refer referrals lacking up-to-date bloods back to primary care and that wider distribution of the proforma with clear blood test requirements may further increase compliance, suggesting a further audit cycle could be beneficial in future.

Lithium is the gold standard treatment for bipolar disorder, but its mechanism of action is not fully understood. Emerging research suggests structural and functional alterations in the retina of people with bipolar disorder and depression, including a thinner retinal nerve fibre layer and ganglion cell layer. Retinal structure and function can be characterised using several noninvasive imaging techniques, from which numerous quantitative metrics can be derived. We aimed to complete a systematic review of the literature to establish which parameters have been evaluated in relation to lithium use and what insights they provide into its potential retinal effects.

Searches using the terms ‘Lithium’ AND ‘retina’ were carried out to identify peer reviewed studies assessing the impact of lithium on retinal structure or function. These included those with or without a control group comparison, pre- and post-lithium comparisons and observational studies. There were no exclusions based on the quantity or preparation of lithium administered, or the length of administration. Any studies where lithium was administered in combination with another intervention were excluded, unless it was directly compared to the other intervention without lithium. The main outcome of interest was optical coherence tomography (OCT) derived metrics, but any measure of structure or function was included.

Seven studies reporting structural outcomes, and 10 reporting functional outcomes, were identified.Structural outcomes were derived from optical coherence tomography (OCT) imaging studies which had multiple limitations. There was no evidence of statistically significant difference in the retinal nerve fibre layer (RNFL) between people with bipolar disorder taking lithium and healthy controls in two studies with larger numbers, indicating a protective effect on the retina. In four studies looking at differences in people with bipolar taking lithium and those taking valproate, two showed no signs of difference and two evidence of statistically thicker RNFL in the lithium group, also in line with a potential protective effect. For all other OCT derived metrics, the evidence was limited.

Studies reporting functional outcomes were highly heterogeneous with multiple limitations and no clear trends. The majority reported a statistically significant effect of lithium on at least one functional measure, derived from electrooculography, electroretinography, and dark adaptation threshold procedures.

Trends indicate that lithium is likely to have an effect on both the structure and function of the retina, but significant limitations in all included studies mean that better designed and adequately powered prospective studies are required for both structural and functional measures of the retina.

The purpose of this review was to methodically assess data from randomised controlled trials (RCTs) that looked at how orange-spectrum or circadian-relevant light interventions affected sleep, behaviour, and circadian outcomes in patients with dementia. Synthesising important findings and critically evaluating methodological quality using the Cochrane Risk of Bias 2 tool were secondary goals.

A systematic research of PubMed was conducted from database inception to the most recent search date, using Medical Subject Headings and free-text terms related to dementia and light-based interventions. Only human RCTs were included. Outcomes of interest included sleep quality, agitation, circadian rhythm measures, and neuropsychiatric symptoms. Data were extracted into standardised tables, and methodological quality was assessed using the RoB 2 tool.

Five excellent RCTs satisfied the requirements for inclusion. People with moderate to severe dementia in residential care and community settings in the USA,UK and Europe were included in the study populations. Bright or circadian-effective lighting was the main intervention, though some studies also included less exposure to blue light in the evening. Agitation, sleep efficiency and circadian rhythm stability were the main results. The results showed mixed effects on agitation and behavioural symptoms, with only slight improvements in sleep and circadian outcomes. The overall risk of bias was rated as low to moderate, with blinding and selective outcome reporting being common issues.

Circadian-oriented lighting interventions showed potential advantages for sleep and behavioural regulation, even though no trials specifically assessed orange-spectrum light. A promising non-pharmacological strategy for treating sleep and behavioural issues in dementia patients may be circadian-friendly lighting interventions. To improve the body of evidence and guide clinical recommendations, high-quality RCTs that specifically look at orange-spectrum lighting are needed.

Behavioural-variant frontotemporal dementia (bvFTD) is a neurodegenerative condition that typically presents in mid-life with early behavioural and personality change,often in the absence of marked global cognitive impairment. This clinical profile substantially overlaps with primary psychiatric disorders (PPDs), contributing to frequent misdiagnosis and diagnostic delay. Cognitive screening is routinely used in early assessment, yet the choice and interpretation of tools is often clinician-dependent and inconsistently taught. This work aims to explore how limitations in commonly used cognitive screening tools contribute to diagnostic uncertainty between bvFTD and PPDs, and to emphasise the importance of structured education on when and how to escalate assessment to appropriate neuroimaging.

A case-based educational analysis was undertaken using a representative behavioural presentation as a teaching framework. The current literature on cognitive screening tools, including the Mini-Mental State Examination, Addenbrooke’s Cognitive Examination, and Montreal Cognitive Assessment, was reviewed with attention to their sensitivity for detecting executive and social cognitive dysfunction. Evidence relating to neuroimaging modalities used in suspected bvFTD was also examined, including structural MRI, FDG-PET, and amyloid PET, with emphasis on their relative diagnostic roles in resolving behavioural diagnostic ambiguity.

Global cognitive screening tools, which are weighted towards memory and orientation, demon3strate limited sensitivity for early bvFTD, where executive and social cognitive deficits often predominate. This contributes to frequent misclassification as psychiatric illness when screening results are interpreted in isolation. Structural MRI provides supportive but often non-discriminatory findings in early disease, particularly where subcortical involvement may precede overt cortical atrophy. FDG-PET offers greater diagnostic utility by identifying frontal and anterior temporal hypometabolism; however, findings are not entirely specific and require careful clinical correlation due to the incidenceof false positives. Amyloid PET does not directly differentiate bvFTD from PPDs but serves an important exclusionary role by ruling out Alzheimer’s disease in atypical behavioural presentations.

Effective differentiation of bvFTD from primary psychiatric disorders requires more than symptom recognition alone. Improved education in cognitive screening–specifically tool selection, interpretation, and limitations–combined with clearer escalation strategies for neuroimaging, is essential. Future educational and diagnostic approaches may benefit from integrating quantitative imaging techniques with emerging biological markers, including genetic testing in early-onset presentations and fluid biomarkers such as neurofilament light chain. Embedding these principles within medical training supports a multimodal diagnostic framework, with important implications for reducing misdiagnosis and improving patient outcomes.

This quality improvement project aimed to enhance staff morale within the Psychiatry of Intellectual Disability service at Lakeview Hospital, part of the Western Health and Social Care Trust. This was achieved through the development and implementation of a ‘GREATIX’ scheme designed to recognise and celebrate exemplary staff practice between April 2025 and June 2025.

Baseline staff morale was assessed using a Likert-style questionnaire distributed to the multidisciplinary team working within Lakeview Hospital. Following this, a ‘GREATIX’ nomination process was introduced, allowing staff to nominate colleagues for recognition. Fortnightly meetings were held with charge nurses to review nominations and determine successful recipients. Eligibility required nominees to demonstrate behaviours aligned with the Trust’s core values: working together, excellence, openness, honesty, and compassion. Successful nominees were awarded a ‘GREATIX’ certificate and a £5 voucher. In July 2025, following implementation of the intervention, a repeat Likert-style survey was circulated to reassess staff morale.

The baseline survey received 28 responses, while the post-intervention survey received 22 responses. Mean self-reported tiredness following a shift decreased from 3.71 atbaseline to 2.41 post-intervention (Likert scale: 1=not tired, 5=extremely tired). Perceived impact of work showed an improvement, with mean scores increasing from 3.54 at baseline to 3.73 post-intervention (Likert scale: 1=little difference, 5=huge difference). Feelings of collegial support also increased, with mean scores rising from 3.68 to 3.87 (Likert scale: 1=not supported, 5=well supported).

Both surveys included free-text responses regarding ward morale. Baseline responses described morale as “OK”, “pretty good”, and “adequate”. Post-intervention responses suggested a modest improvement, with comments such as “a little better” and one respondent describing the GREATIX scheme as “a lovely addition”.

Implementation of the GREATIX scheme was associated with improvements in staff-reported energy levels after shifts, perceived collegial support, and feelings of having made a positive contribution at work. These findings suggest that structured recognition initiatives may have a positive impact on staff morale. Further PDSA cycles are planned within the Western Health and Social Care Trust to build on these outcomes.

Delirium is frequently misdiagnosed as psychosis in general hospital settings, leading to inappropriate Psychiatry referrals and delays in medical management. This quality improvement initiative aimed to reduce the misdiagnosis of delirium as psychosis by improving early recognition across non-psychiatric departments. Secondary aims were to examine department-wise variation in misdiagnosis, assess uptake of the Confusion Assessment Method for the ICU (CAM-ICU), compare the effectiveness of different CAM-ICU teaching strategies, and evaluate changes in time to delirium management.

This quality improvement project was conducted in a tertiary care teaching hospital over six months and included referrals from Medicine, Surgery, Obstetrics & Gynaecology, Orthopaedics, and ICU. A baseline audit was undertaken over two months, including all inpatient Psychiatry referrals labelled “suspected psychosis” (n=130). Data collected included referring department, final diagnosis (delirium or psychosis), CAM-ICU use prior to referral, and time to initiation of delirium management. Pre-intervention CAM-ICU use was 0% across all departments.

A targeted educational intervention was delivered over four weeks. Departments received CAM-ICU training using different methods: didactic teaching sessions (Medicine, Surgery), bedside demonstrations (ICU, Orthopaedics), and visual quick-reference materials with brief ward-based teaching (Obstetrics & Gynaecology). A post-intervention re-evaluation was conducted over a further two months (n=126) using identical outcome measures. Department-wise changes in misdiagnosis rates, CAM-ICU uptake, and time to delirium management were analysed and compared across teaching modalities.

At baseline, 82 of 130 referrals (63%) for suspected psychosis were diagnosed as delirium. Misdiagnosis rates varied across departments: Medicine 70%, Surgery 68%, Orthopaedics 62%, Obstetrics & Gynaecology 58%, and ICU 45%. Mean time to initiation of delirium management was 22 hours.

Following the intervention, overall misdiagnosis was reduced to 39 of 126 referrals (31%). Department-wise misdiagnosis rates decreased to Medicine 38%, Surgery 42%, Orthopaedics 25%, Obstetrics & Gynaecology 34%, and ICU 18%. Overall CAM-ICU uptake increased to 56%, with highest use in departments receiving bedside-based training (ICU 72%, Orthopaedics 65%). Mean time to delirium management reduced from 22 hours to 11 hours.

This quality improvement initiative demonstrates that a substantial proportion of referrals labelled as psychosis represent delirium, with marked department-wise variation. Structured CAM-ICU training improved screening uptake, reduced misdiagnosis, and shortened delays to treatment. Bedside and interactive teaching methods were associated with greater improvements than didactic approaches alone. Embedding routine delirium screeninginto inpatient referral pathways is a feasible and effective strategy to enhance patient safety and consultation–liaison psychiatry practice.

Clinical handovers are vital in the delivery of safe and effective patient care. It is central in relaying important patient information and professional responsibility between healthcare providers. The community-based Crisis Resolution and Home Treatment (CRHT)teams in Worksop conduct their handovers daily with duties distributed among different consultants on a rotating basis. Handovers are utilised for sharing pertinent updates regarding the patient’s journey through the crisis team. This allows for collaborative decision making with the wider team.

The aim of this project is to evaluate the effectiveness of handovers within the Mid and North CRHT by identifying structural and communication gaps in the multidisciplinary team (MDT) and suggesting targeted improvements to promote safe and high-quality patient care.

To understand staff perspectives of how effective current handover processes in CRHT are, a pre-intervention Microsoft forms questionnaire was sent to all clinical members of the team. The questionnaire was anonymous and included Likert-scale questions on patient safety and MDT structure as well as free text for suggesting improvements. Following the collation of results, a meeting with the clinical lead and non-medical prescriber was conducted to discuss previously trialled methods to make handover processes more streamlined.

17 completed pre-intervention forms were received. 23% of staff ‘strongly agree’ that the current handover process ensures patient safety. 18% of staff ‘strongly agree’ that the current handover follows a structured process whereas 6% of staff ‘disagree’. Thematic analysis suggests staff want to enhance current handover by improving its structure and ensuring that individual patients are handed over by designated staff members who are familiar with the patient. The feedback from the questionnaires as well as the discussions from the meeting were used to inform new changes to the MDT.

Staff feedback has provided valuable insight into the limitations of the current CRHT handover process. An amended standardised template and staff reminders to present familiar patients have been introduced. New changes include visible onward referrals and intended date of discharge in the documentation which hopes to track patient journey more accurately. Night shift staff who allocate patients for handover to designated morning staff have been advised to assign staff based on familiarity with patient’s presentation. Post intervention questionnaires will be sent to staff once sufficient time for the implemented changes to take full effect has lapsed.

To improve the quality, accuracy, and consistency of capacity assessments and their documentation in line with the Mental Capacity Act (2005) across inpatient psychiatric wards at The Harbour. The project aimed to ensure assessments were decision specific, clearly reasoned, and compliant with statutory standards, targeting at least 80% of assessments meeting all required components within 12 weeks following a targeted educational intervention.

This quality improvement audit was conducted across all wards at The Harbour, a 154-bed mental health hospital, including general adult, older adult, dementia, and psychiatric intensive care wards. A proportional, representative sample of 40 capacity assessments completed by resident doctors was randomly selected from the Trust’s Clinical Information System using a computer-generated randomisation function. Baseline data were collected over two weeks, with the same process applied post-intervention.

Assessments were audited using a bespoke toolkit based on the Trust’s SoP: MCA Policy and Deprivation of Liberty Safeguards Procedure, the Mental Capacity Act (2005), MCA Code of Practice (2007), and NICE NG97 Dementia (2018), providing measurable standards for documentation, reasoning, and functional testing.

In week three, resident doctors received a 30-minute targeted educational session covering MCA principles, diagnostic and functional testing, decision and time specificity, and correct completion of the Trust’s Capacity Assessment template. Reinforcement occurred through multidisciplinary discussions, handovers, and optional quick-reference guidance. A re-auditof 40 assessments was conducted in weeks nine and ten, with analysis and reporting completed in weeks eleven and twelve.

Baseline audit revealed consistent documentation of decision and time specificity (100%), but lower compliance in key areas: diagnostic test (77.5%), functional components: understand (70%), retain (70%), use/weigh (70%), communicate (70%); clinical reasoning (60%), correct template use (67.5%), and decision-specific framing (60%). Capacity outcome was explicitly stated in 92.5% of assessments.

Post-intervention audit showed marked improvements: diagnostic test documentation 95%; functional components: understand 92.5%, retain 90%, use/weigh 90%, communicate 100%; clinical reasoning, template use, and decision-specific framing all rose to 92.5%; with capacity outcome 97.5%.

A brief, targeted educational intervention substantially improved the quality, accuracy, and consistency of capacity assessments across inpatient psychiatric wards. Improvements in documentation, reasoning, template use, and decision-specific framing enhanced decision specificity and legal defensibility. By increasing familiarity with statutory requirements and structured templates, this low-cost, scalable intervention supports patient autonomy, strengthens clinician confidence, and can be readily applied in other psychiatric services where variability in capacity assessment persists.

This quality improvement project (QIP) aimed to evaluate the impact of a structured escalation framework on identifying, reviewing, and managing patients with prolonged length of stay (LOS) of more than or equal to 30 days in adult mental health inpatient settings from 1 August 2025 to 31 January 2026 in Cheshire & Wirral Partnership NHS Foundation Trust which has six acute inpatient wards where patients are either admitted informally or detained on mental health law.

This project was led by the Rehabilitation access team of Mental health Intensive Support team (MhIST) following the Trust policy to identify the escalation process for the prolonged length of stay. The policy had identified to trigger predefined LOS thresholds: ≥30, ≥40, ≥50, and ≥60 days. It was identified that patients stay due to extended period for clinical optimisation and red alert where they are clinically ready for discharge, but barriers identified internally through the clinical community teams or externally through Local authority. For all external delays, the cases were further escalated through Multiagency Discharge Escalation (MADE) meetings for the suitable pathway.

These barriers cause increased waiting time for admission from Accident & Emergency services leading to delay for appropriate treatment to be initiated and out of area admissions for acute care treatment that takes these patients away from their family and clinical team.

A Board Round framework incorporating the LOS thresholds in the weekly multidisciplinary in-reach meetings was arranged as an interface between inpatient and rehabilitation team. Key clinical and operational questions were embedded to support goal-directed care planning. Data were collected by designated care navigators, and followed by our team including LOS, reasons for delay, escalation actions, and outcomes.

Prior to this prolonged LOS weekly in-reach meeting, the average length of stay days in August 2025 was 74.3 and after the initiation of this meeting, it reduced to 54.2. It also showed the closure of all 29 out of area contracted acute beds. Out of a total of 548 patients, 39.5% (217) were identified as prolonged LOS. Seventy-eight percent (171) were due to clinical factors and 21.1% (46) were due to external delays. Majority (86.6%, 188) suffered with severe mental health illness. There was female predominance noted in both cohorts of delay.

This QIP has helped to identify and reduce the barriers in the discharge pathway, thus improving the inpatient flow. The continued multidisciplinary wider team involvement was the most effective intervention to help work collaboratively.

Lithium is a mood stabiliser primarily used for treatment and prophylaxis of bipolar disorder. Around 25% of people on lithium will experience renal impairment. There is little guidance around when to consult nephrology and psychiatry for consideration of discontinuing lithium. Prompt referral to nephrology can reduce mortality, decline in eGFR and enable initiation of renal replacement therapy.

We aimed to audit all older adults on lithium open to the older people’s community team at Cambridge and Peterborough foundation NHS trust to look at our adherence to standard renal monitoring.

The BNF suggests lithium levels should be monitored 3 monthly if ≥ 65 years old. The BNF recommends avoiding lithium in severe (eGFR 15-29 ml/min) chronic kidney disease (CKD). We looked at whether advice had been sought from nephrology or psychiatry.

NICE recommends repeat urea and electrolytes within 2 weeks if eGFR <60ml/min, urine albumin:creatinine (A:CR) and a urine dipstick to check for haematuria if new decline in renal function. NICE recommends a minimum if 1 urine A:CR if moderate CKD (eGFR 30-59 ml/min), 2 urine A:CR if severe CKD and 4 urine A:CR for end stage renal failure (eGFR <15ml/min) per year. We only looked at renal investigations and monitoring for patients with eGFR <60 ml/min.

7/73 patients had lithium levels checked >3 monthly. 24/73 had eGFR 30-59 ml/min, 2/73 had eGFR 15-29 ml/min and 1 person had an eGFR <15ml/min. Of the 3 with eGFR <30 ml/min, 1 was referred to psychiatry and nephrology, 1 referred to nephrology and 1 referred to neither. 4/27 had a new decline in renal function but none had all of the initial investigations. 23/27 had CKD but only 6 met recommended NICE urine A:CR testing frequency.

There is limited compliance with established standards. These audit results highlight the need for psychiatrists to work with General Practitioners (GP). We have updated laboratory lithium levels to reflect 0.4-0.8mmol/L for 65-80 years old and 0.4-0.7 mmol/L for >80 years old. Our guidelines for psychiatrists and General Practitioners have been updated to include investigations for new and established CKD and when to consult nephrology and psychiatry for discontinuation advice. However, we need a larger consensus to agree on a point at which renal function has deteriorated enough to trigger referrals to specialties to discuss discontinuation early so that patients have sufficient time to be involved in discussions.

Recently the therapies that utilize psychedelics have emerged as promising treatments for mood disorders, trauma-related disorders, and substance use disorders. While there is a growing body of research comparing various interventions directly, the majority of available research has been conducted in an indirect manner; therefore, Network Meta-Analysis (NMA), a statistical method for comparing the efficacy of multiple interventions at once, is well-suited to evaluate the available evidence and create a comparison of relative efficacy among the various psychedelic assisted interventions. This study aims to compare the efficacy of psychedelic-assisted interventions and provide a comparative efficacy ranking of each treatment modality using a Network Meta Analytic approach.

A contrast-based NMA was used to synthesize randomized and controlled trials of psychedelic-assisted interventions. Each treatment node was created based upon the type of drug being utilized (psilocybin, ketamine, MDMA) and the specific therapeutic context (psychotherapy) along with comparator treatments (escitalopram, active placebo, and waitlist). Means and standard deviations (SD) of continuous outcomes were obtained, standardized (as Hedges g) and incorporated into a fixed-effect inverse-variance weightedmodel. Trials with crossover designs contributed their data prior to crossover. Trials that reported binary or time-to-event outcomes were incorporated into the geometric structure of the network. Surface Under the Cumulative Ranking Curve (SUCRA) was used to estimate rankings of each treatment.

A total of six studies comprised the network and all but one study had psilocybin-assisted psychotherapy as the focus of the study. All studies demonstrated that psychedelic-assisted treatments were more effective than control groups (pharmacological, active placebo, and waitlist). Study-level estimates of treatment effect favoured psilocybin (range=−0.6 to −1.4) when compared to all other treatments. Psilocybin at high doses was found to be more effective than low dose psilocybin in reducing symptoms. A large and statistically significant pooled summary effect favouring psychedelic-assisted therapy was observed (−0.89, 95% CI: −1.07 to −0.72). Using SUCRA, psilocybin-assisted psychotherapy ranked highest among all treatments examined and both MDMA-assisted psychotherapy and ketamine-assisted therapy ranked higher than all control condition treatments.

In this network meta-analysis we present encouraging quantitative evidence supporting the clinical efficacy of psychedelic-assisted therapies, particularly psilocybin-assisted psychotherapy. These findings support the potential therapeutic utility of these treatments and suggest the need for additional head-to-head trials to provide more precise comparative effectiveness estimates and develop future clinical practice guidelines.

Procyclidine is frequently prescribed to manage extrapyramidal side effects (EPSE) associated with Long-Acting Injectable (LAI) antipsychotics. However, long-term use carries risks of anticholinergic burden and potential for misuse. Following a Serious Untoward Incident (SUI) involving a fatal procyclidine overdose, this quality improvement project aimed to assess and improve adherence to Kent and Medway Mental Health NHS Trust (KMMH) guidelines within the Dartford, Gravesham, and Swanley Community Mental Health Team (DGS CMHT). The primary hypothesis was that structured review prompts would increase the frequency of attempted dose reductions and withdrawal.

A retrospective clinical audit was conducted in two cycles using the Glasgow Antipsychotic Side-effect Scale (GASS) to monitor side effects. Cycle 1 (September 2023–January 2024) reviewed 36 patients on LAIs. Standards included: adherence to starting dose (2.5mg), regular reviews (3–4 monthly), and attempted withdrawal after 3 months of use. Following Cycle 1, interventions included team-wide dissemination of findings and the implementation of standardised prompts to encourage dose-reduction discussions during reviews. Cycle 2 (January 2025–December 2025) involved a re-audit of the caseload (n=100) to evaluate changes in prescribing and monitoring practices.

Cycle 1 identified 14/36 (39%) patients on regular procyclidine. Although 93% had recorded reviews, clinical inertia was evident: 0% adhered to the recommended BNF starting regimen, and no withdrawal plans were documented.

Cycle 2 (n=100 randomly selected patients on LAI) identified 18 patients (18%) currently prescribed procyclidine. Detailed analysis of these 18 cases revealed a shift toward active management. Successful dose reductions were achieved in 3/18 (17%) patients. Discussions regarding dose reduction were documented in a further 4/18 (22%) cases. Only 1/18 (6%) required a dose increase. Consequently, 44% of the procyclidine cohort in Cycle 2 received active interventions or discussions regarding de-prescribing.

This project demonstrated that there was significant improvement in documentation by clinicians prescribing procyclidine. There was also an observed procyclidine prevalence of 18% in the current cohort as compared to 39% from the previous cycle.

• • To identify and highlight the current practice of doctors at Campbell Centre relating to the driving status of the patients

• • To raise awareness of any deficiencies identified

• • To serve as stimulus for a change process – possibly via a Quality Improvement Project.

2 audits done retrospectively for the periods of 01 - 30 June 2025 and 01 - 30 November 2025.

Sample population drawn from both Hazel (male acute inpatient) and Willow (female acute inpatient) Wards in the Campbell Centre Milton Keynes.

Sample sizes: June 2025 - 62 patients (32 male, 30 female), November 2025 - 59 patients (33 male, 26 female)

Driving status of all patients admitted in those time periods was examined by checking Progress Notes on Electronic Medical Records (SystmOne) throughout that period.

Two categories of searches were conducted: 1. Whether patients were advised of the need to inform DVLA of their mental health status. 2. If it was confirmed from patients that the DVLA had been informed by them.

This data was then collated and presented in percentages of; DVLA Advised, and DVLA Informed. The results of the 1st Audit were presented on 15th October 2025 at the General MDT of the Campbell Centre with recommendations made.

The data for June 2025 and November 2025 were then compared to demonstrate improvement in another presentation done on 28th January 2026 with issues identified and further recommendations made.

June 2025:

• • DVLA Advised: Willow Ward - 7% compliance, Hazel Ward - 0% compliance

• • DVLA Informed: Willow Ward - 0% compliance, Hazel Ward - 0% compliance

November 2025:

• • DVLA Advised: Willow Ward - 27% compliance, Hazel Ward - 21% compliance

• • DVLA Informed: Willow Ward - 5% compliance, Hazel Ward - 0% compliance

• • There was some improvement in compliance after the 1st audit presentation - awareness has been created

• • Improvement was below expected level (50%) however and shows that this is not yet embedded as regular practice.

• • Current practice continues to fall short of expected standard however, and there is thus scope for improvement and need for further re-audits