Weight-loss medications such as tirzepatide are increasingly prescribed, yet their potential psychiatric effects remain under-recognised. This case explores diagnostic uncertainty between personality pathology and hypomania following significant weight loss and exposure to tirzepatide in an individual with pre-existing narcissistic personality traits. The aim was to examine whether behavioural escalation represented an exacerbation of personality traits alone or a superimposed affective episode temporally associated with medication use.

A man in his late 40s with established Narcissistic Personality traits and no prior history of mood disorder was assessed following escalating behavioural concerns in the workplace. Prior to medication exposure, occupational functioning was stable, though interpersonal behaviour was characterised by inconsistency, criticality, and sensitivity to perceived errors in others.

Tirzepatide was initiated for weight loss at a starting dose of 2.5 mg and gradually escalated to 10 mg. Over approximately six months, the patient experienced rapid weight loss of 20 kg. Over the last three months of the treatment, marked behavioural changes were observed, including reduced need for sleep, increased energy, heightened grandiosity beyond baseline, impulsive decision-making, disinhibition, and poor insight into the impact of his actions on colleagues.

He demonstrated abrupt rule-breaking behaviour, including suspending colleagues without completing appropriate investigations or following established procedures, causing significant distress within the workplace. Symptoms were escalating rather than static. There were no psychotic symptoms, substance misuse, or alternative medical explanations identified.

The primary diagnostic considerations included exacerbation of narcissistic personality traits, hypomania, and medication-associated affective destabilisation. Several features supported hypomania over personality traits alone, including a clear change from baseline functioning, reduced sleep, increased goal-directed activity, behavioural disinhibition, and a marked reduction in insight. The temporal association with tirzepatide initiation and rapid weight loss raised the possibility of medication-related affective change in a psychologically vulnerable individual, despite no prior bipolar diagnosis.

This case highlights the diagnostic complexity of distinguishing personality pathology from emergent mood disorder in the context of metabolic pharmacotherapy. Clinicians should remain vigilant for affective destabilisation in patients prescribed GLP-1–based weight-loss agents, particularly those with underlying personality vulnerabilities. Careful longitudinal assessment is essential before attributing behavioural change solely to personality traits.

Many people with eating disorders experience body image disturbance, and there is evidence to suggest that body image difficulties not effectively addressed through eating disorder treatment can contribute to later relapse. Virtual reality (VR) interventions designed to target body image difficulties associated with eating disorders have begun to demonstrate promising evidence of efficacy. However, little is known about the perspectives of people with eating disorders and those who care for them around such interventions. This study aims to explore stakeholders’ views of factors that could impede or support use of such interventions.

Eleven young people with lived or living experience of eating disorders (PWLE), four parents/carers of people with eating disorders, and five clinicians with experience of treating eating disorders took part in semi-structured interviews or focus groups. Qualitative data was coded inductively and analysed using reflexive thematic analysis. Themes and subthemes were iteratively refined through discussions between the authors.

Five themes were generated. These were getting the timing right: highlighting the importance of timing within a person’s treatment journey, with suggestions for optimal timing; tailoring the intervention to the individual: all stakeholders agreed that individualisation to the person accessing treatment was critical; thoughtfully empowering agency: participants suggested that a degree of control over most aspects of the intervention would be helpful, with some key caveats; providing the right support: suggestions were made about both the necessity of support, and what this support might look like; and an overarching theme of on balance is it worth while? This overarching theme involved participants carefully weighing up the risks and benefits of using such an intervention. It included three subthemes: hope of efficacy; fear of difficulty; and desperate belief in necessity.

PWLE, parents and carers and clinicians shared valuable, detailed insights into how they view body image interventions in VR, the key challenging areas and suggestions for how they could be done well. They highlighted that getting these aspects right may make such an intervention on balance worthwhile. Ongoing co-production in order to optimise these components of the intervention should be utilised in the development of VR body image interventions, as they will likely make the difference as to whether people will choose to try them and whether they will be effective.

Sub-optimal prescribing of anti-dementia medications may compromise the cognition of patients with dementia. The aim of this audit was to assess the prescribing of anti-dementia medications, including Donepezil, Rivastigmine and Memantine, for patients diagnosed with dementia against local and national guidelines in relation to three domains: appropriate indication for dementia subtype, optimal dosage titration and recommended physical health monitoring. The target was to achieve a minimum of 90% adherence to guidelines for each domain.

This retrospective clinical audit was based at the Forget Me Not Unit, a specialist dementia intensive care unit in Worthing. The first audit cycle collected data from twenty patients discharged between February and May 2025. Data obtained from electronic medical records included dementia subtype and severity, pre-admission and inpatient-initiated anti-dementia medications, titration regimes, pulse checks and renal function profiles. Results were compared against Trust and Maudsley prescribing guidelines which served as standards. An action plan was subsequently implemented which included raising staff awareness of the audit, disseminating its results and placing visible audit reminders on ward lists. A second cycle was commenced in November 2025 to February 2026 which examined the data of twenty discharged patients following implementation of the action plan.

In the first cycle, thirteen out of twenty patients were prescribed pre-admission anti-dementia medications (65%) whilst seven out of twenty patients were candidates for an inpatient-initiated anti-dementia medication given their dementia subtype (35%). Six of these patients were offered an anti-dementia prescription of which five were clearly indicated (83%). All prescriptions were titrated according to guidelines but recommended physical health monitoring was only completed for five patients (83%). Similar results were demonstrated in the second cycle. Eleven patients were prescribed an anti-dementia medication prior to their admission (55%), six patients were candidates for an anti-dementiamedication (30%) but only four patients were prescribed an indicated drug during their admission (67%). However, all inpatient-initiated anti-dementia medications were titrated and monitored according to standards.

Anti-dementia medications are licensed treatments for dementia but may be underutilised as evidenced by this audit. Although the target was achieved by the second cycle in two out of three domains, the indication of anti-dementia prescriptions was not fully adhered to against guidelines. Further audit cycles and tailored action plans could raise the standards of anti-dementia prescriptions and thereby improve patient safety and care.

This audit aimed to determine the proportion of adults with Intellectual Disability (ID) residing at ‘Dar tal-Providenza’ residence, who had undergone genetic testing confirming a genetic diagnosis, assess documentation of genetic testing discussions or referrals, and evaluate alignment of current practice with national and international guidelines for genetic testing in neurodevelopmental disorders.

All adults under the care of the ID team with a documented diagnosis of ID and/or Autism Spectrum Disorder (ASD) were included. Electronic Patient Records were reviewed for demographic data, primary diagnoses, documentation of genetic testing or referral to genetics services, discussions with patients or carers, and documentation of results and follow-up actions in accordance with National Institute for Health and Care Excellence (NICE) and European Society of Human Genetics (ESHG) guidelines.

The cohort consisted of 80 adults aged ≥18 years, with a mean age of 50.4 years and a gender distribution of 49 males and 31 females. Most individuals had multiple co-existing neurodevelopmental, neurological, genetic, and mental health diagnoses. ID severity was mild–moderate in 23.75% (n=19), moderate–severe in 57.5% (n=46), and unspecified in 18.75% (n=15). An associated genetic syndrome was identified in 16.25% (n=13).

ASD was the second most common diagnosis (22.5%, n=18) and a frequent comorbidity with ID (16.25%, n=13). Other diagnoses included cerebral palsy (13.75%, n=11), trisomy 21 (11.25%, n=9), epilepsy (6.25%, n=5), Fragile X syndrome, Cri-du-Chat syndrome, and Peters-plus syndrome (each 1.25%, n=1). Challenging behaviour co-occurred in 8.75% (n=7). Mental health comorbidity was common, including bipolar affective disorder (6.25%, n=5), emotionally unstable personality disorder, post-traumatic stress disorder, schizoaffective disorder, anxiety disorder, and psychotic depression (each 1.25%, n=1).

Only 6 patients (7.5%) had a documented genetics referral, with genetic testing discussed in one case (1.25%). Among those referred, five had confirmed diagnoses, one was awaiting results, and no follow-up plans were documented.

This audit identified a highly complex cohort with extensive neurodevelopmental and mental health needs. Despite meeting NICE and ESHG criteria, genetics referral was low (7.5%) with minimal documented discussion or follow-up, highlighting the need for further training and collaboration between the Psychiatry and Genetics Department in Malta.

Background

Electroconvulsive Therapy (ECT) is among the most effective treatments for severe and life-threatening psychiatric illness, yet its use in medically complex patients demands refined clinical judgment.

With rising multimorbidity and increasing prevalence of implanted medical devices, clinicians are more frequently required to balance urgency against evolving physical risk.

This presentation introduces the concept of the therapeutic pause; not as delay, but as an active, patient-centered safety strategy, demonstrating how structured reflection and multidisciplinary collaboration can transform high-risk uncertainty into safe, timely intervention.

The aim is to highlight how deliberate pauses at critical decision points can improve both clinical outcomes and patient safety.

Case Reports

Two urgent liaison psychiatry referrals for ECT are presented.

Case 1 involved a 72-year-old man with schizophrenia and mild learning disability, admitted with catatonia, severe self-neglect, and nutritional failure requiring nasogastric feeding. He had a proximal deep vein thrombosis (DVT) diagnosed three weeks earlier and hyperkalaemia, raising concern about embolic risk and physiological stress during ECT.

Case 2 involved a 62-year-old woman with psychotic depression and catatonia, who had an implanted spinal cord stimulator (SCS) for chronic pain, creating potential risks of electrical interference and device damage.

In both cases, ECT urgency was balanced against medical risk using targeted investigations, literature review, consultation with the ECT Accreditation Service (ECTAS) Knowledge Hub, and early multidisciplinary input.

In Case 1, repeat Doppler imaging confirmed resolution of the proximal DVT and electrolyte abnormalities were corrected, allowing ECT to commence three days later. By the third and fourth treatments, the patient showed striking recovery: spontaneous speech, independent mobility, recognition of staff, and restoration of oral intake, facilitating discharge after completing the course.

For Case 2, collaboration with pain specialists and device manufacturers enabled safe deactivation, monitored ECT delivery, and post-treatment device integrity checks, followed by clear improvement in psychomotor function, affect, and nutritional status.

These cases demonstrate that ECT risk is rarely absolute; it is dynamic and often modifiable. In both cases, pausing prevented both premature exposure to harm and unnecessary therapeutic delay.

Pausing before ECT is not clinical indecision; it is clinical leadership. Individualized assessment, proactive multidisciplinary collaboration, and informed use of national guidance allow clinicians to navigate the interface between psychiatric urgency and physical vulnerability.

As ECT increasingly serves patients with complex comorbidity, reflective practice must replace routine automation. Thoughtful pauses protect patients, strengthen decision-making, and ultimately enable ECT to deliver its life-saving potential.

In complex ECT, the safest action may begin with a pause.

Effective communication and comprehensive history taking are core competencies in undergraduate medical education. Emerging digital technologies, including generative artificial intelligence (GenAI), offer novel opportunities to enhance experiential learning in this domain. This service evaluation explored the educational value of a GenAI-simulated virtual patient presenting with psychosis, integrated into psychiatry communication skillsteaching at Cardiff University School of Medicine. The primary aim was to assess student perceptions of the simulation as a learning tool.

A mixed-methods service evaluation design was employed. Quantitative and qualitative data were collected using pre- and post-intervention questionnaires assessing self-reported confidence in communication, history taking, and risk assessment, alongside usability and accessibility. Participants engaged with an AI-simulated virtual patient on the SimFlow.AI platform, receiving pre-task information and automated post-task feedback on performance. The simulation involved an acute psychotic presentation, requiring participants to conduct a psychiatric history and risk assessment. Participants were recruited from Years 2 through to 5 of the undergraduate medical programme at Cardiff University. The AI simulation was also embedded in a Year 2 unit of study to support students’ self-directed practice of communication skills.

Twenty participants completed all study components, including full engagement with the AI simulation and pre- and post-intervention questionnaires. Self-reported confidence in history taking and risk assessment increased significantly following exposure to the AI-simulated virtual patient (z=−3.750, p<0.001), with significant improvements observed across both junior and senior cohorts. All participants reported that the simulation facilitated clinically relevant skills practice, with 94% indicating that the platform helped them identify strengths and areas for improvement in their communication skills. Perceived authenticity was high, with 94% rating the AI responses as realistic and clinically plausible. All participants endorsed the platform as a useful adjunct to existing communication skills teaching. Where the AI simulation was embedded within a Year 2 unit of study, 74% of 93 respondents rated the AI virtual patient encounter as useful in practicing psychiatric history taking during self-directed learning time.

AI-simulated psychosis consultations appear to offer psychologically safe, accessible, and practical opportunities for communication skills rehearsal and reflective learning. Students supported the integration of AI simulations as a supplementary educational resource (particularly for OSCE/ISCE preparation) while emphasising that such tools should complement rather than replace patient actors.

To synthesise qualitative evidence on the lived experiences transitioning from child to adult health and social care services for young people with Attention Deficit/Hyperactivity Disorder (ADHD) in the UK.

A systematic search of MEDLINE, PsycINFO, Embase, Scopus, ASSIA, and grey literature sources was conducted on 3 June 2025. Eligible studies were qualitative or mixed-method, published from 2014 onwards and examined the transition experiences of young people with ADHD in the UK. Studies were excluded if they were purely quantitative, non-UK, or pre-2014. Methodological quality was appraised using the Critical Appraisal Skills Programme checklist. The data was synthesised using thematic analysis and narrative synthesis.

Nine studies were included: seven peer-reviewed papers and two grey literature reports. Across 224 participants (90 young people, 82 family members, 52 clinicians), three overarching themes were identified: (1) communication as a determinant of transition experience, (2) negotiating discontinuity and change and (3) interdependence of individual and systemic factors.

Transition to adult services for young people with ADHD is commonly experienced as fragmented, poorly coordinated and psychologically distressing. The findings highlight the need for developmentally informed, person-centred transition protocols that recognise transition as an active process rather than a discrete administrative event. Future research should prioritise disengaged young people and investigate long-term trajectories to inform evidence-based policy and service development.

The purpose of this thematic review was to analyse and explore the underlying factors contributing to differences in mortality rates among service users from different racial and ethnic groups within South West London and St George’s Mental Health NHS Trust (SWLStG), specifically in ethnic minority groups. By systematically examining deaths occurring under the care of the Trust, the review aimed to identify recurring themes, potentially to inform recommendations to reduce inequalities and improve patient safety.

Information was collected on all reported deaths between February 2025 and April 2025 of service users under the care of the Trust’s mental health services. A total of 145 deaths were reported and included in the review. Incident reports were extracted from Ulysses. Demographic and clinical information was checked and verified using RIO, including recorded ethnicity, progress notes, and relevant clinical and risk assessment documentation.

Of the 145 deaths reviewed, most occurred among White British (66%) or “other white” service users (10%), and of confirmed or suspected suicides, 73% were from white British or “other white” service users. 6.21% of service users’ ethnicity was unknown. Most deaths (84%) were due to natural causes, often at relatively older ages and in the context of significant physical health comorbidity. A proportion of deaths occurred following loss of contact with services, due to patient disengagement or during transition between mental health teams. There was limited information available for some deaths, making cause and circumstance unclear. Variation in service engagement and clinical documentation was observed across teams. Most service users had a documented mental disorder, most commonly cognitive decline or dementia (27%) and mixed anxiety and depression (25%). Among patients who died by possible suicide, 31.8% had a history of drug or alcohol dependence. No clear ethnicity-specific themes were identified, with interpretation limited by the small sample size.

This review highlights that most deaths among mental health service users were due to natural causes and were associated with physical health comorbidities. Recurrent themes included disengagement from services, communication gaps during care transitions, and variable documentation. Although ethnic minorities were a small proportion of the sample, evidence of lower access of these populations to mental health services remains relevant. Improving consistency of ethnicity recording, clinical documentation, engagement with service users, as well as strengthening communication between services, is indicated.

To assess whether reminder telephone calls improve patient ‘Did-Not Attend’ (DNA) rates; evaluate whether specific demographic groups are less likely to attend appointments.

Over 35% of psychiatric outpatient appointments are not attended. High DNA rates increase waiting times and lead to inefficient use of healthcare resources. They are associated with poorer health outcomes, medication non-adherence and higher chances of hospital re-admission.

Reasons for non-attendance are multifactorial, including socioeconomic factors, illness severity and forgetting appointments. Reminder telephone calls were utilised to assess their effectiveness in improving attendance.

A retrospective review of patients booked for mental health outpatientappointments in a South-West Leeds community unit was conducted using electronic patient records (Caredirector). All patients had been sent appointment letters by post. Data was collected over a 16-week period and included 95 patients, of whom 22 patients DNA.

Reminder telephone calls followed a standardised script. Cycle 1 involved the reminder telephone call seven days before appointments, over a 4-week period (35 patients). Cycle 2 involved reminder telephone calls two days before appointments, over a 5-week period (21 patients). Two telephone call attempts were made if patients did not answer.

Qualitative data on appointment awareness and additional patient comments were recorded. Attendance and demographic data were then gathered from CareDirector.

In Cycle 1, 51.4% of patients answered the reminder telephone call, compared to 61.9% in Cycle 2. The average telephone call duration was 3 minutes 29 seconds. The baseline DNA rate prior to intervention was 23.16%, reducing to 14.3% with seven-day reminders and 19.1% with two-day reminders. However, amongst patients who confirmed attendance, subsequent attendance was higher with two-day reminders (100%) than seven-day reminders (83.3%). A higher DNA rate was observed amongst males in Cycle 1 (4:1), but rates were equal across genders in Cycle 2. No clear associations were identified between non-attendance and age, ethnicity, marital status, religion or interpreter requirement.

Findings suggest that forgetting appointments contribute to non-attendance, as reminder telephone calls reduced DNA rates in community outpatient clinics.The intervention was time-efficient, supporting feasibility for routine clinical practice. This simple measure could improve patient outcomes and optimise the use of mental health service resources. Future cycles could assess text-message reminders for patients who do not answer reminder telephone calls, to see if this further reduces DNA rates.

Suicide is a significant cause of death worldwide and is prevalent among homeless individuals. However, aspects of suicide in homeless mental health patients remain under-researched. This study aims to analyse socioeconomic, clinical, and service-related characteristics of homeless mental health patients who died by suicide in England between 2012 and 2022, with a focus on age group and ethnic background.

This retrospective cohort cross-correlational study uses data from the National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH). Homelessness was classified as having ‘no fixed abode’. Comparative analyses, including multivariable logistic regression, were conducted between homeless (n=324) and non-homeless patients (n=12,605). Subgroup analyses were performed within the homeless group based on age group (under 45 years and over 45 years) and ethnic background (Ethnic Minority background and White-British).

Homeless patients were more likely to be male, younger and socioeconomically disadvantaged, to have dual diagnoses of substance dependence, adjustment disorders and histories of substance misuse, self-harm and service disengagement. They were more likely to die within 24 hours of last service contact. Younger homeless patients displayed higher prevalence of substance misuse and self-harm, and for self-harm leading to service contact. Older homeless patients more often faced recent financial difficulties. Homeless patients from ethnic minority backgrounds had a higher prevalence of affective disorders, immigration-related vulnerability and a concerningly lower median age of death.

Suicide in homeless mental health patients is associated with complex socioeconomic and clinical vulnerabilities. Our findings emphasise the need for integrated, culturally sensitive and targeted suicide prevention strategies.

The re-audit aimed to assess compliance with previously implemented recommendations regarding alcohol assessment, intervention, documentation, and signposting for people with gambling disorder presenting to the Southern Gambling Service (SGS), and to evaluate improvements in practice since the initial audit.

The re-audit included all referrals received by the Southern Gambling Service (SGS) between 1 March 2025 and 30 September 2025 who completed an initial assessment.

Baseline data were analysed to stratify patients’ alcohol use risk based on their extended Alcohol Use Disorder Identification Test (AUDIT-C) and Estimated Weekly Alcohol Consumption (EWAC), collected via a digital pre-assessment tool, with escalation to a full AUDIT where indicated. Clinical assessment letters and formulations were reviewed to assess documented compliance with National Institute for Health and Care Excellence (CG115) guidance, Department of Health and Social Care guidance, and Royal College of Physicians regarding appropriate management according to their risk brackets. Outcomes included: completion of full AUDIT for those meeting criteria; delivery and documentation of brief interventions for hazardous or harmful drinking; provision of advice on avoiding abrupt reduction for those scoring ≥20; delivery and documentation of formulations on alcohol use and signposting to specialist alcohol services where appropriate.

A total of 301 referrals were received during the audit period, of which 124 referrals (41.2%) were accepted and assessed. AUDIT-C and EWAC were completed for 100% of assessed patients. Fifty-five patients (44.4%) met criteria for escalation and completed a full AUDIT. Of these, 27 patients (49.1%) scored 8 or above, indicating hazardous or harmful drinking, and 10 patients (18.2%) scored 20 or above, suggesting possible alcohol dependence. Among patients scoring ≥8, 18 (66.7%) received a documented brief intervention and 20 (74%) had an alcohol-related formulation recorded. Of those scoring ≥20, seven (70%) received documented advice on avoiding abrupt alcohol reduction and eight (80%) had a formulation addressing alcohol use. Signposting to specialist alcohol services was documented for 7 of 10 (70%) patients who met criteria.

The re-audit demonstrates substantial improvements across all areas compared with the initial audit. Full AUDIT completion improved from 0% to 100%, delivery of brief interventions from 7% → 67%, advice on safe alcohol reduction from (0% → 70%) and signposting for patients improved substantially. Maintaining current standards with improvement in documentation consistency, staff education and reinforcement of intervention thresholds can help improve these gains.

To evaluate clinical activity, patient outcomes, and staff perceptions following integration of senior clinical fellows into a nurse-led crisis team.

In August 2025, senior clinical fellows were embedded within the Royal Edinburgh Hospital’s Mental Health Assessment Service to provide in-hours medical support, previously covered ad-hoc by medics from other services.

A prospective activity log and a database of patients booked for medical follow-up after out-of-hours nursing assessment were maintained between 28th September 2025 – 21st January 2026 within the Mental Health Assessment Service. Staff feedback was obtained via an anonymous nursing survey.

Senior clinical fellows recorded 82 activities. There were 45 direct clinical contacts, mainly joint assessments with nursing staff, and indirect clinical contacts such as case discussions and GP liaison. Direct clinical contacts included both scheduled medical follow-up appointments and unscheduled reviews. The primary reasons for medical input were diagnostic clarity, risk assessment, prescribing, or Mental Health Act (MHA) decisions.

28 patients received 33 in-hours scheduled follow-ups, most commonly for suicidal ideation (n=14) or psychosis (n=10). Medication was initiated in 14 appointments (50%). Outcomes included signposting (n=10); referral to third sector services (n=5); referral to CommunityMental Health Teams (n=4) or Intensive Home Treatment Team (n=5); informal admission (n=2); admission under the MHA (n=2).

There were also unscheduled medical reviews according to clinical need. This included one patient detained by police and one further admission under the MHA.

Senior clinical fellows delivered 17 teaching and supervision sessions to nurses, foundation doctors, and students. They also formally supervised three nurses through a Clinical Assessment and Decision Making module for Advanced Nurse Practitioner training.

Seven nurses completed the survey. Prior to senior clinical fellows, reported time to access medical support for MHA assessments ranged from 30 to over 240 minutes. Post-implementation, access time ranged from immediate to under 60 minutes for all respondents. Reported benefits of senior clinical fellows included improved patient flow; reduced waiting times; enhanced confidence managing complex cases; and educational benefit. One postulated downside of senior clinical fellows was potential to disincentivise nurses to make complex decisions.

Embedding senior clinical fellows in a nurse-led crisis team generated a range of clinical activity. It was associated with service enhancements to benefit patients, including diagnostic assessments and prescribing. Access to senior medical input was streamlined, with reduced delays and more efficient use of nursing time. There were also benefits for staff development. This model may be replicable across crisis services.

Personality disorder (borderline type), previously known as Emotionally Unstable Personality Disorder (EUPD), is a complex psychiatric condition associated with unstable relationships, emotional lability and transient psychotic-like features. National Institute for Health and Care Excellence (NICE) guidelines for EUPD (CG78) advise against routine use of psychiatric medication for personality disorder symptoms, recommending pharmacological treatment only for comorbid mental illness in accordance with relevant guidance. Antipsychotics are not licensed for EUPD. Where used, prescribing should be short-term, crisis-focused, and accompanied by clear documentation and informed consent. However, national data from the Prescribing Observatory for Mental Health indicate that antipsychotic prescribing in EUPD often occurs off-licence and may continue long-term by default, with variable documentation and review. This audit evaluated antipsychotic prescribing practices for inpatients with EUPD within Sussex Partnership NHS Foundation Trust, focusing on documentation of prescribing rationale, communication with patients regarding above license and physical health monitoring.

A retrospective review of clinical records was conducted across all working-age adult inpatient wards within the Trust. Data were collected as cross-sectional snapshots at three time points, each one month apart. Inpatients aged 18-65 years with a documented diagnosis of EUPD were included. Patients with primary psychotic disorder and out-of-area admissions were excluded. Where diagnostic ambiguity existed, a senior psychiatrist reviewed clinical notes to determine eligibility on a case-by-case basis. Outcomes were assessed against NICE and local Trust guidelines using descriptive statistics.

Of 508 records reviewed, 52 patients met the inclusion criteria. Antipsychotics were prescribed in 86.5% (45/52) of patients, with 20% (9/45) initiated during admission and 8.9% (4/45) receiving polypharmacy. None of the antipsychotics initiated were documented as time-limited. Documentation of communication regarding off-licence prescribing was present in only 6.6% (3/45) of cases. Physical health monitoring was inconsistently completed: body mass index was tracked in 80.7% (42/52) patients, HbA1c in 21.1% (11/52), electrocardiogram in 48.1% (25/52), blood pressure in 98.1% (51/52), prolactin in 42.3% (25/52), and cholesterol in 53.8% (28/52). Random glucose was requested instead of HbA1c in 42.3% (22/52) of cases, contrary to Trust guidelines.

Antipsychotic prescribing for EUPD inpatients frequently deviated from guideline recommendations, with significant gaps in documentation, consent recording, and physical health monitoring. These findings highlight the need for improved adherence to guidance, clearer documentation standards, and structured monitoring pathways to enhance patient safety and quality of care.

Autistic adults are at increased risk of mental health crises, yet their representation within crisis services and staff preparedness remain under-researched. This study aimed to determine the prevalence of diagnosed and suspected autism spectrum disorder (ASD) among referrals to a Crisis Resolution and Home Treatment Team (CRHTT), describe associated crisis presentations, and assess staff training experiences and knowledge.

A retrospective observational service evaluation was conducted within a crisis team in Sheffield, UK. A random sample of 400 adult referrals was selected from 2397 referrals. Demographic data, ASD diagnostic status, and presenting complaints were extracted from electronic records. Staff knowledge and training were assessed using an adapted National Autism Implementation Team questionnaire. Quantitative data were analysed descriptively and compared with population prevalence estimates; qualitative free-text responses were analysed thematically.

Among the 400 referrals, 10.5% had a formal ASD diagnosis and 11.3% were suspected cases, yielding a combined prevalence of 21.8%, over nine times higher than general population estimates. Common crisis presentations included suicidal thoughts or behaviours (41%), acute psychotic episodes (24%), and worsening psychiatric comorbidities (18%). One-third of suspected ASD cases had not been referred for diagnostic assessment. Forty percent of staff reported no ASD-specific training, and only 10% rated their knowledge as full. Qualitative findings highlighted insufficient, overly generic training and low confidence in managing autistic adults in crisis.

Autistic adults are substantially overrepresented in mental health crisis services, yet diagnostic delays and limited staff training persist. Improving autism-specific training, strengthening diagnostic referral pathways, and adopting more proactive models of care are essential to enhance crisis support and reduce repeated emergency presentations among autistic adults.

Involvement in Quality Improvement (QI) is an important component of Core Psychiatry Training. The Psychiatry Silver Guide states that trainees should be supported to be involved in one QI project and/or audit per year. We have seen our resident doctors face significant barriers in engaging with QI activities at South West London and St George’s Mental Health NHS Trust (SWLSTG). The Quality Improvement and Innovation (QII) Team coach and track the impact of QI projects at SWLSTG. Since 2023, the QII team have aimed to increase the number of resident doctors involved in QI projects overseen by the QII team.

Since 2023, we have tested 4 change ideas to increase the number of resident doctors involved in QI projects with oversight from the QII team.

Firstly, a cohort programme was designed to coach a group of resident doctors through a joint project with integrated QI training. The pilot of ‘Streamline QI’ began in early 2023 and included bespoke QI teaching and the coaching of participants through a group project. Subsequent cycles in 2024 and 2025 refined the model.

Additional change ideas tested included creating a SpR Special Interest role to support resident doctors, the targeted advertisement of QI training to doctors and the circulation of a trust criteria for QI project endorsement.

We used registration of QI projects with the QII team and repeated surveys of involvement to measure improvement.

In February 2025, 45 resident doctors were surveyed. 42% of respondents were not involved in QI projects. Of the respondents involved in QI projects, 65% were involved in projects without QII team involvement and 35% had QII oversight. The QII caseload of registered QI projects was reviewed and revealed that 0 resident doctor projects were actively progressing.

In January 2026, a repeat survey of 25 resident doctors showed 40% had not been involved in QI projects. Of the respondents involved in QI projects, 100% had QII oversight. This represents an improvement of 65%. The QII caseload had 8 active resident doctor projects and 9 enrolled in Streamline QI.

Feedback from all three cohorts of Streamline QI has been unanimously positive.

Here we have shown that a multi-dimensional approach can engage resident doctors in QI. Future change ideas to test will include a monthly ‘QI project idea’ clinic for resident doctors and delivering QI training to resident doctors on induction.

Superficial siderosis of the central nervous system is a rare progressive disorder caused by chronic deposition of haemosiderin in the superficial layers of the brain and spinal cord, often following recurrent subarachnoid bleeding. The cerebellum and hindbrain structures are particularly vulnerable to iron-related toxicity. Although classically characterised by ataxia, dysarthria, and gait disturbance, cognitive impairment is increasingly recognised as part of its presentation. This overlap can obscure diagnosis, especially when patients first present to memory services with primarily cognitive complaints.

A 75-year-old woman was referred to the memory clinic with a one-year history of worsening forgetfulness, difficulty recalling recent events, and episodes of disorientation. Her family reported rapid decline in her functional abilities, and she had become dependent on her son for daily organisation. She appeared anxious during cognitive testing and showed impaired short-term memory, word-finding difficulty, and repetitive speech, although reading and writing remained intact.

Initially, her presentation resembled a primary cognitive disorder. However, neurological examination revealed significant abnormalities, including difficulty following complex commands, tongue and limb apraxia, bilateral dysdiadochokinesia, and impaired tandem walking. Although there were no cranial nerve deficits or nystagmus, prominent cerebellar signs prompted neuroimaging. MRI demonstrated severe superficial siderosis symmetrically affecting the infratentorial region with lesser supratentorial involvement.

Her cognitive and neurological function deteriorated despite anti-dementia medication. A neurology opinion was sought, and she required multidisciplinary involvement, including speech and language therapy for dysphagia and fallsprevention support. As the condition progressed, she developed leftsided weakness, an upgoing plantar response, and reduced ankle reflexes. Chelation therapy with deferiprone was considered but not pursued due to advanced cognitive impairment, marked ataxia, and limited potential for benefit.

This case highlights an important diagnostic challenge for memoryassessment clinicians: superficial siderosis can initially present as a cognitive disorder, even though the underlying pathology is neurological. Without thorough neurological examination, such cases may be misdiagnosed as dementia, particularly when dysarthria and inconsistent cognitive testing obscure the picture. Dysarthria limits verbal responses, reduces the validity of cognitive scores, and can exaggerate perceived deficits. The patient’s apraxia, coordination abnormalities, and gait disturbance indicated a broader process inconsistent with typical neurodegenerative dementia. Early recognition is essential, not because curative therapy exists, but to guide appropriate imaging, avoid unnecessary treatments, initiate timely multidisciplinary care, and prepare families for progressive decline.

Cognitiveled presentations of superficial siderosis are uncommon but clinically important. This case highlights the value of thorough neurological assessment in memory services, particularly when cognitive symptoms present with atypical neurological features.

The Triangle of Care (ToC) is a national framework, developed by the Carers Trust, comprising six standards to ensure carers are identified, supported and included in mental health care, which is especially pertinent for Crisis Resolution and Home Treatment (CRHT) “limited-contact” services.

Undertaking this Triangle of Care audit within CRHT is crucial because, in a short-term, high-intensity, limited-contact crisis setting, it checks whether carers are identified, supported and meaningfully involved (notably around consent and discharge planning), assures compliance with Trust policy and the Health and Care Act 2022 duty to involve carers, and drives a targeted action plan with scheduled re-audit to secure measurable improvements.

We hypothesised that compliance would be high for staff training and availability of carer information/support, but lower for documentation-dependent items such as consent and recording carers’ special circumstances.

Retrospective review of 30 cases over 6–8 weeks (July–September 2025), excluding instances where no carer was identified despite reasonable enquiry.

Data sources included electronic case notes (carer identification, consent, documentation, discharge planning), staff training records, qualitylead feedback, and local policy/pack review.

A threecase pilot established interrater consistency; a subsample was checked by a senior colleague and carer lead for validation, in line with standard audit methodology.

Overall compliance across ToC standards was 77% (Green/Amber).

By individual standards:

• • S1 Identification 55%

• • S2 Staff training 100%

• • S3 Confidentiality/information sharing 50%

• • S4 Defined carer roles 67%

• • S5 Carer introduction & information 90%

• • S6 Range of carer support 100%.

Sub-items illustrating key gaps included:

• • Recording special circumstances 27%

• • Documented consent/limits 54%

• • Routine discussions on sharing information 45%

• • Revisiting non-disclosure 33%

• • Offering support when disclosure declined 0%

• • Carer involvement in discharge planning 50%

Strengths included universal carer-awareness training, an accessible introduction/information pack (including cultural/language considerations), and comprehensive signposting to support.

Findings support the hypothesis: the CRHT team showed strong performance for staff training and information/support availability. There is much needed for improvement in consent processes, systematic recording of carer special circumstances, and consolidation of local carer-champion arrangements. These improvements would be an essential element in enhancing care for high-risk patients. Supporting wider organisational objectives to promote recovery in the community.

An action plan is in development to enhance service user and carer experience with a re-audit scheduled for 2026.

This audit aimed to determine clinician adherence in Leeds and York Partnership NHS Foundation Trust’s (LYPFT) Older People’s Service (OPS) North as part of the Community Mental Health Team (CMHT), for the NICE guidance regarding:

1. Provision of advice for people with depression for regular physical activity to enhance patients’ sense of wellbeing with potential for added benefits for outdoor activity.

2. Advising people with depression that maintaining a healthy lifestyle by, for example, eating a healthy diet, avoiding excess alcohol, and maintaining a healthy sleeping pattern, can also improve their sense of wellbeing.

The first 200 consecutive contacts by service users with the service from 1st July 2024 onwards were analysed. Seventy-six separate service users were identified. After excluding those without a depressive disorder noted, frail service users, and those who were exclusively seen by a psychologist within the defined study period – first contact from 1st July 2024 up to one month later – 31 service users formed the final sample. Records were then searched to identify clinicians’ interactions with the service user and whether there was evidence of following the NICE guidelines for the provision of advice to improve patients’ sense of wellbeing.

Of the 31 patients in the final analysis, the NICE guidelines regarding the provision of advice for regular physical activity to enhance a sense of wellbeing were followed in 35% of cases (11 service users) with there being no documented evidence of such advice for the remaining 20 (65%) service users. Eighteen service users (58%) had no documented evidence of the provision of advice for maintaining a healthy lifestyle but 13 service users (42%) did. When analysing by staff group, compared to Care Coordinators and Health Support Workers, Doctors performed worst with regards to evidence of providing advice for behaviours to enhance wellbeing.

This audit demonstrated that documentation of LYPFT CMHT OPS North clinicians’ advice to patients with depression that wellbeing can be improved by engaging in regular physical activity, and by maintaining healthy lifestyle habits is absent in the majority of cases (65% and 58% respectively). Following the audit, an action plan was created to improve adherence to the guidelines. This included staff education and creation of a patient information leaflet. A re-audit is planned to analyse whether the action plan has led to improvement.

Alcohol withdrawal can potentially result in a life-threatening condition. This requires early recognition, prompt assessment and treatment. The National and Humber Trust guidelines emphasise use of validated tools such as Severity of Alcohol Dependence Questionnaire (SADQ) and Clinical Institute Withdrawal Assessment for Alcohol–Revised (CIWA–Ar) to guide treatment decisions.

An incident of alcohol withdrawal in the 136 suites, in which the patient’s symptoms were not recognised early and treatment was inadequate, alongside the presence of new staff within the team and informal discussions with staff, highlighted variability in staff knowledge regarding assessment tools and the treatment pathway.

The aim of the project was to improve staff confidence and knowledge in assessing and managing alcohol withdrawal in line with Trust Guidelines as measured by the pre-and post-intervention questionnaire.

The project followed the PDSA cycle of Quality Improvement:

Plan: Improve staff knowledge and confidence in managing alcohol withdrawal.

Do: We conducted a teaching session with staff on alcohol withdrawal symptoms, assessment tools and how they are used and required treatment.

We also created a flowchart to summarise the diagnosis and treatment of alcohol withdrawal. These flowcharts were pasted in suite 136 for staff to use as quick reference.

Study: Post-intervention results showed improved staff knowledge and confidence. Flowcharts were frequently used as quick reference points, and lectures enhanced understanding of assessment and management.

Act: Continue teaching and display of flowcharts. Future cycles may focus on evaluating clinical outcomes of alcohol withdrawal management.

The results showed that the intervention carried out led to significant improvement in staff knowledge of alcohol withdrawal assessment tools, treatment pathways, and guideline access.

The project showed that combining lectures and visible flowcharts effectively improved staff knowledge and confidence in managing alcohol withdrawal. Ongoing reinforcement and feedback are essential to ensure that improved knowledge translates to consistent practice.

This project helps staff to manage alcohol withdrawal more efficiently thereby saving time. It also helps to optimise use of resources. Early recognition and treatment initiation helps to prevent complication thereby cost saving.