To audit DNACPR (Do Not Attempt Cardiopulmonary Resuscitation) documentation within inpatient units of the Mental Health Care Division at Mersey Care NHS Foundation Trust, assessing compliance with Resus Council and BMA standards.

This retrospective audit reviewed DNACPR forms identified via the in-house assessment database, with data extracted from electronic systems and case notes. The audit population included 30 patients, of which 8 were applicable during the audit period (January–June 2025). Compliance was assessed against seven defined criteria, including patient information, rationale for DNACPR decision, healthcare professional details, review information, notification, discussion documentation, and CPR alert on RIO.

Overall compliance was 72%, with an assurance level of Limited. High compliance (100%) was achieved for patient information, rationale for DNACPR, healthcare professional details, and CPR alerts on RIO. However, significant gaps were observed in review information (0% compliance), notification details (33% compliance), and documentation of discussions on RiO (60% compliance).

While DNACPR forms generally captured essential patient and professional details, critical areas of non-compliance were identified, particularly around review, notification, and documentation of discussions. These deficiencies pose risks to continuity and quality of care.

To explore how young people with a diagnosis of Anorexia Nervosa and their carers describe shifts in understanding, thinking and perspective during a clinician-moderated online forum group within a children’s eating disorder service.

Digital interventions are increasingly used within eating disorder services to provide peer connection, psychoeducation and clinician support. Young people with a diagnosis of Anorexia Nervosa and their carers from Mid Mersey children’s eating disorder service were offered digital platform based clinician moderated forum groups as part of TRIANGLE research project, which generated discussions around their illness and their understanding and perceptions of recovery from Anorexia Nervosa. Previous qualitative studies have shown perspectives and sense making inAnorexia Nervosaare central to recovery processes and online support groups can reduce isolation and influence emotional regulation, however, little is known about how shifts in understanding, meaning and perspectives of an eating disorder are experienced within online group intervention in both patients and their carers. This study addresses that gap by analysing group transcripts to identify the processes through which participation may reshape cognitive and emotional narratives related to eating disorder experience and recovery.

Verbatim transcripts from three cohorts of seven consecutive online forum groups were analysed using reflexive thematic analysis, using NVivo software the discussions of 13 youngpeople with a diagnosis of Anorexia Nervosa or Atypical Anorexia Nervosa and 13 of their carers were analysed with attention to changes in participants’cognitive and emotional narratives over time.

Ethical considerations: This included informed consent for research use, anonymisation of transcripts and processes for escalation of safeguarding concerns within the groups. The ethical approval for the TRIANGLE study was taken from REC Liverpool, REC Ref – 25/NW/0029.

Preliminary patterns suggest that young people experience changes in understanding and insight into the impacts of eating disorders, greater capacity for emotional awareness and reframing of ED identity over the course of the online groups. Carers also experience shifts in understanding of young people’s eating disorder behaviours but also a greater ability to reflect and an increased perspective of the impact of their own emotional regulation. Clinician support provided prompts to reframe experiences and promote self-reflection, increased awareness about concepts such as expressed emotion and accommodation within the participants.

These findings suggest that digital group interventions within children’s eating disorder services can support recovery by facilitating shifts in cognitive, emotional and meaning based processes that may underpin change and motivation for recovery.

The effective implementation of evidence-based interventions is heavily dependent on matching interventions correctly to patients’ clinical needs, which, in turn, relies on the way the patients’ clinical needs are understood. Although previous research indicates a high degree of variability in assessment approaches, it remains unclear how clinicians determine clinical ‘caseness’ in routine practice. The aim of this study was to examine how clinicians make judgements about the nature of patients’ presentations when making care-related decisions in acute scenarios.

Semi-structured focus groups were undertaken with clinicians whose primary roles included assessments and decision-making in acute psychiatric scenarios. Participants were presented with a real-life vignette of a complex yet common presentation and asked to discuss their approaches to the assessment, conceptualisation and understanding a range of patient experiences illustrated in the vignette (with a particular focus on how the participant understands these experiences from perspective of phenomenology, psychopathology, causation and diagnosis). The interviews were recorded, transcribed and anonymised and the transcripts were subject to thematic analysis.

The results reported were based on an analysis of data from 4 focus groups involving a total of n=21 participants.

1. The thematic analysis of the way clinicians reached judgements about clinical ‘caseness’ identified four main themes:

2. Specific terminology to convey the relative clinical significance of patient experiences (e.g. ‘intrusive thoughts’ versus ‘voices’ or ‘hallucinations’).

3. Informal rules to reach a judgement about the clinical significance of signs and symptoms (e.g. rules based on the patient’s demeanour to determine whether or not to accept a patient’s self-report at face value).

4. Judgements about the typicality of the self-report.

5. Judgements based on causal assumptions about patients’ presentations (e.g. ‘drug-induced’ or ‘personality disorder voices’).

The findings of this study indicate that in routine mental health practice clinicians reach judgements about the clinical significance of patients’ presentation by using a range of assumptions that are outwith conventional guidance for assessing mental health morbidity. If these findings are supported by the results of other studies, then consideration should be given to (i) developing and implementing agreed approaches to determining clinical caseness in routine practice and (ii) ensuring that implementation research includes an evaluation of the impact of caseness-related judgements on the effectiveness of interventions in routine care.

Substance misuse and addiction-related problems are routinely encountered within psychiatric services, yet many core psychiatry trainees report limited confidence in assessing and managing alcohol- and opioid-related presentations. Traditional didactic teaching may not adequately prepare trainees for the complexity of real-world clinical encounters. Simulation-based education allows learners to practise challenging scenarios in a controlled setting, while case-based discussions (CBDs) encourage reflective learning using authentic clinical material. This educational initiative aimed to explore whether combining simulation with CBDs could improve trainee confidence in addiction psychiatry.

Two dedicated addiction psychiatry teaching days were delivered within a regional core psychiatry training programme. Each day consisted of immersive simulation scenarios, structured debriefs, and faculty-facilitated CBDs. Scenarios focused on core clinical skills including substance use history taking, assessment of risk, and management planning for alcohol withdrawal and opioid use. The first session was attended by 12 trainees and the second by 11 trainees (CT1–CT3). In response to feedback, a simulation scenario was revised for the second teaching day to prioritise collaborative discussion of short- and long-term management plans with the patient. Changes in self-reported confidence were measured using pre- and post-session questionnaires, alongside qualitative feedback.

Prior to the first teaching day (n=12), most trainees reported low or neutral confidence in managing addiction-related presentations. Following the session, all trainees reported increased confidence, with the majority describing themselves as somewhat confident and a smaller proportion as extremely confident.

At the second teaching day (n=11), baseline confidence levels were higher, with over one third of trainees reporting some confidence before the session. Post-session responses again demonstrated an upward shift, with most trainees reporting being somewhat or extremely confident. Attendance at both teaching days by some trainees may have contributed to this higher baseline confidence.

Qualitative feedback across both sessions consistently identified simulation as the most impactful learning modality. Trainees valued the opportunity to practise clinical decision-making in real time, make mistakes in a safe environment, and receive immediate, structured feedback. The integration of CBDs was viewed as complementary, supporting consolidation of learning and reflective discussion based on authentic clinical cases.

This combined simulation and CBD teaching programme was associated with improved self-reported confidence. While limited by small participant numbers and reliance on subjective measures, the findings support the continued use of experiential learning approaches. Future iterations will aim to enhance realism through involvement of individuals with lived experience of addiction, with further sessions planned for April 2026.

Poor IT experience and support are well-recognised contributors to inefficiency, frustration, and burnout among resident doctors. Within West London NHS Trust, informal feedback suggested significant difficulties with access to clinical systems, hardware availability, and IT support responsiveness, impacting both workflow and patient care. This is especially noticeable during the rotation time–February and August. This Quality Improvement Project aimed to identify the IT difficulties resident doctors were facing and to improve resident doctors’ IT experience at West London NHS Trust by addressing key barriers.

Baseline data were collected using an anonymised online survey assessing access to IT hardware, login functionality, system reliability, and IT support satisfaction. Process mapping and stakeholder engagement with IT services, clinical leads, and junior doctor representatives identified priority areas for intervention. Change ideas were tested using Plan–Do–Study–Act (PDSA) cycles. Medical education manager attended the induction and ensured that all the new starters have access to the key systems–clinical system, pathology etc. Difficulties were flagged up to the ICT service.

In the pre-intervention questionnaire, 67% residents reported of experiencing some IT difficulties. The difficulties were with regards to accessing pathology system (ICE), hardware related, windows and NHS email log in. Key concerns around the IT experience were addressed this December, during the rotation of FY doctors. And they reported of improved experience. However, much larger number of doctors rotate in February and August. Similar induction day IT support will be made available in the first week of February. Data from this rotation will show the full impact.

IT system’s access was made part of the induction and early detection of difficulties helped to resolve some of the issues which would otherwise impact work in the first few weeks of the rotation. During the December rotation favourable outcome was noted.

Psycho education is a vital component of holistic and effective care within Child and Adolescent Mental Health Services (CAMHS). High-quality, accessible information enables young people and their families to better understand their mental health conditions and recommended treatments. This helps engagement, informed decision-making, improve clinical outcomes and patient safety. However, services face challenges in delivering consistent psychoeducation due to variability in available resources and clinician awareness. This Quality Improvement Project aimed to assess clinicians’ awareness, confidence, and use of psychoeducation resources within CAMHS in BCHFT and to develop a centralised system to support high-quality psychoeducation across the Trust.

This project was developed using the PDSA quality-improvement framework. An anonymous self-report survey was distributed to clinicians across the four boroughs, consisting of 14 items: 11 Likert-scale questions and 3 open-ended prompts. The survey examined clinicians’ awareness of psychoeducation resources, confidence in delivering psychoeducation, frequency of use, and familiarity with local materials such as websites, books, apps, leaflets, workshops, and skills groups. Clinicians were also invited to propose ways to improve psychoeducation provision to guide us in the development of a centralised resource for each borough.

A total of 32 clinician responses were analysed. Most respondents (96%) recognisedthe importance of psychoeducation for recovery and relapse prevention, and 90.5% reported routinely offering it in consultations. However, notable knowledge gaps emerged: 37% were unaware or strongly unaware of the Trust’s Service Directory, and 25.5% were neutral or unaware of existing CAMHS psychoeducation workshops. Although 85% felt confident delivering psychoeducation, only 62% were satisfied with current provision. Verbal explanation and website signposting were used most frequently, followed by leaflets. Clinicians recommended improving access to resources through printed materials, shared drives, and Microsoft SharePoint, as well as increasing availability in waiting areas. Additional suggestions included materials on parental mental health, coping strategies, condition summaries, staff training, and a parent portal.

The survey highlighted a wide range of psychoeducation resources used across CAMHS but revealed inconsistent awareness, with more experienced clinicians accessing a broader selection. These findings highlighted the need for a centralised approach to share resources. In response, a resource booklet has been developed for each locality and will be circulated to all clinicians, with plans for regular review. This project aims to strengthen clinician confidence, improve service quality, and enhance the wellbeing and safety of children and families accessing CAMHS.

Unlawful medication administration under the Mental Health Act (MHA) poses significant patient safety and legal risks in Old Age Psychiatry. Cognitive impairment, fluctuating capacity and behaviour disturbances increase the likelihood of patients requiring rapid tranquillisation. In August 2025, four incidents occurred, where either the route or frequency were administered outside the parameters of medication authorisation forms (T3 particularly).

This Quality Improvement Project aimed to eliminate T3 medication errors by improving Registered Nurses' (RN) knowledge and confidence in compliance with MHA medication authorisation forms. We hypothesised that a combined intervention of a visual prompt and targeted teaching would improve compliance and reduce errors to zero.

We included all RNs on a 16-bed Old Age Psychiatry ward (n=10). Baseline data included incident reports and questionnaires identifying inconsistent knowledge and varied confidence of medication form processes among RNs.

Two interventions were implemented: (1) a visual whiteboard placed above the drug trolley identifying patients with active T3 medication forms to prompt checks at administration times; (2) a targeted teaching session using real ward-based incidents to reinforce legalrequirements for T3 authorisation. Monthly audits monitored medication authorisation errors, and questionnaires were repeated following the teaching session.

Following implementation, off-T3 medication incidents reduced from four in August 2025 to zero in September 2025, and remained at zero for four consecutive months. Staff reported that the visual prompt aided adherence to MHA T3 medication forms. Mean knowledge questionnaire scores increased from 58% at baseline to 71% after the teaching session. Mean self-reported confidence in interpreting T3 forms increased from 3.7 to 4.3 on a 5-point Likert scale.

Low-cost, scalable interventions integrating visual aids and focussed education eliminated unlawful T3 medication errors to zero and significantly improved staff knowledge and confidence, ensuring sustainable T3 compliance. This Quality Improvement approach supports safer practice and is transferrable to other inpatient psychiatric services.

Pregnancy/Childbirth is a period of immense physical, emotional and social changes to women’s life due to drastic hormonal, body image changes. The immunological and circadian rhythm disturbances postpartum is compounded by potential obstetric complications.

Postpartum psychosis can arise in about 1-2/1000 live births, developing rapidly within weeks of delivery. Presentation is heterogeneous ranging from affective, psychotic and a mixture of symptoms. A smaller proportion of women can have Catatonia presenting with abnormal movements/behaviours.

A 26year old woman was brought to A/E, confused and disorientated 5weeks after her first childbirth. Pregnancy was uneventful until 40weeks when developed hypertension. She was induced at 41weeks/3days after passing meconium-stained liquor. Labour lasted 3nights with postpartum haemorrhage of 1600mls. She had mastitis and UTI postpartum.

She was admitted to a mother and Baby Unit due to her deteriorating mental state. She was noted to present as mute periodically, with labile mood and abnormal movements. Other features of her presentation included thought disorder, gross confusion, delusions of paranoia and misidentification.

She experienced distressing visual, tactile and auditory hallucinations. In addition to catatonic features of echolalia, abnormal movements like walking backwards, crawling or climbing, negativism and staring with periods of immobility.

She had no previous psychiatric or medical history. She had no family history of mental illness and the rest of her psychiatric history was unremarkable with a good social support.

She had extensive investigations including Haematological, CSF tests, brain and body scans, EEG to rule out Autoimmune encephalitis or other organic aetiology. Results were unremarkable. She was commenced on Olanzapine with poor response despite optimisation resulting in a switch to Risperidone. She was commenced on Intra-muscular (IM) Lorazepam and responded to daily doses at 5mg though improvements were not sustained. There was a poor response to oral and sublingual Lorazepam that was tried due to concerns about frequent IM treatments.

She was subsequently treated with Electroconvulsive therapy (ECT), which led to a dramatic and rapid response. By the second session, most of the catatonic and psychotic symptoms resolved. She was subsequently discharged after 8sessions of ECT, and was able to rebuild the bond with her baby and reconnect with her family.

Postpartum Psychosis is a psychiatric emergency with significant impairment in functioning and impact on parenting, with associated risks to self and the infant. Diagnosis and treatment must be timely. ECT remains an evidence-based treatment for rapid relief of symptoms of postpartum psychosis with Catatonia.

Performing a comprehensive physical health examination is crucial for individuals admitted to a neuropsychiatric inpatient unit as it helps identify potential underlying organic conditions that may contribute to a patient’s psychiatric presentation. To ensure optimal care, it is essential for the team to prioritize physical health assessments and maintain clear, timely communication to address all health aspects within the recommended time frame.

Aims

To improve the quality of physical health assessments performed by clinicians across the wards.

To assess whether physical health assessments being performed met the standards and were carried out within the time frames recommended by the Royal College of Psychiatrists and North Staffordshire Combined Healthcare Trust (NSCHT).

To assess whether physical health assessments were being recorded onto Lorenzo electronic patients record (EPR) as recommended by NSCHT.

As part of the admission clerking process, the clinician is advised to fill out the General Condition Examination form on Lorenzo (EPR) which ensures a complete examination to be carried out within the recommended time frame.

This was a retrospective study using records from patients admitted to Ward 5 of the NSCHT between March 2023 and March 2024, a total number of 44 patients were included in this study. A data collection form was used which included the following parameters:

Completion status of physical health assessments

• • Completed Physical Health Assessment

• • Incomplete Physical Health Assessment

• • Missing Physical Health Assessment

Completion status of General Condition Examination form on Lorenzo (EPR)

• • Completed physical health assessments and completed General Condition Examination form on Lorenzo

• • Completed physical health assessments but no form on Lorenzo

• • Data was analysed and graphically represented.

The analysis revealed that 70% of patients underwent complete physical health assessments within the designated timeframe, 14% of the examinations were incomplete/not up to standard and 16% were missing altogether. Reasons for missing assessments were recorded for only 2 patients. These figures fall below the recommended standards.

In relation to the General Condition Examination form on Loranzo EPR, only 18% of patients had the form completed, leaving 82% without the recommended documentation.

Figures from the data analyses were found to be below the standards set out by the NSCHT and the Royal College of Psychiatrists. This would suggest potential communication lapses between clinicians and ward staff.

Key Recommendations:

• • Emphasising the importance of physical health assessments and filling the General Condition examination form as a fundamental component in the resident doctor’s induction handbook and induction meetings.

• • Adding the procedure of filling out the General Condition Examination form on Lorenzo to the induction smartphone application (EOLAS).

Sodium valproate safety protocols historically focused exclusively on women of childbearing potential. However, 2024 Medicines and Healthcare products Regulatory Agency (MHRA) alerts represent a significant paradigm shift, extending safety requirements to include male patients due to emerging evidence of potential risks regarding male infertility and offspring congenital and neuro developmental disorders.

Recognising an ethical duty to ensure transparency and patient autonomy, the East Bromley Intensive Case Management in Psychosis (ICMP) team conducted this audit to:

Establish a clinical registry to monitor all valproate prescribing within the service.

Assess baseline compliance with national standards (risk communication, contraception advice, informed consent).

Deploy targeted interventions to strengthen shared decision-making and ensure regulatory adherence across all genders.

Cycle 1: A retrospective review of Electronic Patient Records for 330 patients was performed. A registry was established for all patients prescribed sodium valproate. Baseline data captured adherence to updated guidance, including documentation of risk discussions, contraception advice, informed consent, and Annual Risk Acknowledgement Form (ARAF) completion.

Interventions: Targeted interventions included clinician education, structured outpatient reviews (26 conducted), distribution of MHRA materials, and the creation of a live ARAF tracking system.

Cycle 2: A focused re-audit in July 2025 evaluated the impact of these interventions.

A registry of 46 patients was established (30 Males(M), 5 Females(F)<55, 11 F>55).

Baseline Compliance (Cycle 1): Data revealed a marked gender disparity in regulatory adherence, with male patients significantly falling behind:

• • Risk Discussions: 37% (F:80%, M:17%)

• • Contraception Advice: 15% (F:80%, M:3%)

• • Informed Consent: 61% (F:80%, M:20%)

• • MHRA Material Provision: 11% (F:60%, M:6%)

Dual-signed ARAF in eligible females: 0%

Post-Intervention (Cycle 2): Targeted interventions successfully bridged this gap, achieving marked improvements in the male cohort:

• • Risk Discussions: 17%→87%

• • Contraception Advice: 3%→83%

• • Informed Consent: 20%→87%

• • MHRA Materials: 6%→83%

The pathway for second-consultant sign-off was clarified, with 100% of eligible females reviewed.

Furthermore, 26 structured reviews directly influenced prescribing: 13% of patients transitioned to alternative treatments, and 9% deliberating alternatives, reflecting a significant shift toward active shared decision-making.

This project exposed and successfully closed a critical safety gap in male valproate prescribing by deploying targeted risk discussions and active clinical re-evaluation. The 13% treatment switch rate underscores the impact of shared decision-making, proving that informed consent is an evolving dialogue rather than a static achievement. Ultimately, this work reaffirms the clinicians’ ethical duty to challenge long-standing treatment plans in light of new evidence, ensuring psychiatric practice remains both evidence-based and ethically robust.

Multiple projects across the country are fortunately looking closely at violence and aggression happening to health and social care workers. This is a piece of work around experience of support made available to resident doctors in psychiatry following violence and aggression incidents.

This QI project aims to improve the quality of support and spread awareness about available channels to resident doctors following abuse incidents. A baseline survey was conducted to explore awareness of available channels, rate satisfaction with them, improve them as well as suggest new possible ways of providing support.

As a part of the QI project, we did a baseline survey to explore whether resident doctors had access to support after a violence and aggression incident and how satisfied they were with it. We then did a root cause analysis (RCA) workshop where resident doctors identified reasons for not accessing these channels.

41 resident doctors participated in the survey. 12 residents reported experiencing anincident of violence and aggression (1–2) times and 8 of these residents were in a junior entry level (CT1–CT3). 22 of these incidents were identified as verbal. 85.71% of residents were not aware of available channels of support in the trust. This coincided with 75% of residents not seeking support. Of the participants that did seek support, 2.44% graded the level of satisfaction with the type of support as 1 (very unsatisfied) and the follow-up answer was (due to lack of communication following the report and not knowing what the outcome of the report was). We then carried out an RCA and the resident doctors identified multiple causes to not seeking support including (not knowing how to access support, feeling speaking up is a burden, feeling the process is not followed through, feeling like they don’t belong due to rotating every 6 months) etc.

The residents have overall agreed there is room for improvement on the level of support available. We used the suggested themes in the RCA to come up with an action plan. Measures we have come up with are including all information around support channels in the induction file given to all new starting resident doctors, spreading awareness about available support on the trust intranet, liaising with the incident reporting system representatives in the trust to improve reporting process and include proper follow up. We are also still meeting regularly to discuss and improve our action plan.

There is clear evidence that Black men are disproportionately detained under the Mental Health Act (MHA). Our aim was to explore and characterise the clinical, social, organisational and structural factors contributing to this phenomenon, by examining the pathways to compulsory admission among Black adult males, and to generate hypotheses to inform future research and service improvement.

We completed a thematic analysis of Structured Judgment Reviews (SJRs) of a consecutive series of Black adult male patients detained under the MHA within a single NHS mental health trust. The MHA team provided ten consecutive cases organised by date of detention; two cases were excluded due to being minors, leaving eight cases. The reviews were completed by trained clinicians using NHS SJR methodology, to apply structured judgment and qualitative narrative across phases of care. We identified themes relating to routes to detention, (dis)engagement with services, quality of care and social context.

Most patients had psychotic diagnoses (schizophrenia or BPAD), with histories of multiple detentions. Patient-related themes included: disengagement from CMHT services, poor medication adherence, and substance misuse. Several patients experienced significant social adversity, including homelessness, socioeconomic deprivation, exploitation and limited support networks. Migration-related stressors, trauma and language barriers were also evident.

Regarding organisational factors, inpatient care was generally timely and of adequate or good quality, with appropriate multidisciplinary involvement. Transitions from inpatient to community care emerged as a consistent point of vulnerability. Communication difficulties between services, missed opportunities for assertive follow-up, inconsistent provision of interpreters, and delays in initiating substance misuse interventions were recurrent. In several cases, rapid relapse occurred within months of discharge, leading to repeated crisis presentations and subsequent detention.

Our analysis of the themes suggests that compulsory admission under the MHA disproportionately affect Black males due to cumulative interactions of clinical complexity, social deprivation and system-level gaps in care continuity, rather than care quality alone. Although our findings cannot establish generalisability or causation, they are supportive for the hypothesis that earlier, more tailored and integrated community care may reduce detention for Black men. Future work could practice on larger samples and lived-experience perspective to inform culturally responsive service models and ongoing MHA reform. The Trust’s Quality Committee welcomed the report, endorsed further exploration of the key theme, and agreed the recommendations would be progressed through relevant governance committees.

Delusional parasitosis is defined by a persistent belief of infestation despite absence of objective evidence and is classified as a somatic delusional disorder in ICD-11 and DSM-5-TR. It often arises where plausible environmental exposure interacts with affective vulnerability and pre-existing anxiety traits, blurring the line between obsessional preoccupation and psychotic conviction. Such cases provide insight into how real-world threats can crystallise into enduring delusional beliefs, exposing the limitations of rigid diagnostic categories.

Mrs X, a 65-year-old woman with a history of obsessive–compulsive disorder, agoraphobia, and depression, was referred for psychiatric assessment because of persistent concerns that insects inhabited her skin, clothing, and living environment. Her symptoms began following a suspected flea exposure while living in Cornwall, which she experienced as highly distressing. Despite relocation, repeated cleaning and environmental interventions, and multiple medical reviews showing no evidence of infestation, her conviction persisted.

She described ongoing sensations of particles entering her skin, ears, and face, with burning and itching, worsened at night. These experiences became central to daily life. She discarded most personal belongings, slept on inflatable mattresses, engaged in repetitive washing and decontamination rituals, and spent hours documenting “evidence” through photographs, videos, and microscopic examination. Progressive social withdrawal, disrupted sleep, reduced appetite, and secondary low mood developed as her preoccupation intensified.

Examination revealed only healing excoriations and minor skin dryness without objective signs of infestation or systemic illness. Mental state assessment showed anxiety, labile affect, circumstantial speech, and fixed somatic beliefs with limited insight. There were no hallucinations or formal thought disorder, and she denied suicidal ideation. While relapse of obsessive–compulsive disorder or severe health anxiety was considered, the persistence and rigidity of her beliefs supported a diagnosis of delusional disorder, somatic type.

This case illustrates how a plausible environmental event may catalyse the consolidation of somatic delusion, marking a transition from threat-based anxiety and obsessional monitoring to psychotic-level conviction. It highlights the phenomenological continuity between obsession and delusion and exposes the limitations of rigid diagnostic boundaries when symptoms evolve across domains. Clinically, the case underscores the profound functional impairment associated with somatic delusions and the therapeutic challenges posed by limited insight and partial engagement with treatment.

This presentation emphasises the need for integrative formulations that account for environmental triggers, affective vulnerability, and evolving belief structures. It supports a dimensional understanding of psychopathology and the value of multidisciplinary approaches in assessing and managing complex somatic delusional states.

This re-audit evaluated local management of acutely disturbed and violent patients against NICE guideline NG10 (2015) and aimed to develop a targeted action plan. It compared trends between an initial audit in 2024 and a re-audit in 2025, focusing on gender differences in RT use, clinical presentation, and post-intervention care.

A retrospective re-audit of 79 RT incidents between February 2024 and July 2025 was conducted on Mulberry Ward (Scunthorpe), an acute adult inpatient psychiatry ward and compared with 37 incidents from the 2024 audit (April 2022–July 2023). RT was defined per NICE NG10 (2015) as parenteral medication used for urgent sedation. Data were extracted from electronic medical records and Incident Report Form 1 (IR1). Analyses were performed using Microsoft Excel. Compliance with predefined standards of good clinical practice was assessed using a traffic-light system: green (≥80%), orange (60–79%), red (<60%). Gender-specific trends in demographics, RT frequency, clinical diagnoses, post-RT monitoring, and incident reporting were examined.

The 2024 audit included 17 patients (9 women, 8 men) and 37 RT incidents; the 2025 re-audit included 10 patients (7 women, 3 men) and 79 incidents. Female representation increased from 53% to 70%, with mean age decreasing from 43.8 to 30.3 years. RT frequency rose sharply among women (2.2 → 10.5 incidents per patient) and declined in men (2.0 → 1.5). Psychotic disorders remained common, but emotionally unstable personality disorder increased markedly (11.7% → 50%), predominantly affecting women. Secondary diagnoses, including poly-substance misuse (29.5% → 40%) and autistic spectrum disorder (23.5% → 40%), indicated rising clinical complexity.

Pharmacological management shifted substantially: lorazepam became the primary agent (43% → 69.6%), haloperidol-based regimens declined sharply, and aripiprazole injection increased (11% → 22.7%). Use of zuclopenthixol acetate and promethazine ceased in 2025. Self-harm (67%) and suicidal behaviour (13%) emerged as the main triggers for RT in women, while physical aggression declined to 16.5%. Seclusion use fell from 30% → 5%. NICE compliance remained excellent for risk assessment, patient rights, and documentation; however, post-RT monitoring, debriefing, medication review, and incident reporting remained below standard. Advance directives were absent in both audits.

The re-audit demonstrates strong adherence to NICE standards and reduced reliance on seclusion, but persistent gaps in post-RT care and governance remain. The substantial increase in RT frequency among younger female patients with complex comorbidities highlights the need for gender-sensitive strategies, preventive interventions, trauma-informed care, and enhanced multidisciplinary follow-up. Findings support targeted service improvements and the ongoing role of audit in acute psychiatric care.

Risky drinking causes substantial harm in Sri Lanka, yet despite WHO endorsement, brief interventions remain unevaluated in primary care settings. Sri Lanka’s outpatient departments record 55 million visits annually, representing an untapped opportunity for systematic opportunistic alcohol intervention delivery. This pilot randomized trial aimed to assess feasibility and acceptability of three brief intervention intensities, evaluate appropriateness of outcome measures including an innovative family member-reported burden measure, and generate preliminary data to inform a future adequately powered effectiveness trial.

One hundred and fifty adult male risky drinkers (AUDIT-C ≥4) presenting to the outpatient department of Teaching Hospital Peradeniya were randomized equally to three arms representing increasing intensity along a brief intervention continuum: Feedback on AUDIT-C (FOA, approximately 3 minutes), Unit of Alcohol education (UOA, approximately 5 minutes), or Adapted Brief Intervention (ABI, 15-30 minutes). Trained non-specialist research assistants delivered all interventions and followed up at six months. Feasibility was assessed through recruitment rate, retention at 6-month follow-up, and participant-reported acceptability. Drinking-related outcomes included AUDIT-C scores, binge drinking frequency, and Alcohol Problems Questionnaire (APQ) scores. Family burden was measured using the AFI-Net Family Member Questionnaire.

Target recruitment (n=50 per each arm) was achieved within approximately six weeks. Patient retention at 6-month follow-up was 92%, 84% and 90% for FOA, UOA and ABI arms respectively. Family member retention was 93.7% (74/79 enrolled), demonstrating feasibility of this novel dyadic design. All questionnaires were comprehensible and outcome measurement was feasible. Patient feedback was overwhelmingly positive across all three arms. Of the 133 who came for follow-up 111 (83.4%) were in precontemplation, at recruitment. Baseline scores in all outcome measures were comparable between the three arms. Pilot data indicate improvements in all outcomes in all three arms–change from baseline (mean±SD) in AUDIT-C score were −0.80±1.94, −1.55±2.50, and −2.36±2.81; in binge drinking days per month −1.99±6.20, −1.75±6.17 and −3.75±9.52; APQ score −2.23±5.84, −2.24±4.14 and −2.45±4.37; and family burden −3.65±6.37, −1.3±8.37 and −1.8±9.39, for FOA, UOA and ABI arms respectively.

This is the first alcohol brief intervention pilot trial conducted in Sri Lankan primary care. It is, to the best of our knowledge, also the first brief intervention study internationally to measure family member-reported burden as a primary outcome. All three intervention intensities proved feasible and acceptable in a high-volume, resource-limited outpatient setting. The observed dose-response pattern in patient-reported outcomes across intervention intensities is promising but warrants confirmation in an adequately powered efficacy trial.

A HSIB (2023) report highlights the substantial impact of menopause on mental health, with up to 40% experiencing depressive symptoms and a seven-fold increase in suicidal ideation risk. Despite this, menopause remains under-recognised in community mental health team (CMHT) psychiatric assessments, with symptoms often misattributed to, or exacerbating, severe mental illness. This quality improvement project aimed to enhance CMHT clinicians’ awareness and knowledge of the menopause–mental health link, targeting a 50% increase within the Barnet North Core CMHT, measured through clinicians’ understanding of its relevance to mental health, incorporation into assessments, and knowledge of NICE treatments guidelines.

Baseline knowledge of menopause and mental health among 35 CMHT healthcare professionals (HCPs) was assessed using a questionnaire. Targeted educational training was delivered to address identified knowledge gaps and support improved integration of menopause considerations into mental health assessments. Outcomes were measured via pre-training and post-training questionnaires. Supplementary interventions included: (1) review of existing Trust resources, (2) promotion of patient leaflets, (3) provision of screening and diagnostic tools, (4) development of a narrated menopause training module, and (5) display of reminder posters to reinforce learning.

All HCPs recognised the relevance of menopause to mental health pre- and post-training (100%), with awareness of its impact increasing slightly from 74% to 80%. Self-rated sufficient knowledge increased from 16% to 40%, although most continued to desire further training (100% pre; 93% post). Consideration of menopause in assessments was largely unchanged (68% to 60%), while incorporation into mental state examinations improved markedly (42% to 87%). Knowledge of appropriate treatment increased substantially from 23% to 80%, and awareness of available resources also improved, though gaps remained (8% to 40%).

Targeted CMHT training improved awareness of menopause’s impact on mental health, alongside enhanced knowledge of associated risks, clinical integration into mental state examinations and knowledge of NICE treatment guidelines. Despite these gains, only 40% of HCPs reported sufficient knowledge post-intervention, and 93% expressed a desire for further training.

These findings underscore the need for sustained educational interventions, particularly in the context of staff turnover, which may have limited engagement. To support sustainability, a narrated training module, validated tools, patient leaflets, and reminder posters were implemented. Persistent knowledge gaps highlight the importance of ongoing training, embedding menopause–mental health content within mandatory Trust programmes, and evaluating the impact of sustainability measures on improving knowledge and application of the menopause–mental health link in clinical practice.

Stimulant use disorder is associated with increasing morbidity, mortality, and high relapse rates, yet there is currently no approved pharmacotherapy. Relapse vulnerability is increasingly recognised as arising from dysregulation across dopaminergic, serotonergic, and noradrenergic neurocircuitry. Serotonin-Norepinephrine-Dopamine Reuptake Inhibitors (SNDRIs) modulate these monoaminergic pathways and represent a mechanism-informed pharmacological strategy. This review aimed to evaluate the neurobiological rationale, translational potential, and emerging clinical feasibility of repurposing SNDRIs for stimulant use disorder.

A review was conducted integrating preclinical neuropharmacological evidence, human neuroimaging and behavioural studies, and clinical trial data examining monoamine transporter modulation. Evidence relating to dopamine transporter (DAT), serotonin transporter (SERT), and norepinephrine transporter (NET) function was analysed to evaluate reinforcement neurobiology, relapse vulnerability, pharmacokinetic characteristics, and clinical safety data from candidate SNDRIs including dasotraline, centanafadine, and ansofaxine.

Psychostimulant reinforcement is strongly associated with DAT occupancy and dopamine elevation within mesolimbic reward circuitry. However, relapse vulnerability is increasingly linked to serotonergic and noradrenergic dysregulation contributing to stress sensitivity, affective instability, and cue-driven drug seeking. Preclinical evidence demonstrates that NET inhibition reduces stress-induced and cue-mediated stimulant seeking, while SERT modulation influences impulsivity and negative affective states associated with relapse. SNDRIs produce sustained, moderate monoaminergic modulation that normalises hypodopaminergic states observed during stimulant withdrawal without producing rapid dopamine elevations associated with abuse liability. Pharmacokinetic data demonstrates extended elimination half-lives supporting once-daily dosing and improved treatment adherence. Clinical trials investigating SNDRIs in attention-deficit/hyperactivity disorder and major depressive disorder demonstrate favourable tolerability and sustained monoaminergic modulation in human populations. Advances in transporter structural modelling and computational pharmacology support the use of dynamic transporter-ligand profiling to stratify therapeutic development and improve prediction of abuse liability.

SNDRIs demonstrate mechanistic plausibility and clinical feasibility as candidate pharmacotherapies for stimulant use disorder. Multi-transporter modulation may address both reward-driven reinforcement and relapse-related neuropsychiatric processes. However, current evidence remains indirect and derived primarily from mechanistic, preclinical, and non-addiction clinical populations. Targeted, stratified clinical trials in stimulant use disorder populations are required before treatment recommendations can be made.

To identify the use and prescribing of anxiolytics and hypnotics pre-admission, during the inpatient admission and on discharge and if such medications are reviewed during the inpatient admission on the adult mental health male and female wards.

A list of patients admitted from 01-Dec-2024-28-Feb-2025 were collated using IBM Cognost Analytics. The electronic patient records (EPR) were used to identify patients who were discharged after 28-Feb2-2025, and such patients were excluded from the audit. Medications prescribed pre-admission were identified using the medicines reconciliation in the EPR. Medications prescribed during the inpatient admission and on discharge were found on the electronic prescribing system and EPR. Microsoft forms were used to collate data and Microsoft excel was used for data analysis. Lorazepam, promethazine, diazepam and zopiclone prescriptions were analysed.

A total of 100 prescriptions on the female and 35 prescriptions on the male were prescribed during the inpatient admission. 26% (female) and 46% (male) of prescriptions were reviewed throughout the inpatient admission and documented. 6% (female) and 0% (male) of prescriptions were reviewed weekly. 9% (female) and 14% (male) prescriptions were changed in terms of dose, frequency and/or maximum dose.

A total of 48 (female) and 18 (male) prescriptions on the male wards were prescribed upon discharge. 71% (female) and 22% (male) prescriptions were changed in terms of dose, frequency and/or maximum dose. 74% (female) and 91% (male) of discharges had a documented plan regarding the review of benzodiazepines and/or z drugs.

To conclude, the audit demonstrates poor compliance of the TEWV trust policy regarding regular reviews of anxiolytics and z-drugs and documentation during the inpatient admission. The female ward had a greater number of patients and prescriptions, which was attributed to the high turnover of patients. However, on discharge there was a higher percentage of prescriptions that were reviewed, changed and documented. Evidenting that majority of prescriptions were reviewed at the point of discharge. This poses a risk to patient safety especially when discharged to a least restrictive environment in which symptoms of withdrawal cannot be closely monitored when compared to an inpatient setting. This audit encourages clinicians to ensure regular reviews are maintained through weekly reviews with the MDT and patient, and more training to staff, particularly doctors in training.

Methylphenidate is a relatively safe medication used frequently in ADHD with only a few dermatological side effects reported up-to-date. While direct relation between the medication and the dermatologic side effects on children are discussed and supported by the disappearance of reactions after medication withdrawal, other confounding factors such as parental stress and coping mechanisms, were indeed observed to have a direct impact on children’s wellbeing. The higher the maternal anxiety was related to the worse outcome in children with stress. This fact could explain recently emerged or prolonged skin reactions especially during the pandemic, as it provokes health-related anxiety, especially in vulnerable people.

Our case is a 9-year-old boy with ADHD who experienced digital desquamation after using methylphenidate-containing prescriptions. To the best of our knowledge, he was the first child having persistent non-pruritic, non-painful acral swelling and desquamation without any benefit from discontinuation of medications containing methylphenidate, and without any rheumatological condition.

There have been a few unusual adverse skin reactions to Methylphenidate reported, differing widely from general to local, pruritic to non-pruritic, and exfoliative to non-exfoliative. Our case had local non-pruritic exfoliation started 2 months after initiation of Methylphenidate -IR, however, the symptoms did not disappear after the withdrawal of prescriptions.

Persistent peeling after discontinuation of any Methylphenidate prescription was a unique situation. Thus, we investigated whether Methylphenidate has triggered and/or masked any rheumatologic condition especially juvenile rheumatoid arthritis and juvenile scleroderma. He was examined by a paediatrician with no anomaly found. Another reason for such prolonged skin reaction could be personal and parental stress. This could also explain why he has abdominal pain triggered only by going to school, as it may be related to parental expectations in addition to his ADHD and dyslexia comorbidity. The literature findings support the idea that high maternal anxiety elicits worse health outcomes in children with a neurodevelopmental disorder. Unfortunately, we could not have a chance to assess the anxiety level and coping mechanisms of the mother of our case, other than observing her stress-related behaviours as frequent doctor visits, to have a more concrete debate.

Any skin finding after methylphenidate prescription must be monitored closely to have early preventive measures, better adherence to treatment, and quality of life for both patients and their parents. Also, both children and their parents could be controlled for stress and coping mechanisms to diminish their negative effects on dermatological or any other health-related outcome.

Effective handover of patient care is essential for patient safety. In psychiatric inpatient wards, morning multidisciplinary team (MDT) handover is used to communicate information from previous shifts; however, this process was criticised locally for lack of structure, prolonged duration and omitted information. This quality improvement project aimed to reduce the duration of morning handover through implementation of a structured handover tool. A secondary aim was to explore the relationship between the number of attendees and handover duration.

The Model for Improvement methodology was used. Initial qualitative discussions with both junior and senior MDT members identified perceived problems with the existing handover process and informed potential change ideas. Baseline data were collected over approximately 1 month (N=17), recording total handover duration and number of attendees. Comparable data were also collected from four other inpatient wards where structured handovers were already implemented, providing benchmarking.

A structured morning handover tool based on the SBAR framework was developed and implemented, then disseminated to nursing staff responsible for leading the handover. Following implementation, handover duration and attendance were measured over a further one-month period (N=19), with additional data collection (N=5) during two separate weeks in subsequent months to assess sustainability. Qualitative feedback was obtained from the MDT to assess attitudes to the intervention.

Mean handover duration decreased from 68 minutes (range 35–102) to 52 minutes(range 38–78)following implementation, representing a 24% reduction. During months three and four, one-week samples showed mean handover duration of 53 and 48 minutes respectively, demonstrating sustained improvement.

With an average attendance of 9 staff members per handover, this reduction equated to 720 minutes (12 hours) of MDT clinical time released per week. Qualitative feedback was positive, comments included ‘continuous positive influence’, ‘a huge improvement’ and ‘concise without sacrificing thoroughness’.

Baseline handover duration on comparator wards, using alternative structured approaches, ranged from 35–47 minutes, suggesting that using a structured handover rather than the specific format used was the key factor associated with decreased duration, although ward differences likely also contributed.

Correlation coefficients between attendance and handover duration ranged from +0.13 to +0.69 across wards and time points, however no intervention targeting this was implemented.

Implementation of a structured morning handover was associated with a sustained reduction in handover duration and improved perceived quality. The findings suggest that implementing any structured approach is more important than the specific framework used. Increased attendance was associated with longer handover duration.