Aims: Scotland has the highest drug-related death rate in Europe, with 27.7 deaths per 100,000 people. The average age of drug-related deaths in Scotland has increased from 32 in 2000 to 44 in 2021, with a significant proportion involving multiple substances. According to NICE and Scottish Intercollegiate Guidelines Network (SIGN) guidelines, best practice management for inpatients with co-occurring substance misuse and mental health should involve: Screening and Identification of Substance Misuse, Integrated Dual Diagnosis Care, Pharmacological and Psychosocial Interventions, Harm Reduction Approaches in Acute Psychiatric Wards and Safe Discharge and Aftercare Planning. We have designed a closed-audit loop which has evolved into a quality improvement project to enhance the identification, management, and follow-up care of substance misuse among inpatients in general psychiatry ward at St John’s Hospital, Livingston, Scotland. This project seeks to achieve an 80% compliance rate in substance use assessments, implement standardized protocols for managing active substance misuse, and develop a policy for handling patients under the influence, in possession, or distributing substances by December 2025. Data presented in this abstract is for the closed-loop audit part of a larger quality improvement project.

Methods: Data for the initial audit was collected from Trak, the electronic patient record (EPR) system, for patients admitted to and discharged from a mixed acute general adult ward at St John’s Hospital, during the period from 13 February to 13 May 2024. Data was collected on documentation of previous substance misuse and substance misuse urine screening. As an intervention, our team introduced staff reminders for biological testing and incentivised staff, patients and carers to provide feedback on substance misuse history, substance misuse on the ward and testing. From 30 October till 30 January, a further cycle was conducted to assess for changes post-intervention.

Results: The closed-loop audit included 84 patients pre-intervention and 49 patients post-intervention. 35.3% had co-morbid schizophrenia/psychosis and a further 24.7% had combined depressive disorder and suicidality. Alcohol misuse was the highest reported substance misuse (33.33%), followed by cannabis (27.03%) and cocaine (11.71%). Post-intervention there was a 35.18% increase in biological testing compliance (post-intervention 57%) and 51.36% increase in substance misuse history documentation compliance (post-intervention 75%).

Conclusion: Substance misuse worsens prognosis for many patients with other mental health co-morbidities. We have identified that compliance is still low for documentation and testing. By identifying gaps in achieving compliance, this project seeks to guide better local policy in order to implement evidence-based practices improving patient outcomes.

Aims: This audit aimed to assess nicotine use patterns in inpatients and evaluate adherence to the Essex Partnership University Trust Nicotine prescribing guidelines, as well as British Thoracic Society’s recommended dual nicotine replacement therapy (NRT) regimen. It also aimed to examine the documentation of smoking status, NRT usage, and cessation planning.

Methods: A sample of 40 inpatients was selected from 4 Mid-Essex general adult inpatient wards, using a random number generator. Data was collected from PARIS inpatient admission assessments, physical health checks (PHCs) and paper or online prescription charts to identify smoking status, nicotine use, and cessation discussions. Nursing staff provided information on vaping. The audit assessed whether patients were on dual NRT (short-acting and long-acting forms) and whether cessation plans were documented for patients using inhalators or vapes.

Results: The audit revealed that 57% of patients were smokers, and 72% of smokers were using vapes. None of the patients were receiving dual NRT, and no cessation plans were found for those using any form of NRT. While 75% of patients had a documented discussion about smoking and nicotine use, not all included NRT options. Vaping use was poorly documented, and most patients relied solely on short-acting NRT, such as vapes and inhalators. This lack of adherence to best practice creates challenges, especially during busy on-call shifts when short acting NRT prescriptions are frequently requested. Additionally, smoking cessation discussions were not consistently revisited, and vaping use was poorly documented. The absence of structured cessation strategies, including plans for maintenance or weaning, indicates a need for clearer management of nicotine dependence.

Conclusion: This audit recommends that every patient be asked about smoking status and that electronic records be updated accordingly. This should be re-visited if not possible initially. A dual NRT regimen (nicotine patch plus a fast-acting NRT) should be initiated as soon as possible. Vaping can be used as a short-acting method but not concurrently with other short-acting options, and needs to be clearly documented. Smoking cessation discussions should be consistently documented in PHCs, and all patients starting NRT should have a documented management plan. Furthermore dual NRT therapy should be incorporated into a prescribing bundle. We recommend a follow-up audit in 4–5 months to assess improvements in adherence to dual NRT therapy and vaping reliance.

Aims: This audit aims to assess whether the anticholinergic burden is being appropriately considered in the management of patients referred with cognitive difficulties to East Hub Older Adult community mental health team.

Methods: A retrospective audit was conducted on the medical records of 49 patients referred from the Memory Assessment Clinic to the East Hub Older Adult CMHT over a one-year period. Data was collected using an audit tool that included patients with diagnosed dementia or cognitive decline, excluding those with substance abuse disorders. The primary focus was on whether anticholinergic burden (ACB) scores were assessed and whether medication regimens were optimized in line with NICE guidelines. The ACB score was calculated using acbcalc.com

Results: The audit revealed that 24% of patients with an ACB score greater than 3 had no documented evidence of an assessment of their anticholinergic burden or any medication optimization. This suggests that the East Hub Older Adult CMHT is not consistently adhering to NICE guidelines in the management of anticholinergic medications in older adults at increased risk of cognitive decline.

Conclusion: This audit highlights the need for more rigorous evaluation of anticholinergic drug use in our clinical practice to reduce the risk of cognitive decline in older adults. It underscores the importance of anticholinergic medications as a modifiable risk factor for dementia, emphasizing the need for healthcare providers to prioritize reducing anticholinergic burden in this population. The findings suggest that alternative medications should be considered for patients with high anticholinergic burden. These results were disseminated Trust-wide, with a plan to conduct re-audit to evaluate whether changes have been implemented in our clinical practice.

An advanced tool to calculate the ACB score using medichec.com was agreed by the clinical lead of Dementia and Frailty for use in daily clinical practice by the various older adult clinical teams in BSMHFT.

Aims: To explore whether locally described ‘gold standards’ have been met for transfers of older people (over 65 years of age) from a district general hospital to inpatient psychiatric units and to generate suggestions for further quality improvement.

Following concerns raised by inpatient consultants about patient safety during transfer of care from local acute trusts to the mental health trusts, gold standards were identified in collaboration with liaison and inpatient psychiatry consultants. Based on these gold standards, a transfer checklist was developed to support psychiatric liaison and acute hospital staff in facilitating transfers. This checklist includes documentation by the acute trust to confirm that the patient is medically optimised prior to transfer, medical and nursing handover to the receiving team, attachment of relevant clinical documentation, including discharge letters and keeping patients and their next-of-kin updated.

Methods: We prospectively collected National Health Service (NHS) numbers and dates of transfer for all older people transferred from the district general hospital to inpatient psychiatric units between 1 January2024 to 30 June2024. Data was anonymised, stored in an encrypted file and accessed only on hospital computers. The audit was registered with both the acute and mental health trust. Electronic patient records (EPRs) of both trusts were reviewed retrospectively for evidence of completion of the transfer checklist.

Audit sample: Over the six-month data collection period, 42 older people were transferred from the district general hospital to inpatient psychiatric wards.

Results: For more than 90%of the patient transfers, evidence of the following documentation was present: Mental Health Act paperwork and H4 forms (36 out of 36 for whom this was required), patients being informed of transfer (40), discharge letters sent to General Practitioners (40) and confirmation of medical optimisation prior to transfer (38).

Fewer than half of the patients had evidence of National Early Warning Score (NEWS) charts (17), oral intake records (13) and Deprivation of Liberty Safeguards (DOLS) paperwork (4 out of 9 for whom this was required) being sent.

Performance in the remaining areas was variable between 50% (26) to 90% (40).

Conclusion: The transfer checklist was adhered across several areas, however key issues were identified, namely NEWS charts, oral intake and DOLS paperwork not having been sent. Audit findings will be presented to key stakeholders at the acute trust. This will be accompanied by teaching to try and improve on these issues followed by a repeat audit. Findings will also be presented to liaison service teams to agree on how to incorporate quality control of transfers into standard operating procedures.

Aims: Severe mental illness (SMI) can have a profound effect on one’s physical health. There are proven long-term effects on morbidity, mortality and total life expectancy for those living with SMI. To address this the Royal College of Psychiatrists (RCPsych) set out a standard in the publication “Standards for Inpatient Mental Health Services” that new inpatient admissions should have routine blood tests performed within 24 hours, unless they have had a recent blood test. NHFT has also adopted this view, as they have set out the same standard in “CLPr041 – Procedure for Physical Healthcare for Patients with Severe Mental Illness”. The aim of this audit was to review whether blood tests were performed within 24 hours of admission, and whether tests performed in the admission set complied with trust recommendations for physical health monitoring.

Methods: Clinical records were reviewed for all inpatients to a psychiatric hospital, including three general adult wards, two older adult wards, two child and adolescent wards, a rehabilitation ward and a low-secure forensic ward. Patients who were admitted on the days of data collection were excluded, as were those who were transferred to a psychiatric intensive care bed within 48 hours, who may have later returned to a general ward. Outcome measures observed were time from admission to initial bloods being performed, and compliance of blood requests with local recommendations.

Results: 96 patient records were reviewed. 39% of patients had a set of bloods performed within 24 hours of admission. 16% of patients did not have a set of admission bloods performed. Overall compliance with recommended admission blood investigations was 78%. The average time for admission bloods to be performed to the nearest day was 15 days for general adult wards, 2 days for child and adolescent wards, and 3 days for older adult wards.

Conclusion: This audit highlighted significant delays to patients having admission bloods performed. This could be improved by setting electronic reminders and mandatory fields in the electronic patient record to prompt clinicians to perform blood tests, or document clearly in the instance of patient refusal or procedural failure. Also, there was disparity in which tests were initially being ordered by different clinicians. Better compliance could be achieved by introducing a standardised blood test order set for new admissions, which could then be added to if clinically indicated. Results and recommendations have been escalated internally, with a subsequent quality improvement project in development to improve practice.

Aims: People with psychosis die, on average, 15–20 years earlier than the general population, with cardio-metabolic syndrome as the biggest contributor to excess mortality. Compounding this, poor concordance with antipsychotic medications is often attributed to weight gain.

In recent years, there has been rising media coverage, public awareness, and utilisation of weight loss medications such as Ozempic (semaglutide). NICE Weight Management guidelines recommend diet and lifestyle advice, followed by escalation to pharmacological management or specialist weight management services for those with a BMI over 30, or a BMI over 28 with other risk factors for cardio-metabolic syndrome. Furthermore, a 2022 systematic review showed pharmacological weight loss management to be effective in those with psychosis.

With this audit, we sought to determine the degree to which a Birmingham Early Intervention in Psychosis service was adhering to the steps laid out in the NICE Weight management guideline (NG246) during annual physical health assessments.

Methods: We assessed the documentation of all physical health assessments completed by the East Birmingham Early Intervention in Psychosis Service between August and November 2024. We then excluded any patients with a BMI under 30, providing a sample of 17 patients who would fit the criteria of the NICE Weight Management guideline. We then determined if they had previously received diet and exercise advice, if they or the clinician were concerned about their BMI, and finally if the clinician had documented advice to seek weight management support from their GP.

Results: We found that of the 17 patients with a BMI over 30, in 12 cases (71%) the patient or clinician had recorded concerns about their weight. Sixteen (94%) had been given diet and exercise advice in their most recent physical health review. Of the 12 (71%) for which concern had been documented, 6 (50%) had previously received diet and exercise advice at a previous review. Of the 17 patients with a BMI over 30, none (0%) had been directed to explore Weight Management tools beyond diet and exercise advice.

Conclusion: Patients under the care of secondary psychosis services were not advised to discuss further weight management options with their GP. Highlighting a vital missed opportunity to provide care that could have long-term impacts on patients.

This leaves us with the vital question: Could we do more to advocate for this patient group, who may not have the financial or social capital to seek the management that they are entitled to?

Aims: This is an audit that combines the audit on relapse prevention and the audit on the side effects of the depot/LAI on cycle 2 with the aim of benchmarking the compliance of the clinicians’ current clinical practice compared with the POMH-UK and NICE CG178.

Methods: The audit was completed with a retrospective electronic medical note review between Oct 2023 and Oct 2024, including patients who were above 65 and currently on depot/LAI. Total of 61 patients were identified, but only 59 patients were included (1 deceased and 1 duplication excluded). The audit was completed using pre-designed questionnaires based on POMH-UK (relapse prevention) and NICE CG 178 (side effect).

Results: For relapse prevention, most of the data from cycle 2 showed improvement compared with cycle 1, where the care plan included a crisis plan (89.7%); a plan to respond when defaulting from treatment (34.3%); the review of the therapeutic responses of the depot/LAI (90.7%); and involving patients in generating their own care plan (89.7%).

There were decrease in the percentage of accessibility of the care plan in the clinical record (98.3%), documentation of the relapse “signature” signs and symptoms (39.7%), and the annual review by the prescribing team (72.9%). The lack of documentation might be contributing to the low percentage for the review of relapse “signature” signs and symptoms.

Cycle 2 is a pan trust audit, which might have impacted the decrease in the percentage of the above questions, whereas the improvement in the small percentage also reflected the significant improvement of the clinical practice since cycle 1.

For the depot/LAI medications side effects assessment, there were minimal increases in the assessment of side effects over the last 12 months (76.2%). However, there was a decrease in the percentage where the side effects were identified and followed by the change of plan (90%). The one patient who did not have the changed plan was struggling with the side effects of sedation. The common side effect identified from this audit was EPSE (extrapyramidal side effect).

Conclusion: Although we are not achieving 100% on each component, there is evidence of improvement in good clinical practice as shown in the result compared with cycle 1.

There is still work that needs to be done in order to address the improvement of both completing and documenting the annual review of the care plan and side effects of the patients who are on depot/LAI antipsychotic medications.

Aims: Care plans can be integral to community psychiatric services to evidence personalised care through shared decision-making. Black Country Healthcare NHS Foundation Trust (BCHFT) guidelines require a documented care plan for each patient, outlining their needs, goals and preferences. Additionally, the GMC advises doctors to keep contemporaneous records for children and young people. This maintains clarity with the patient, their family, GP, and the wider multidisciplinary team.

This audit aimed to evaluate whether doctors’ care plans at Sandwell CAMHS aligned with BCHFT guidelines, providing insight into their quality and completeness.

Methods: From the doctors’ caseloads, 40 patients aged 18 and under were selected using a randomised generator. The data was collected retrospectively by reviewing the most recent outpatient clinic letters on electronic patient records from the past 12 months. The focus was identifying whether 5 key criteria from the local guidelines were covered in the care plans: ‘My Medication and Treatment’ (including psychological therapies); ‘My Education/training’; ‘My Physical Health’; and ‘When I Need Urgent Support’.

Results: The majority of care plans included medication information (79%) when relevant, demonstrating good adherence to local guidelines. However, only few care plans included documentation of physical health considerations (36%) and crisis planning (20%). 15% of letters did not have a clear ‘Care Plan’ subheading.

Conclusion: Care plans at Sandwell CAHMS do not currently fully comply with local guidelines across 5 criteria. Although care plans are by nature individualised, and hence subjective, we suggest implementing a standardised template for clinic letters that doctors could adjust according to the patient context. A specific subtitled section ‘Care Plan’ would help to make information clearer for the patient and other healthcare professionals. Local crisis contacts and safety netting information could be included as standard on every clinic letter. Re-audit following implementation of these recommendations will complete the audit cycle.

Aims: This re-audit assessed whether Barnet’s Service for Children and Adolescents with Neurodevelopmental disorders (SCAN) prescribing practices are in line with the National Institute for Care and Excellence (NICE) guidelines and the “Stopping Overuse of Medication in People with Learning Disability, Autism or both” (STOMP) and “Supporting Treatment and Appropriate Medication in Paediatrics” (STAMP) pledge. It also looked at whether psychotropic prescribing practices changed following the introduction of Positive Behavioural Support (PBS) Workshops in SCAN.

Methods: The sample consisted of 161 patients attending Barnet SCAN, Holly Oak Unit in Edgware Hospital as from January 2025. Electronic Patient Records via Rio were reviewed with data gathered on presence of LD and/or neurodevelopmental disorder, comorbid mental illness, documented use of therapeutic interventions and psychotropic medication prescribed.

Results: 88 out of 161 children and adolescents (55%) were on psychiatric medication. 48 of the children on psychotropic medication (55%) had a diagnosis of Attention Deficit Hyperactivity Disorder (ADHD), whilst 68 had a diagnosis of Autism Spectrum Disorder (ASD) (77%). 40 children (45%) had a diagnosis of both ADHD and ASD.

The number of clients offered therapeutic interventions increased from 50% to 91%. There was a higher number of young people prescribed psychotropics despite a rise in nonpharmacological interventions (19% in 2020 vs 24%).

Conclusion: The rise in use of psychotropic medication could be secondary to the increasing acuity and complexity of cases presenting to the SCAN team post COVID pandemic. The initial audit took place during lockdown, during which fewer cases were being seen by mental health services. COVID-19 had a profound negative impact on children’s mental health, behaviour, social skills and learning overall.

SCAN is working on pursuing further training in other therapeutic modalities including the ‘Intensive Interaction’ Course. SCAN will also continue promoting PBS through parenting programmes, individual sessions and psychoeducation.

Aims: The transfer of care from CAMHS to AMHS is often poorly managed which is distressing for young people and their families. The implications of poor transition include disengagement from services and deterioration in young people’s mental health.

In Devon Partnership NHS Trust (DPT) the transfer of care standard operating procedure (SOP) outlines 8 core standards of transition including clarification of clinical responsibilities, proposed timelines for task completion and documentation requirements. This audit compared DPT patient data against these core standards.

We aimed for 100% compliance between current practice in the transfer of care of patients from CAMHS to AMHS in North Devon and the recommended practice laid out in DPT’s SOP.

Methods: Data was collected via retrospective review of electronic patient notes of 51 young people aged 18–25 years old that presented to North Devon Liaison or Home Treatment Teams between 01/05/2024–01/08/2024.

28 participants (55% of the original cohort) were formerly known to CAMHS. 12 participants (43% of the former CAMHS sub-cohort) underwent transfer of care to AMHS. Data was collected on these 12 participants comparing case notes to SOP transition standards.

Results: There were evident strengths of current transition practices demonstrated by 100% of CAMHS specialist service users at the time of transition securing AMHS input and 57% of those referred for transition were issued a care plan with a defined exit from CAMHS.

Weaker areas included only 14% of young people receiving explanation as to why services could not be offered and only 14% were allocated a doctor with medical responsibility on transfer. There was a disappointing lack of collaboration between services as only 29% had a documented joint meeting between CAMHS and AMHS.

Conclusion: There is certainly room for improvement in current transfer of care practices in DPT. Hopefully this audit generates discussions and reconsideration of current practices to initiate change at which point a re-audit could be conducted. Ultimately it is hoped to improve the level of care for young people at a vulnerable time of change in their care provision between CAMHS and AMHS.

Aims: Delirium is an acute confusional state, characterised by impacting the affected individual’s cognition and consciousness level to varying degrees over the course of an episode. Certain patient populations are more vulnerable to its development, of which the elderly are at particular risk. There are many factors that both predispose to and perpetuate a delirium, including having experienced it before. Not only does experiencing delirium once increase an individual’s risk of experiencing it again, but it also increases the risk of developing progressive, terminal cognitive conditions such as dementia. Strong associations between delirium and increase in overall morbidity have also been confirmed in recent literature.

Despite this, recognition and documentation of inpatient delirium still has room to improve. There is ongoing investigation into the recognition, documentation and appropriate investigation/monitoring of delirium at my clinical base, Friarage Hospital (Northallerton), which is reflected both regionally and nationally. Even when delirium is diagnosed, monitored and investigated with the input of the psychiatry team, the documentation in the discharge letters from the ward often does not reflect this part of the patient experience: compromising vital opportunity for pattern recognition and early intervention.

Aims were: To determine the consistency in documentation of delirium in elderly patients who have had psychiatric involvement whilst admitted.

To advocate for awareness of inpatient delirium as a predictor for morbidity, specifically:

1. Further episodes of delirium on subsequent admissions.

2. Development of chronic cognitive conditions, such as dementia.

Methods: Retrospective analysis of all patients discharged from the medical wards at FHN in November 2024, with the following inclusion criteria:

Over the age of 65 years old.

Admitted for an organic illness to medical ward in Friarage Hospital, Northallerton.

Referred to psychiatric liaison services during inpatient stay.

Discharge letter completed by ward upon completion of inpatient stay.

The appropriate patient population was pulled from Liaison Team records of patient reviews. This was a total of 60 patients in the month of November 2024.

The documentation of the respective patients’ inpatient stays was reviewed, using Miya and Patientrack for any mention of delirium or its varying presentations (confusion/agitation/aggression). Their discharge letters were then reviewed for any corresponding acknowledgement of this condition.

Results: 38 patients fit the inclusion criteria (above) in November 2024. When reviewing the Miya profiles of the selected patients, it was documented that 22 of these 38 (58%) experienced delirium during their inpatient stay.

Of those who experienced delirium, 13 (59%) had documentation of this in their final discharge letters. The remaining 9 patients (41%) had no mention of delirium OR its various presentations (confusion/agitation/aggression) in their final discharge letters.

The population was taken from all inpatient medical wards in the Friarage Hospital, Northallerton. This included the CDU (Clinical Decisions Unit) and the UTC (Urgent Treatment Centre), as well as the following wards: Romanby, Ainderby, Rutson.

In terms of patient location, the following was noted: 8 of the 22 patients with documentation of delirium were discharged from Romanby ward, 6 from Ainderby, 1 from Rutson, and 7 from CDU/UTC. The breakdown in documentation consistency was as follows:

Out of the 8 discharged from Romanby, 2 (25%) had appropriate documentation and 6 (75%) did not have documentation in their discharge letters.

Out of the 6 discharged from Ainderby, 5 (83%) had appropriate documentation and 1 (17%) did not have documentation in their discharge letters.

The single patient discharged from Rutson did not have documentation in their discharge letter.

Out of the 7 discharged from CDU and UTC, 6 (86%) had appropriate documentation and 1 (14%) did not have documentation in their discharge letters.

Conclusion: Understand that this is the patient population wherein the diagnosis of delirium is taken for granted, as it was recognised and investigated, with referrals made to psychiatry for management. There is likely a larger patient population who have experienced delirium as an inpatient: those who may not have been referred for psychiatric assessment or even been noted to have delirium.

Having aimed to assess the consistency of the existing documentation, there is hope that – by working backwards – can move to improve documentation of known cases initially and ultimately increase awareness and recognition of the condition in those who otherwise would not have been assessed. There is exciting potential in broadening the scope of this audit to cover all medical admissions.

Actions prior to re-audit (projected to be March 2025):

Education for ward staff in importance of including delirium/dementia in discharge summaries:

Teaching session for Foundation Year doctors in regards to documentation in discharges.

Informational posters on wards from 08/01/25.

Encourage documentation of previous episodes of delirium upon clerking (as other comorbidities are documented in ‘Problems’ section), even if patient doesn’t immediately present as confused.

In the small population audited, results demonstrated that only a slim majority (59%) of patients who required psychiatric input for their delirium had this documented in their medical discharge letters.

We hope to re-audit in March 2025 (as a retrospective of discharges in February 2025), giving minimum of 1 month to assess for change to practice.

Aims: In August 2023 the Trust-wide standard operating procedure (SOP) titled ‘Prevention and Management of Venous Thromboembolism (VTE) for inpatients within Mersey care foundation trust (MCFT)’ was developed. The purpose for this was to explain the procedure to be followed for assessing and managing VTE in inpatient (IP) services as it is a common and potentially preventable problem. NICE Guidance recommends that all service users admitted to any hospital should receive a VTE risk assessment and prophylaxis where appropriate.

In secure settings, catatonia, use of supportive holds and sedation can be associated with reduced mobility and increased risk of VTE. Therefore the policy was updated to allow for use in Secure Divisions within MCFT as well.

The aims of this audit was to: critique the audit to ensure it is fit for purpose for trust-wide use and identify any shortfalls in the practice and if required to rectify these.

Methods: A VTE audit tool was initially designed on Trust AMAT software for Mental Health IP wards to complete, this was later adapted to reflect Secure IP. The tool assessed whether VTE was assessed appropriately during the total time of their admission as well as during the trigger points set out in the SOP.

All patients in one team on Birkdale ward were included: this was 8 in total.

Results: The overall compliance level was 0% which is extremely poor. 68% of patients were appropriately assessed during all trigger points in their admission however 38% were not and required an up-to-date VTE assessment.

Conclusion: As part of critiquing the audit tool, as mentioned before changes were made to questions in order to reflect the long-term admissions that patients can experience in secure settings. Due to this a time frame for data collection needed to be defined as using the total admission length was not viable.

In order to improve practice, all patients who required an up to date VTE assessment received one and the SOP was disseminated to the ward staff to increase awareness of what current practice is meant to be.

However many concerns were raised about applicability and effe ctiveness of the current SOP, both in acute and secure IP settings. Therefore following a discussion with the trust-wide team involved, a decision was made to amend the SOP. Following this, IP services will need to be re-audited to see if they are complaint with the new version.

Aims: Vitamin D deficiency mainly occurs due to inadequate sun exposure and a diet insufficient in vitamin D sources. Patients undergoing rehabilitation as an inpatient have long admissions that could last years. The evidence has suggested that vitamin D deficiency is commonly observed in psychiatric inpatients and is linked to a variety of psychiatric disorders.

Aims were to evaluate the prevalence of vitamin D deficiency in a psychiatry rehabilitation unit.

To establish the treatment compliance with the current available guidance – Local Trusts and Public Health.

Methods: This is a re-audit of the original done in 2023 to close the loop. Data was collected for patients admitted to the psychiatric rehabilitation unit over a 3-month period in 2024. Blood tests were reviewed using the I-Lab, and treatment records were reviewed through WellSky. The data was then compared with regional standards set by the LPT (Leicestershire Partnership Trust).

Results: An audit conducted in 2023 involving 38 patients revealed that 5 patients (13%) had vitamin D deficiency, none of whom received replacement. Additionally, 23 patients (60.5%) out of the total 38 were administered vitamin D maintenance therapy.

A re-audit conducted in 2024, which included 35 patients, found that 3 patients (8.5%) had vitamin D deficiency, defined as a serum level below 25 nmol/L. Of those with deficiency, only 1 patient received a vitamin D replacement. Overall, 14 patients (40%) of the 35 were prescribed vitamin D supplements.

Guidelines: LPT guidance:

All mental health and learning disability inpatients to have vitamin D levels checked on admission and then annually.

Patients should be treated with standardised vitamin D replacement as needed.

All long-term (more than 3 months) inpatients should be prescribed 400 units (10 mcg) daily.

Public Health England (PHE) is advising that 10 micrograms of vitamin D are needed daily to help keep healthy bones, and muscles particularly in in autumn and winter (21 July 2016).

Conclusion: The earlier mentioned guidelines advise that everyone should take vitamin D supplements. However, only 40% of the patients in the re-audit were receiving the recommended supplementation.

Vitamin D deficiency is commonly observed in psychiatric patients, particularly in rehabilitation settings, due to limited sun exposure. Timely identification and treatment of vitamin D deficiency have the potential to improve patients’ mental health and prevent further deterioration of psychiatric symptoms.

Aims: To understand the number of men of childbearing age that are prescribed valproate on the inpatient wards in GMMH.

The number of men who are advised about the reproductive safety of valproate.

The number of men who have consented to valproate following discussion around the reproductive issues and have a risk assessment completed.

Methods: Attaining patients’ details was initially done by communicating with lead pharmacists in every ward, to help with the data collection, in line with collecting data available also on PARIS system, EPMA the electronic prescribing system, having the information about patients’ prescriptions, doses, ward, ward capacity, consent, and start date of the prescription, has been done through patient notes on PARIS system, going through the notes for the last 20 years to ensure having all the information needed, and searching for every needed information with more than keyword, for example:

Deep searching for the notes for the valproic acid by the word (Valproate, Valproic, Epilim, Depakote, Epistena, Convulex, Sodium Valproate).

Deep searching for the notes if the patient was informed on Contraception and potential teratogenic harm by the words (Contraception, Birth, Teratogenic, PREVENT, informed).

Results: A considerable number and percentage of inpatient males, around 16%, aged between 18 and 55 years, are prescribed valproate.

The main rationale/indication behind the prescribing was as a mood stabilizing agent.

There was no evidence on the notes, or forms on the system, that any of the patients were advised regarding its reproductive side effects and long-term safety.

There was no evidence on the notes, or forms on the system, that any of the patients discussed the reproductive side effects or filled out a risk form for valproate before taking it.

Conclusion: The results show that the current prescribing of valproate for male inpatients within GMMH on 8 May 2024 does not meet the MHRA guidance.

There was no documented evidence that any of the males prescribed valproate were informed of the risks associated with reproductive safety or had received the patient information leaflet or had a risk assessment completed or had a review date set.

Given the current and updated MHRA guidance, as of Jan 2024, GMMH needs to implement measures at pace to improve the prescribing practices associated with valproate in males.

Aims: Assess whether antipsychotics were prescribed according to MHRA (2021) and NICE (2023) guidelines.

Identify areas requiring improvement in clinical practice.

Methods: Retrospective case audit of older adults (65+ years) referred to Liaison Psychiatry at Chesterfield Royal Hospital for confusion/delirium between 01/08/2023–31/05/2024.

Data was extracted from patient records and analysed in Microsoft Excel. Ethical approval obtained from Derbyshire Healthcare NHS Foundation Trust (26/04/2024).

Results: Haloperidol was the most used antipsychotic (65.38%). Lorazepam (4 cases) or no medication (1 case) was used instead when contraindications were present.

Antipsychotic use was predominantly guided by clinical presentation, with most cases aligning with best practice recommendations. Patients who did not receive haloperidol had documented contraindications, emphasising appropriate clinical decision-making.

100% of patients who received antipsychotics had documented distress or risk to self/others.

•Baseline ECG compliance was suboptimal (47.06%), highlighting an area for improvement. Repeated ECG monitoring after dose escalation was infrequent (5.88%), indicating a gap in guideline adherence. Some documentation gaps may have contributed to apparent non-compliance.

Conclusion: The assessments done by Liaison Psychiatry team were mainly compliant with the standards provided by the MHRA and NICE. Most patients (65.38%) who received an antipsychotic were prescribed haloperidol as per NICE guidelines. It was clearly documented in the medical records for all patients that their presentation was a possible risk to others or themselves. Compliance to ECG requirement and recording previous ECG were weaker; though, it is important to acknowledge that in some instances, severe patient agitation made obtaining an ECG challenging. It was felt that the urgency of situation, patient’s level of agitation and distress caused to other ward patients were the most common causes that prompted Liaison team and Acute Trust staff to prescribe haloperidol without first obtaining an ECG. It is also important to consider the possibility that lower compliance might be related to lack of documentation rather than ECG not being done.

Recommendations:

Ensure ECG is performed and documented before prescribing antipsychotics.

Record reasons if ECG is not feasible due to patient agitation.

Repeat ECG after every dose increase to monitor QTc prolongation.

Liaison team nurses to receive ECG interpretation training.

Poster to remind staff to ask for and document ECG.

Create and distribute a guideline summary to the team.

Explore feasibility of including ECG specific reminder in the new core assessment/letter template (e.g. prompt).

Aims: This audit aims to assess the prescribing practices of benzodiazepines and hypnotics within the Heddfan inpatient psychiatric unit. These medications are effective in managing acute anxiety, agitation, and insomnia; however, they carry significant risks, including dependency, cognitive impairment, and an increased likelihood of falls.

This audit seeks to identify prescribing patterns, evaluate compliance with established guidelines, and suggest recommendations to enhance clinical usage, in light of the significant prevalence of their use and misuse as indicated by recent data.

The aims are as follows:

1. Evaluate the prevalence and patterns of benzodiazepine and hypnotic prescribing in psychiatric inpatient settings.

2. Assess adherence to national guidelines, including treatment duration and dosage limits.

3. Identify factors contributing to misuse or overprescribing, such as prolonged PRN use or multiple concomitant prescriptions.

4. Provide evidence-based recommendations to enhance patient safety and prescribing practices.

Methods: The audit will involve a retrospective review of medical records over a month in the Heddfan Psychiatric Unit. Data will be collected and analysed to evaluate prescribing patterns, including:

Frequency of benzodiazepine and hypnotic prescriptions.

Duration and dosages of treatment.

Documentation of prescribing rationale and adherence to guidelines.

Data Collection: The following data points were collected:

Patient demographics (age, gender, diagnosis, and length of stay).

Type of benzodiazepine or hypnotic prescribed (e.g. lorazepam, zolpidem).

Dosage and duration of each prescription.

Indication for use (e.g. agitation, insomnia, anxiety).

Use of multiple benzodiazepines or hypnotics simultaneously.

Adverse events reported during treatment (e.g. falls, agitation).

Discharge plans, including tapering schedules or withdrawal strategies.

Results: Of the total sample observed, out of the 40 patients, 38 were prescribed PRN benzodiazepines. The indication was agitation in about 18 and anxiety in the other 20.

Most patients studied were commenced on lorazepam (35 of 38; 92%) while the rest received diazepam (3 of 38).

Out of the 38 patients, only 12 were reviewed for PRN medication in a week. Only one patient had their PRN medicines stopped while exactly half continued receiving PRN benzodiazepine for more than 3 weeks. 28 patients out of 38 were written up for a maximum dose of up to 4 mg per day. 2 patients received 8 mg and one patient received 15 mg diazepam.

50% (20) of patients received zopiclone as a secondary sedative of which 66% (8) continued for 3 weeks or more than 3 weeks.

Of the total 20 patients, 3 (15%) were on regular benzodiazepine of which 2 received diazepam and 1 received zopiclone.

The most common concurrent antidepressant prescribed was sertraline, closely followed by mirtazapine. Among antipsychotics, there was an equal prescription of regular olanzapine, quetiapine and aripiprazole.

Of the total sample, 27.5% (11 patients) were already on regular benzodiazepine, of which 4 were receiving diazepam, followed by 3 receiving temazepam and 1 was on clonazepam.

Conclusion: Our recommendations from this audit are as follows:

Enhanced training for prescribers on guideline adherence.

Increased involvement of pharmacists in monitoring and auditing prescriptions.

Development of standardized protocols for prescribing and tapering benzodiazepines and hypnotics.

Promotion of non-pharmacological alternatives to manage agitation and insomnia.

We will be liaising with the pharmacist to generate a protocol for weekly reviews during ward rounds and to make a protocol for reducing PRN medications and stopping them, both while in the inpatient unit and at discharge.

Aims: The National Institute for Health and Care Excellence (NICE) recommends that individuals aged 18–25 or those at increased risk of suicide should be reviewed within one week of initiating or increasing a selective serotonin reuptake inhibitor (SSRI) dose. This study aimed to assess compliance with these guidelines in primary care, identify barriers to timely reviews, and evaluate changes following a previous audit.

Methods: A retrospective review was conducted using SystmOne to identify patients aged 18–25 who started an SSRI between 1 December 2023 and 15 July 2024 in a Nottingham GP surgery. Data collected included the time from SSRI initiation to a booked and completed review, as well as instances of non-attendance (DNA). Findings were compared with a prior audit (1 August–24 November 2023) to assess improvements and ongoing challenges. Following the first audit cycle, results were shared and discussed within the practice, prompting greater awareness from all members of the multidisciplinary team (MDT) upon current guidance and performance.

Results: In the initial audit, none of the 21 eligible patients had a review booked within one week, with an average booking time of 20 days and 30 days to an actual review. In the re-audit, 36 eligible patients were identified, with a slight improvement in booking time (19 days) and review completion (23 days). Three patients (8.3%) had a review scheduled within the recommended one-week timeframe.

The main barrier remained appointment availability, with a shortage of GP slots limiting one-week follow-ups. High DNA rates persisted, with 14 patients missing their reviews in the re-audit. No standardised approach to DNAs was implemented, with some patients receiving multiple recall attempts and medication re-issues, while others had no further action documented.

Conclusion: Over this one-year period, noticeable improvements were observed in both booked and actual SSRI review times. However, most patients still did not receive a timely review. Limited appointment availability and inconsistent follow-up for DNAs remained significant challenges. Expanding the role of other healthcare professionals, such as pharmacists, to conduct initial medication reviews could improve guideline compliance and reduce GP workload. Establishing a standardised protocol for DNAs, ensuring a set emergency medication supply and a timely follow-up, is essential to improving patient safety and treatment outcomes.

Aims: To identify any patients on OST who have not been offered or received naloxone.

To improve documentation of naloxone provision.

To explore reasons why clients have declined naloxone.

The standard audited against was that 100% of clients prescribed OST should be offered naloxone. This is advised in the Department of Health publication “Drug misuse and dependence, UK guidelines on clinical management”, which advises services should be “offering all opiate users in the community access to a take-home supply of naloxone with instructions on its use”.

CGL is a charity which provides medical and psychosocial support for people who are affected by alcohol and drugs. As of January 2025, they prescribe Opiate Substitute Treatment (OST), typically a formulation of methadone or buprenorphine, to 748 clients in East Sussex. Naloxone is an opioid antagonist which can reverse the effects of opiate overdose, and is offered to service users to reduce mortality from overdose.

Methods: It was recorded for each of the 748 clients whether they had been offered naloxone and training, and whether they had accepted. The data were collected from the CGL County-wide Opiate report in January 2025, and cross-referenced with a manual review of notes on Criis, the electronic clinical notes platform used by CGL.

Results: Of the 748 clients prescribed OST, 65 total clients did not have naloxone (8.7%), while 60 had expired naloxone. 54 clients did not have naloxone documented in the opiate report, but on a manual review of notes it was confirmed to have been given, but the dispensing form had not been completed on Criis. Of the 65 clients without naloxone, 100% had been offered naloxone and had declined.

Conclusion: The manual review of notes showed that naloxone uptake was better than the opiate report suggested, due to a lack of coding. Most commonly, this was a result of clients already having naloxone from another service or from earlier course of treatment. A potential barrier is the data entry required – if a client was dispensed from another location, it must also be confirmed by the keyworker and manually entered into a form on Criis.

The keyworkers of those clients with expired naloxone were informed, to arrange suitable follow-up.

The most common reason for declining naloxone was that the client was no longer injecting, and had no contacts who used opiates (57%). Also mentioned was the stigma of carrying naloxone, and the fear that others would assume they had relapsed.

Aims: This audit aims to assess adherence to the ‘CRAMS’ criteria in clinical records for patients on a blended low/medium secure women’s forensic ward. In response to feedback from a CQC Mental Health Act Review that some daily entries in patient notes included insufficient detail to properly inform decisions on care (particularly with regard to qualitative information regarding leave), the service adopted the CRAMS criteria for these entries, which specify that information on 11 points relating to care plan, risk, activity, mental state, and Section 17 leave should be included.

Methods: Data were collected from daily electronic patient record entries for ten randomly selected patients on two different weeks – in total 140 entries were examined in this initial sample. Each of these entries was assessed to determine if it contained each of the 11 aspects of the CRAMS criteria.

Following the initial data collection, findings were disseminated and discussed with the team, an information sheet was produced, and CRAMS was discussed at daily team huddles with the aim of improving adherence. A further sample of 140 records was examined a year following the initial cycle, using the same methodology.

Results: The initial cycle of the audit found that from the 140 clinical note entries that were examined, a total of 814/1540 (52.9%) of CRAMS criteria were met. This included:

212/420 (50.5%) criteria pertaining to care planning.

99/140 (70.7%) criteria pertaining to risk.

153/280 (54.6%) criteria pertaining to activity undertaken.

209/420 (49.8%) criteria pertaining to mental state.

141/280 (50.3%) criteria pertaining to S17 leave.

The second cycle of the audit found that a total of 1120/1540 (71.6%) of CRAMS criteria were met. This included:

305/420 (72.6%) criteria pertaining to care planning.

105/140 (75.0%) criteria pertaining to risk.

198/280 (70.7%) criteria pertaining to activity undertaken.

296/420 (70.5%) criteria pertaining to mental state.

198/280 (70.7%) criteria pertaining to S17 leave.

Conclusion: The audit showed a significant improvement in adherence to the CRAMS criteria following the action plan enacted following the initial cycle. However, there were still numerous entries in which the full CRAMS criteria were not met. The ward team continues to discuss CRAMS as part of morning briefings to sustain and build upon this improvement, and the adoption of an electronic template to help further build on this once the Trust moves to a new electronic patient record system has been discussed.

Aims: To ensure adequate availability and stocking of benzodiazepines on the wards for management of status epilepticus.

To ensure ward staff can locate treatment for status epilepticus during a medical emergency.

To ensure current ward staff are up to date with local ALS guidelines on status epilepticus.

Methods: Three general adult wards, two old age wards, and one intensive psychiatric care unit were audited. Two cardiac arrest packs were also audited as these are part of the cardiac arrest team protocol in Woodland View Hospital. Ward and pack audits occurred at random, and wards were not informed prior. Each ward was checked for medication availability, dosage available and expiration date.

Benzodiazepines were checked for as per the ALS guidelines; this included lorazepam, diazepam, and midazolam. These preparations were intravenous lorazepam 2–4 mg, rectal diazepam 10 mg, and buccal midazolam 10 mg.

Following the first cycle of data collection, a questionnaire was distributed to the ward team to identify gaps in ward knowledge of benzodiazepine location on the ward and status epilepticus management.

The intervention was a teaching session which was held with the ward staff to help improve staff confidence with identifying status epilepticus, medications, as well as timely management of seizures on the wards.

A second cycle of data collection and questionnaires was completed.

Results: The results showed that intravenous medications (lorazepam) are not regularly supplied at Woodland View. This was due to lack of IV training amongst the nursing staff.

All wards (100%) were adequately stocked with a supply of rectal diazepam which was the correct dose and in date. Buccal midazolam was only available in two (33%) of the six wards audited. The emergency packs had two preparation options of either midazolam or diazepam which were both in date with the correct dosing.

Following the intervention of staff education, ward staff self-reported that they felt more comfortable with identifying a seizure and locating medications in a timely fashion. There was a 50% self-reported improvement in staff’s ability to identify the medications required for seizure management and a 19.5% self-reported improvement in staff’s confidence of locating medications.

Conclusion: This audit demonstrated that first-line benzodiazepines for the treatment of status epilepticus are available on all wards in at least one preparation. It highlighted the need for staff education about these preparations and their location on the wards. Staff self-reported an improvement in their confidence and knowledge of status epilepticus following the intervention.