People with intellectual disability have a higher risk of developing dementia, yet assessment and diagnostic pathways can vary across services and regions. This service evaluation aims to evaluate how dementia referrals for people with intellectual disability are processed within Mental Health of Learning Disability (MHLD) services across Kent and identify opportunities to standardise referral and care pathways.

A retrospective review was conducted of all referrals received by MHLD services in Kent from June 2022 to May 2023. Referrals were included if they contained themes suggestive of cognitive decline: changes in memory or function, forgetfulness, and confusion. Data were collected on referral source, demographics, reason for referral, acceptance or refusal, assessing discipline, follow-up plans, diagnoses at initial assessment and at 3 months. Referrals were analysed by region.

A total of 47 referrals met inclusion criteria. Acceptance rates varied by region and accepted referrals were younger on average than refused referrals across all regions. Down’s syndrome was present in a substantial proportion of accepted cases. Regional variation was observed in diagnostic pathways. Initiation of medication for dementia varied by clinician with consultants more likely to commence treatment than trainees.

This evaluation highlighted regional variation in diagnostic pathways for people with intellectual disability and suspected dementia. The variation suggests a need for a standardised dementia referral and diagnostic pathway, guidance on in-house diagnosis, enhanced training for clinicians and allocation of wider resources to improve equity, efficiency and quality of care.

Complex psychosis, characterised by severe, treatment-resistant psychosis with associated functional impairment, is one of the most challenging conditions to manage in psychiatric practice. Evidence-based guidelines recommend clozapine for treatment-resistant psychosis, though in practice less than 1/3 of potentially eligible patients receive clozapine in a timely manner. The Complex Psychosis Service (CPS) was established in Kent in 2022, with the goal of providing a specialist multi-disciplinary opinion to clinicians for the management of patients with complex psychosis.

This paper aims to describe our model for developing and implementing this new consultation service for complex psychosis in Kent and Medway Mental Health NHS Trust. We aim to describe the clinical characteristics of individuals referred to CPS, treatment recommendations made, rates of uptake, and staff experiences of the service.

Retrospective data was collected on the number of referrals to CPS from its inception in December 2022 to September 2024. Data was collected on several measures including primary psychiatric diagnosis, comorbid mental disorders and prior antipsychotic treatment, including whether clozapine had been trialled in the past. Questionnaire data was collected from referrers, and qualitative experiences explored through semi-structured interviews with six referrers and discussions with the CPS team.

62 referrals were made to CPS during this time period. The most common primary diagnoses were treatment-resistant schizophrenia (n=29) and schizoaffective disorder (n=19), and 26 had another comorbid mental disorder, most frequently mood disorder (n=7) and personality disorder (n=5). Patients had a mean of 5.7 prior inpatient admissions and average of 6.2 antipsychotic trials. 18 patients had never tried clozapine despite treatment-resistance. CPS recommendations proposed trials of clozapine (n=12), augmentation with other psychotropics (n=16), ECT augmenting clozapine (n=5), and non-pharmacological interventions including psychology and occupational therapy.

56% of referrers implemented the recommendations and 90% reported high levels of satisfaction with the service provided by CPS. However, some referrers felt limited by CPS often not reviewing patients face-to-face. Qualitative data indicated that referrers valued the specialist input and expertise, and Psychiatry trainee doctors felt that working in CPS offered a rich educational experience.

Individuals referred to CPS primarily had schizophrenia-spectrum illness with treatment-resistance, with significant burden from untreated symptoms. Input from the CPS multi-disciplinary team was well-received by referrers, and there were high levels of satisfaction both from referrers and CPS clinicians. Future directions to expand CPS would include specialist psychology input, and potentially inpatient beds on a specialist unit to increase the uptake of treatment recommendations.

The National Institute for Health and Care Excellence (NICE) and local prescribing guidance recommend that, after titration and dose stabilisation, prescribing and monitoring of Attention Deficit Hyperactivity Disorder (ADHD) medication should be carried out under shared care arrangements with primary care. In practice, shared care requests are accepted to varying degrees, thereby increasing service burden for secondary care.

We aimed to estimate the current acceptance rate of shared care requests for ADHD medications in Hull and the East Riding, explore factors influencing uptake, and recommend improvements to shared care arrangements with primary care.

A retrospective exploratory audit was conducted using electronic patient records from the Children and Young People’s Neurodevelopmental Service.

The data capture period was from 01/07/2025 to 01/09/2025. The audit included a consecutive sample of all patients identified.

The patient’s ADHD medication, shared care request, outcome, and reasons for prescription decisions, despite a shared care agreement, were recorded in an Excel spreadsheet. Data were collected retrospectively in December 2025.

Of 114 patients identified, 62 (55%) had shared care requests, 50 (45%) had none, and 2 were not medicated. Of the 62 patients who had shared care requests, 43 (69%) were accepted, 13 (21%) received no response, and 6 (10%) were declined. 4 of the 6 patients whose shared care protocol was declined are from the same General Practitioner (GP) Practice, which cited local prescribing guidelines for declining to prescribe or monitor methylphenidate. There was no clear documentation regarding prescribing decisions despite a shared care agreement in place. Prescribing commonly followed dose changes, formulation changes, or drug holidays. 2 patients were still undergoing titration.

Shared care uptake in primary care could be improved primarily by increasing the rate and timeliness of requests from secondary care, implementing systematic follow-up, and targeting engagement with GP practices that are not responding to or declining shared care. These recommendations, along with routine documentation of shared care status in clinic letters and a clear rationale for prescribing despite a shared care agreement, have been communicated to all prescribers in the service and other relevant stakeholders. A re-audit is planned to assess the impact of the implemented recommendations on improving uptake, facilitating easier access to medication, reducing service burden, and increasing capacity for new patients.

Acknowledgements

We thank:

Dr Syed S. M. H. Naqvi, Consultant Child and Adolescent Psychiatrist, for supervision and guidance.

Jo Allison, Nurse Prescriber, for data support.

The Medicines Reconciliation 'Med Rec' is a important, structured process which takes place on admission. It involves comparing the patient’s current medication list from various sources such as the primary care record, previous discharge letters and the patient themselves. This audit aims to highlight the invaluable support of the pharmacy department in ensuring safe prescribing for psychiatric inpatients - a population with a known potential for significant comorbid physical health conditions and high rates of polypharmacy.

NICE guidelines state that “people who are inpatients in an acute setting (including mental health inpatient wards) should have a reconciled list of their medicines within 24 hours of admission.” Sussex Partnership NHS Foundation Trust local targets specify that 60% of Level 2 (pharmacy-led) medicines reconciliations should be completed within 24 hours of admission, or 90% by the next working day by 5pm.

A total of 100 records were reviewed for patients admitted to Bodiam Ward, an adult male inpatient psychiatric ward in East Sussex, between 2024 and 2025. Of the records reviewed, 73 were retrospective admissions and 27 were prospective records.

In this audit, 66% of medicine reconciliations were completed within 24 hours, and 87% were completed by the next working day. The majority (84%) were completed by Pharmacy Technicians, with the remaining 16% completed by Pharmacists. Of the completed medicine reconciliations, 54% identified at least one omitted drug. The most omitted drug classes were analgesics (13.7%), benzodiazepines (13.1%), and regular oral antipsychotics (10.2%). Other notable omissions included physical health medications, such as cardiovascular drugs (including antihypertensives and statins), and medications related to alcohol dependence (such as thiamine and chlordiazepoxide). In addition, 7% identified ‘other errors’, including missing or incorrect doses, incorrect formulations (immediate-release versus modified-release), and in one instance, an entirely different medication being erroneously prescribed.

This audit demonstrates that medicine reconciliation is more than a 'tick-box exercise' and plays a critical role in identifying prescribing errors on admission. The findings emphasise the significant timely contribution of the pharmacy team to patient safety in adultin patient psychiatric settings. Based on these findings, future education could focus on reminding resident doctors to thoroughly review previous discharge summaries and primary care records when clerking a patient, and to liaise with the pharmacy team for a better standard of care.

Assessing risk is a fundamental skill in psychiatry, particularly for Core Trainees who are developing their skills during Out-of-Hours (OOH) shifts. However, the time pressure in these shifts often leads doctors to quickly document their admission notes without much thought for risk management. Failing to record Mental Health Act (MHA) status, leave permissions, or observation levels may create significant safety gaps and falls short of the standards set by the Mental Health (Care and Treatment) (Scotland) Act 2003. We retrospectively collected data that supported this notion and posted simple, structured posters to guide trainees in robust risk documentation. The goal was to encourage active thought processing that aligns with local risk protocols, ensuring that documentation isn't just a box-ticking exercise but a helpful guide for nursing staff. This helps empowers nurses to use their discretion in line with the admitting doctors opinion and adjust care safely as a patient's risk fluctuates on the ward.

We conducted a retrospective audit (Cycle 1, n=52) of OOH admission notes which showed only 15.4% of notes documented observation levels and 13.5% failed to mention leave status entirely. In response, we placed posters in key resident doctor work areas to act as a visual “nudge,” explicitly prompting doctors to define legal status and safety monitoring plans. A re-audit (Cycle 2, n=29) was completed one month later to see if these visual cues changed behaviour.

The second cycle showed a distinct improvement in how risk was recorded. Documentation of observation levels rose from 15.4% to 55.2%. Documentation regarding leave status also improved significantly, reaching 65.5% vs 1.9%. MHA status documentation remained roughly consistent (82.7% vs 75.9%). The rise in documenting recommended observation and leave status suggests that trainees are no longer relying on implied safety levels and are instead engaging in active risk assessment when there is a clear reminder to prompt them.

The marked increase in recording observation and leave decisions suggests that visual prompts are an effective way to remind trainees to pause and reflect on their risk assessment and how this applies to the patient’s admission journey. The posters helped convert risk assessment from an administrative afterthought into a conscious and adaptable management strategy. This simple intervention not only improves compliance but fosters a culture where active risk management is embedded into the admission process, ultimately ensuring safer handovers and better support for the nursing team.

To evaluate whether the pre-lithium workup in patients with Bipolar Affective Disorder (BPAD) initiated on lithium in Psychiatry in patient unit of Allied Hospital, Faisalabad adheres to the Maudsley prescribing guidelines in psychiatry.

This study was conducted in 2025 at a tertiary care hospital in Faisalabad, data was collected from files of 72 inpatients in psychiatry ward prescribed lithium, to check if adequate pre lithium workup was done for each patient as recommended by Maudsley prescribing guidelines. A baseline audit was followed by a faculty led presentation on guidelines, and a re audit 3 months later, in which data was observed from 86 patients files. Initial findings revealed unsatisfactory workup . Results were discussed in a departmental meeting, leading to targeted teaching session for all the residents. The reaudit showed significant improvement in workup practices prior to prescribing lithium as recommended

The initial audit revealed that only 50(69.4%) out of 72 patients had their LFTs done, 3 (4.2%) had TFTs, 14(19.4%) had ECG and None of the patients got their weight measured before prescribing lithium.

A reaudit done 3 months later showed results from 86 patients according to which there was much improvement in compliance with the guidelines as 74(86%) had their LFTs, 53 (61.6%) had TFTs, 58 (67.4%) had ECG and 33 (38.4%) had weight measured before prescribing lithium.

These findings indicate a positive staff response and significant progress in adhering to pre lithium workup guidelines

Lithium is the most effective mood stabiliser for the treatment and long-term prophylaxis of BPAD and helps in reducing relapse and suicide risk. Although it is very effective, lithium has a narrow therapeutic index and can cause range of adverse effects involving renal, thyroid, cardiovascular and metabolic systems. Therefore, it is essential to do baseline physical health assessment before initiating lithium therapy. It helps to identify pre-existing risk factors and ensures safe prescribing. Lithium can commonly cause hypothyroidism, renal impairment, weight gain and cardiac conduction abnormalities. The risk increases with longer treatment duration and cumulative exposure.

This audit demonstrated initially poor compliance with pre lithium workup as recommended by Maudsley prescribing guidelines. Rates of RFTs, TFTs, ECG and Weight measurement were very low which could have resulted in avoidable complications. Later intervention and reaudit showed much improved compliance with recommended standards. This highlights the importance of audit driven interventions leading to improvement in quality of care for patients in their best interest. Ongoing education, standardised pre-lithium checklists and regular re-auditing are recommended to ensure sustained compliance and further improvement in patient safety

Rapid tranquillisation (RT) is a high-risk intervention used in acute psychiatric settings when de-escalation strategies fail and there is an immediate risk of harm. Best-practice guidelines emphasize comprehensive pre-RT clinical assessment, documentation, and monitoring; however, adherence is often inconsistent, particularly in resource-constrained settings. This audit aimed to assess compliance with established standards for pre-RT workup and documentation and to evaluate the impact of targeted quality improvement interventions through re-audit.

This was a retrospective, episode-based audit. Forty-two RT episodes over a six-month period (January–June 2025), involving oral or parenteral psychotropic medication administered with the explicit aim of RT, were reviewed against predefined standards. These standards were derived from National Institute for Health and Care Excellence (NICE) guidance, the Maudsley Prescribing Guidelines, and British Association for Psychopharmacology/National Association of Psychiatric Intensive Care Units (BAP/NAPICU) consensus statements. Data were extracted using a structured audit tool. Following baseline analysis, quality improvement measures were implemented, including the introduction of a structured pre-RT checklist and staff education. A re-audit of 28 RT episodes was conducted six months later (July–December 2025).

Baseline compliance with pre-RT standards was variable. Documentation of de-escalation prior to RT was present in 71% of episodes, a clear clinical indication in 83%, and pre-RT clinical workup in 47%, all below target thresholds. Baseline physical observations were documented in 85% of episodes, medication details in 100%, and capacity or consent in 90%, meeting standards. Cardiac/QT risk assessment was documented in 85% of episodes involving haloperidol. However, reassessment prior to repeat dosing was documented in only 42% of episodes, airway and respiratory risk assessment in 78% of benzodiazepine-related episodes, and documentation of contraindications or drug interactions in 66%.

Following intervention, compliance improved across all domains. Documentation of de-escalation increased to 92%, clear indication to 96%, pre-RT clinical workup to 85%, reassessment prior to repeat dosing to 92%, airway and respiratory risk assessment to 92%, and documentation of contraindications to 85%. Medication safety checks, cardiac risk assessments, post-RT monitoring, senior review, and post-incident management planning met or exceeded predefined standards.

This audit identified suboptimal compliance with pre-RT documentation standards, particularly in relation to clinical workup and reassessment. Implementation of a structured checklist and staff education resulted in marked improvements across all measured domains. These findings suggest that focused, low-cost quality improvement interventions can significantly enhance patient safety and documentation standards in resource-limited inpatient psychiatric settings. Ongoing monitoring and periodic re-audit are recommended to sustain improvements.

Methamphetamine-induced psychosis (MIP) is recognised in both ICD-11 and DSM-5-TR as a substance-induced psychotic disorder which is associated with severe agitation, violence risk, and medical complications. In Pakistan, MIP presentations to inpatient addiction services have increased recently, however, data on service impact and adherence to best-practice standards remain limited. This audit aims to describe monthly trends and proportions of MIP admissions among all inpatient addiction ward admissions, and to evaluate compliance with international best-practice standards for assessment and management of MIP, in order to identify areas for quality improvement.

A mixed-method clinical audit was conducted in the inpatient addiction ward at Allied Hospital II, Faisalabad. A descriptive service-activity review examined all inpatient addiction admissions over a six-month period (01 July–31 December 2025) to quantify monthly MIP admissions. Subsequently, an admission-based case-note audit assessed consecutive MIP admissions against predefined standards derived from NICE guidance, the Maudsley Prescribing Guidelines, and international recommendations. Adults (≥18 years) admitted with a clinical diagnosis of MIP were included. Admissions with primary psychotic disorders, delirium, psychosis attributable to another substance, or incomplete documentation were excluded. Data were extracted from clinical notes using a structured audit tool.

During the audit period, 82 inpatient addiction admissions were recorded, of which 19 (23.2%) were for MIP. Monthly MIP admissions ranged from 2 to 4 cases, representing 18.2% to 33.3% of total admissions, indicating a sustained and clinically significant service burden. In the standards audit (n=19), documentation of stimulant use history (94.7%), temporal relationship between methamphetamine use and psychotic symptoms (89.5%), exclusion of delirium or medical causes (100%), baseline physical observations (94.7%), and mental state examination (94.7%) met audit targets. Prescribing details and adverse-effect documentation were complete in all cases (100%). Areas of lower compliance included objective toxicology confirmation (42.1%), baseline blood glucose measurement (52.6%), structured risk assessment (78.9%), documentation of de-escalation prior to medication (73.7%), medication safety checks for contraindications or interactions (78.9%), post-medication monitoring (84.2%), and timely reassessment following intervention (73.7%).

Methamphetamine-induced psychosis accounted for nearly one-quarter of inpatient addiction admissions over six months, highlighting a substantial and ongoing clinical burden. While core diagnostic assessment and prescribing practices were generally well documented, important gaps were identified in toxicology confirmation, metabolic screening, structured risk assessment, and post-intervention monitoring. These findings informed the development of a standardized MIP admission checklist and targeted staff education, with re-audit planned to assess the impact of these quality improvement interventions.

Suicide remains one of the leading causes of death worldwide. It kills over 700,000 people every year. The most crucial steps to prevent suicide throughout the world are the accurate identification and good recording of suicidal risk. The Columbia-Suicide Severity Rating Scale (C-SSRS) is a validated tool that is commonly recommended in the evaluation of suicidal thoughts and behaviors, but clinical practitioners are experiencing difficulties in practicing it in an effective way, especially in emergency departments and psychiatric clinics. The psychiatry residents are typically the first to be consulted, and they have an instrumental role in conducting and recording the suicide risk assessment. This clinical audit was to evaluate how properly the psychiatry residents documented their suicide risk assessments using the C-SSRS as a standard.

A retrospective clinical audit at the department of psychiatry was organized. The researchers examined the psychiatric records of adult patients seen by residents during a three-month period. A standardized audit checklist based on C-SSRS criteria was used to evaluate the documentation of suicidal ideation, suicidal behavior, intensity and frequency of thoughts, use of C-SSRS, risk stratification, protective factors, and safety planning. The reporting of ideation and behavior and the use of a structured tool were expected to be 100% according to compliance standards, while risk level and safety planning were expected to be 90%.

A total of 118 patient charts were analyzed. Most of the notes (79.7%) indicated that the patients entertained suicidal thoughts, and only 47.5% of the notes indicated that the patients attempted suicidal behavior. Only a paltry 25.4% of the hospital records included the extent or frequency of the suicidal thoughts. The application of the Columbia-Suicide Severity Rating Scale was only documented in one case, equal to 0.8%. Almost all of the cases never provided risk level, protective factors, and safety plans, standing at 2.5%, 0.8%, and 0.8%, respectively. The lack of documentation was consistent throughout all residency training levels, and it was not an experience-based problem.

The audit found that the medical records of the patients were not adequate. A validated tool to evaluate suicide death risk was not utilized. There is an urgent need to train residents, adjust the suicide evaluation, and introduce the ideas of C-SSRS into electronic records and review them regularly. Recording proper notes is a vital aspect of suicide prevention that keeps patients safe. It allows hospitals and staff to provide more effective care.

Use of amphetamines is linked to serious cardiovascular events such as tachyarrhythmias, QTc prolongation, myocardial ischemia, and even sudden death from cardiac arrest. The discontinuation of these substances will increase these risks, especially because of autonomic instability and the possibility of polypharmacy with psychotropic drugs. Although the American Heart Association (AHA) recommends using the ECG when withdrawing, there is no certainty that these procedures are followed in psychiatric withdrawal units. This audit was focused on assessing the adherence to the recommended ECG monitoring guidelines in amphetamine withdrawal inpatients and determining the gaps in the current practices that require quality improvement efforts.

A retrospective clinical audit was carried out at the Department of Psychiatry and Behavioral Sciences, Allied II Hospital, Faisalabad. A standardized checklist was used to examine the medical records of 70 inpatients admitted during a three-month time interval for amphetamine withdrawal, based on the AHA guidelines. The information was gathered, including demographic data, ECG performance, record of interpretation, repeat ECGs, and follow-up measures. The data were evaluated descriptively with Microsoft Excel, in which frequencies and percentages were computed to identify the adherence to each audit criterion.

The average age of the patients was 30.3 years (9.6), and the majority were males (97.1%). Even though all the patients confirmed taking amphetamine, only 7.1% of the patients were subjected to a baseline ECG at admission. Worryingly, none had recorded the results of ECG interpretations and QTc measurements. In addition, no repeat ECG checks or cardiac laboratory assessments were done, including the 37.1% of the patients who complained of cardiovascular symptoms. The compliance with AHA standards of monitoring was generally of low quality, which points to deep-seated flaws in the cardiac safety monitoring.

This audit has shown that there is a distressing absence of ECG checks and recording in the treatment of amphetamine withdrawal. In order to improve patient safety, it is important to introduce mandatory baseline ECG policies and staff education on the need to monitor and incorporate ECG prompts into admission workflows. It is highly advisable that a follow-up re-audit be done between 6 and 12 months after these corrective measures are put in place in order to determine how much compliance and patient outcomes have improved. With these efforts, it will be possible to protect the cardiovascular health of patients with amphetamine withdrawal symptoms in an effective way.

Electroencephalography (EEG) is frequently used within psychiatric services to support diagnostic clarification in presentations such as first-episode psychosis, suspected seizure disorders, dissociative episodes, catatonia, and complex neurodevelopmental conditions. In many low- and middle-income countries (LMICs), EEG services are embedded within psychiatry departments and support both psychiatric and neurological referrals. This audit aimed to evaluate EEG utilisation, documentation quality, and diagnostic yield within a psychiatry-led service, benchmarked against international standards, and to identify areas for quality improvement.

A retrospective service audit was conducted of all EEGs performed between 2019 and 2024 in the Department of Psychiatry and Behavioural Sciences at Allied II Hospital, Faisalabad, Pakistan. The department provides EEG services for both psychiatric and neurological referrals. Data were extracted from the departmental EEG reporting system and analysed using Python and Microsoft Excel. Variables examined included annual EEG volumes, recording duration, wake versus sleep recordings, diagnostic outcomes, and completeness of clinical documentation. Findings were benchmarked against guidance from the International Federation of Clinical Neurophysiology (IFCN), American Clinical Neurophysiology Society (ACNS), and NICE.

A total of 2,670 valid EEGs were analysed over 6 years. Annual EEG volumes remained stable, including during the Covid-19 pandemic, demonstrating sustained service delivery, with activity increasing to 503 EEGs in 2024. Overall, 13.9% (n=405) of EEGs showed abnormal findings, 85.8% (n=2,494) were normal, and 0.2% had unclear outcomes, consistent with expected diagnostic yield. Wake EEGs accounted for 69.8% of recordings, while 28.4% included sleep recordings, indicating appropriate use for paediatric and complex cases; sleep-wake state was unclear in only 1.6% (n=47). The mean EEG duration was 25.2 minutes (median 19.0 minutes, IQR 16–23 minutes) showing satisfactory adherence to standards, with some recordings below recommended minimum durations. Documentation quality was generally strong, with missing data only limited to weight 12.8%, height 4.0% and gender 0.4%

This audit demonstrates that EEG services delivered within a psychiatry-led department in an LMIC largely comply with international standards, with appropriate diagnostic yield and sustained utilisation over six years. Overall documentation quality was high, Identified areas for quality improvement include ensuring minimum recording durations, improving structured data entry, and refining referral practices to optimise diagnostic efficiency. An action plan has been implemented, with re-audit planned within 12–18 months to assess impact.

Leaving Against Medical Advice (LAMA) in psychiatric settings poses significant clinical, ethical, and legal challenges, particularly in low-resource countries like Pakistan. Inadequate documentation exacerbates risks to both patients and healthcare providers, yet compliance with institutional standards remains poorly evaluated. The aim of this audit is to assess adherence to LAMA documentation protocols and characterize the demographic and diagnostic profiles of psychiatric inpatients who left against medical advice.

A cross-sectional clinical audit was conducted from February to July 2025, reviewing all LAMA cases (n=75) in the Psychiatry Inpatient Unit of Allied II (DHQ) hospital. Data were extracted from medical records, admission/discharge registers, and LAMA documentation using a structured checklist aligned with institutional standardoperating procedures. Compliance was evaluated across five core criteria: LAMA form completion, date/time documentation, dual-signature verification, LAMA register entry, and inclusion of a treatment summary

While 73.3% of cases documented the LAMA date and time, critical medico-legal elements were missing: 0% had completed the LAMA Notification Form or LAMA Register entry, and only 13.3% included dual signatures. Physician involvement was minimal (8.0%). Most patients were male (65.3%) with a mean age of 29.1 years. Substance use disorders (24.0%) and psychotic disorders (17.3%) were the most common diagnoses. Notably, reasons for LAMA were never documented.

Profound documentation deficiencies undermine patient safety, legal protection, and quality of care. System-level interventions including standardized protocols, staff training, and structured exit interviews are urgently needed to improve LAMA management.

Discharge summaries are essential documents that promote continuity of care and patient safety and communication between inpatient and outpatient providers. They are especially important in the psychiatric setting since they need to contain accurate records of the mental status of the patient, risk evaluation, and the education of both the patient and caregiver to avoid relapses and adverse events. This audit aims at evaluating the quality of psychiatric discharge summaries in our hospital and finding out the main areas that need improvement to be used in quality improvement initiatives

This clinical audit was conducted to determine the completeness and quality of 80 discharge summaries of patients admitted to the Psychiatry Department of Allied-2 Hospital, Faisalabad, using a structured checklist based on Royal College of Physicians (RCP) guidelines, between January and June 2025. The main components were patient identifiers, diagnosis, mental state at discharge, risk assessment, treatment summary, medications, follow-up plan, counseling documentation, and legibility. The data analysis was done descriptively using frequencies and percentages, with 100 percent compliance considered the gold standard.

The degree of compliance with RCP standards was overall 47.5, which was significant. There were high scores in the elements of administrative data such as admissions and discharge dates (100), final psychiatric diagnosis (100), a review of treatment (100), discharge medications (100), and patient identifiers (98.75). Nevertheless, compliance among critical psychiatric-specific elements was very low: presenting complaint (0%), examination of mental state at discharge (0%), documented risk assessment (1.25%), patient and care giver counseling (1.25%), and typed/legible discharge summaries (0%). There were critical deficiencies in five components that had a great impact on patient safety, continuity of care, and managing risks.

A review audit should be conducted to assess the effects of this intervention and to ensure that the RCP standards are followed so that psychiatric discharge paperwork and patient outcomes are improved. The absence of documentation of the mental state examination, risk assessment, and counseling places patients at a significant safety risk. To be able to deal with these issues, electronic discharge summaries and standardized templates with mandatory psychiatric assessments, structured counseling protocols, and targeted training of personnel should be introduced.

To assess the quality of mental capacity assessments completed on admission and compliance with Devon Partnership Trust’s Inpatient Admissions Standard Operating Procedure. This requires that each patient admitted to a mental health ward has an assessment of capacity to consent to treatment completed within 24 hours of admission. In line with the Mental Capacity Act (MCA) Code of Practice, capacity assessments should be decision-specific, include the four-part functional test of mental capacity, represent the least restrictiveoption and be made in the patient’s best interests where capacity is lacking.

Retrospective audit of clinical records for the most recent 30 patients admitted to the Beech Unit in Torbay, Devon until December 2025. Records were assessed according to the following audit criteria:

1. Assessment of capacity to consent to admission and treatment documented within 24 hours of admission

2. Nature of decision clearly documented

3. Use of the four-part functional test (ability to understand, retain, use or weigh up and communicate a decision)

4. Reference to least restrictive practice and best interests where patients lacked capacity

Every patient had a mental capacity assessment documented within 24 hours of admission (100%). The standardised MCA template (which prompts clinicians to document all parts of a capacity assessment) was completed for 90% of the patients and only half were completed in the timeframe. 90% of the records clearly documented the decision in question and 90% had clear documentation of the functional test. Fewer records contained the direct statements ‘least restrictive’ and ‘best interests’ (53%).

All patients (100%) had an assessment of mental capacity documented following admission to the ward, showing that clinicians have a good understanding of when the Mental Capacity Act should be considered, but timeliness of completing the MCA template could be improved. While the nature of decisions and use of the four-part test werewell documented overall, documentation around recording of best interests and least restrictive options could also be improved.

There are some limitations to this audit: variability in clinician documentation styles may affect interpretation of the data and retrospective data collection limits clarification of clinical reasoning.

Recommendations include targeted interventions to guide clerking doctors about when to complete MCA assessments and what should be included. It is recommended that the Trust’s standardised MCA template is used to improve the quality of documentation, as this prompts clinicians to address the key elements of a good capacity assessment.

This comprehensive Trustwide Reaudit aimed to evaluate patterns of psychotropic and sleepmedication prescribing within the CAMHS service at Black Country Healthcare NHS Foundation Trust for children diagnosed with Autism Spectrum Disorder (ASD). It comparedthe current practice against NICE guidelines. The key objectives were to identify variations in prescribing practices across different localities within the Trust and to assess both the improvements achieved and the remaining gaps when comparing the initial audit with the reaudit.

A detailed retrospective review was carried out on 137 randomly selected cases involving children diagnosed with ASD who had been prescribed psychotropic or sleep medications. Comprehensive examination of patient records, including progress notes and clinic letters, enabled the collection of robust and meaningful data. To minimise bias, cases from each locality were evaluated by clinicians from different areas within the Trust. The assessment focused on comparing prescribing practices against NICE guidelines, and all stages of the process were conducted in accordance with strict ethical standards

Across the cohort of 137 children diagnosed with ASD, several areas of clinical practice showed clear improvement compared with the initial audit as follows. The proportion of children receiving alternative interventions before starting medication increased from 44% to 60%, and documentation of consent rose markedly from 62% to 93%. Specialists continued to initiate psychotropic medications at the minimum effective dose, and timely followup within 3–4 weeks improved from 70% to 75%. Recording of side effects also increased, moving from 61% to 70%, while documentation of prescribing indications rose from 83% to 93%, reflecting stronger clinical rationale and overall enhancement in practice standards in the Re-Audit.

The Reaudit showed marked progress in several key areas, including consent procedures, the use of prior interventions, followup practices, and overall documentation,when compared with the initial audit. However, despite these improvements, the findings revealed inconsistencies in some areas in adherence to NICE guidelines. To address these gaps in the future, recommendations were made to strengthen collaboration with supporting agencies to increase the use of nonpharmacological interventions before medication is considered. Additional recommendations included implementing trustwide clinic letter templates to standardise documentation of indications, side effects, and consent, and to establish consistent followup intervals for reviewing medication side effects. These steps were viewed as essential for ensuring safe, effective, and highquality patient care.

Psychiatric conditions and psychotropic medications can significantly impair driving ability through sedation, impaired judgment, or delayed reaction times. According to DVLA and GMC standards, clinicians must advise patients when their mental state or medication may affect driving, inform them of their duty to notify the DVLA, and clearly document this advice. This audit assesses compliance with these requirements on two psychiatric inpatient wards.

A retrospective review of 20 discharge summaries (10 from Edisford Ward, 10 from Hyndburn Ward at the Royal Blackburn Hospital) dated up to 15/09/2025 was conducted. Data were extracted under the following domains: diagnosis, driving status, medication class, evidence of driving advice on discharge, and evidence of DVLA contact on behalf of the patient.

Across both wards, 20 patients were reviewed in total. The vast majority (n=19, 95%) were prescribed psychotropic medications that may impair driving, including antipsychotics, antidepressants, benzodiazepines, and mood stabilisers.

Only 1 patient had documented evidence that driving advice was given at discharge. No cases recorded that the clinician contacted the DVLA on behalf of the patient, even where severe psychiatric illness (e.g. schizophrenia, bipolar disorder, or mania) was present.

Discussion:

The findings demonstrate a clear gap in documentation regarding driving advice in psychiatric inpatient discharges. Despite all patients being prescribed medication with potential to impair driving, almost none had documented advice, and there was no evidence of clinician escalation to the DVLA.

Recommendations:

Provide ward-based education sessions on DVLA standards and GMC responsibilities. Ensure driving advice is provided to patients on discharge and is clearly documented. Re-audit after 1 month to assess improvement.

This audit highlights poor compliance with national guidance regarding driving advice and documentation at discharge. Improved awareness and systematic prompts are required to ensure patient and public safety and to maintain medico-legal standards.

Tobacco use remains highly prevalent among individuals with severe mental illness and is a major contributor to excess physical morbidity and premature mortality. Institutional smoking cessation policies aim to standardise nicotine dependence assessment, nicotine replacement therapy (NRT) prescribing and monitoring, patient education, and dischargeplanning in psychiatric inpatient settings. However, local data evaluating adherence to these standards in routine clinical practice are limited. This audit aimed to assess adherence to the institutional Smoking Cessation Policy across inpatient psychiatric services at Hamad Hospital, with a focus on documentation of nicotine dependence, NRT prescribing and monitoring, patient education, referral practices, and discharge continuity. It was hypothesised that documentation quality and continuity-of-care components would demonstrate lower compliance than initial screening processes.

A retrospective clinical audit was conducted between January and August 2024 across inpatient psychiatric units at Hamad Hospital. A total of 144 inpatient medical records were reviewed using the Cerner electronic health record system. Audit standards were derived from the institutional Smoking Cessation Policy and included documentation of smoking status, nicotine dependence screening and severity assessment, initiation and monitoring of NRT, documentation of side effects, delivery of patient and family education, provision of motivational interventions, referral to the Tobacco Control Center, and smoking cessation planning within discharge summaries. Data were extracted using a standardised audit tool and analysed descriptively.

Approximately 40% of admitted patients were identified as current smokers. Nursing compliance with initial nicotine dependence screening was high, exceeding 97%. In contrast, documentation of nicotine dependence severity was recorded in only 30.2% of cases. Appropriate NRT strength was documented in 12.3% of smokers, while monitoring for NRT-related side effects was not documented in any record. Only 20% of identified smokers received NRT, while 29% declined treatment. Referral to the Tobacco Control Center was documented in 18% of cases, with a further 13% documenting patient refusal. Motivationalinterventions were documented in 1.8% of cases. No records contained documentation of patient or family education or provision of educational materials. Discharge summaries showed limited continuity planning, with NRT prescriptions documented in only 3.3% of cases.

This audit demonstrates significant gaps between institutional smoking cessation policy standards and routine clinical practice within psychiatric inpatient services, particularly in documentation quality, patient education, and discharge continuity. While initial screening processes were consistently completed, downstream interventions and continuity-of-care measures were poorly documented. Targeted staff training, improved access to educational resources, and structured monitoring and documentation systems are required to strengthen implementation of smoking cessation policy and improve tobacco-related health outcomes for psychiatric inpatients.

In Qatar, there are currently no published local data and no standardised inpatient policy/care pathway for personality disorder (PD) management. This creates variability in assessment, crisis planning, psychological input, and prescribing practice. We aimed to establish a baseline epidemiological profile of inpatient PD presentations and describe current inpatient management processes to inform service development. We hypothesised that borderline personality disorder (BPD) would be the most frequent PD diagnosis and that care processes would show wide variability in the absence of a local guideline.

We conducted a retrospective audit within Hamad Medical Corporation Mental Health Services using electronic health record review (Cerner) and structured case-note abstraction. All eligible psychiatric admissions between January and December 2025 were included (N=171). Extracted variables included PD diagnosis and type, documentation supporting BPD diagnostic criteria, MDT review, crisis planning, documented individual and group psychotherapy sessions, inpatient self-harm incidents, documented substance use, and psychotropic prescribing.

A personality disorder diagnosis was recorded in 83 of 171 admissions (48.5%); the remaining 88 admissions (51.5%) did not carry a documented personality disorder diagnosis during the admission period. BPD was the most frequent PD diagnosis (54/83, 65.1%), followed by antisocial PD (13/83, 15.7%). Mean age was 26.8 years (SD 10.9); 55/83 (66.3%) were female and 49/83 (59.0%) were readmissions. For BPD admissions, documentation supported ≥5 diagnostic criteria in 40/54 (74.1%) (median 6 criteria). MDT review was documented in 72/83 (86.7%) and a crisis plan in 51/83 (61.4%). Individual psychotherapy session counts were recorded for 48/83 (57.8%); of these, 26/48 (54.2%) had zero documented sessions. Group psychotherapy session counts were recorded for 51/83(61.4%); of these, 34/51 (66.7%) had zero documented sessions. Self-harm incidents occurred in 21/83 (25.3%), and substance use was documented in 33/83 (39.8%). Antipsychotics were prescribed in 58/83 (69.9%) and benzodiazepines in 33/83 (39.8%).

This first inpatient PD audit in Qatar shows a substantial service burden dominated by BPD, high readmission rates, limited documented psychological input, and incomplete crisis planning. In the context of no local policy/guideline, the findings support developing a standardised inpatient PD pathway by adopting international guidance (with cultural adaptation for the region), strengthening crisis planning and psychological interventions, and reviewing prescribing practice–particularly reducing benzodiazepine use and promoting safer alternatives.

Background:

Sexual safety is a core component of providing a safe and therapeutic inpatient mental health environment. Devon Partnership NHS Trust's (DPT) Sexual Safety Policy (C60) outlines responsibilities to protect patients from sexual harm, promote consent, and ensure appropriate sexual health assessment. National guidance from NICE, the CQC, and the Sexual Safety Collaborative highlights the importance of routine sexual history taking, trauma-informed care, and safeguarding, particularly for vulnerable inpatient populations.

Aim: This audit aimed to evaluate compliance with DPT's Sexual Safety Policy (C60) on Haytor Ward by assessing documentation of sexual health and sexual safety during inpatient admissions, and to explore resident doctors’ knowledge, attitudes, and practices regarding sexual history taking.

A retrospective review of ten inpatients admitted to Haytor Ward in May 2025 was conducted using System One (s1). Patients were selected using a randomised bed-number approach. Documentation within physical health clerking, the assessment tab, and tabbed journal entries was reviewed using predefined search terms aligned with Trust policy requirements. In addition, a qualitative and quantitative survey of South Devon resident doctors was undertaken using Google Surveys to assess awareness of policy, clinical practice, and perceived barriers. The survey was open for 30 days and achieved a 50% response rate.

Documentation of sexual health and sexual safety was below expected Trust standards. Sexual history was inconsistently recorded, largely due to the absence of a sexual health section within the routinely used admission clerking proforma. The existing Sexual Health template on s1 was not easily accessible and did not capture several policy-required elements, including gender identity, sexual orientation, sexual safety understanding, historyof sexual harm, and MAPPA/safeguarding status. Patients who were acutely unwell on admission were less likely to engage in sexual history discussions. Only 50% of surveyed doctors were aware of the Sexual Safety Policy, and most reported not routinely undertaking sexual history taking, citing time pressures, patient distress, lack of training, and system-level barriers.

Sexual safety assessment on Haytor Ward is inconsistently documented, primarily due to IT system limitations and reduced staff awareness. Improving S1 templates, enhancing training, and embedding sexual safety into routine admission processes are essential to align practice with Trust policy and national guidance, and to ensure patient dignity, safety, and safeguarding.

High-dose antipsychotic therapy (HDAT) refers to antipsychotic prescribing above recommended limits, either as a single drug exceeding the BNF maximum dose or combined drugs with a total dose above 100% of the maximum dose. This may be necessary for some patients due to symptom severity or treatment resistance; however, it is associated with an increased risk of side effects.

NHS Lanarkshire guidelines suggest that patients on HDAT should have regular monitoring of clinical progress, risk factors, side effects, ECGs, LFTs, U&Es, temperature and blood pressure. At present, there are no dedicated clinics in the region to monitor patients on high-dose antipsychotics.

This audit therefore aims to investigate the number of patients within the Bellshill Community Mental Health Team (CMHT) who are prescribed HDAT, and to assess whether appropriate monitoring has been carried out in line with local guidelines.

The medical notes of 551 patients open to psychiatry in the Bellshill locality were reviewed to see how many were on high dose antipsychotics. The health records of the patients on high dose antipsychotics were then reviewed to see how many had appropriate monitoring in the last 6 months in line with NHS Lanarkshire guidelines.

There were 551 patients under Bellshill CMHT of which 366 were on antipsychotics (48%). Of the 366 patients on antipsychotics, 10 were prescribed HDAT (2.7%). None of the patients on HDAT had evidence of full appropriate monitoring within the past six months in accordance with local guidelines. Among the 10 patients receiving HDAT, 7 (70%) had appropriate bloods taken in the last 6 months, while only 1 (10%) had an ECG completed within the last 6 months.

The findings demonstrate that high-dose antipsychotic monitoring is not being consistently carried out in Bellshill CMHT. This has prompted the expansion of the audit across Lanarkshire and underlines the need for HDAT monitoring clinics to improve patient safety and adherence to recommended standards. Further work is recommended to develop robust monitoring strategies for patients on HDAT, including the implementation ofstructured monitoring sheets, electronic alert systems, and dedicated clinic appointments for ongoing assessment.