To assess adherence to recommended baseline physical, laboratory, and additional investigations within 24 hours of admission in psychiatric inpatients, identify gaps, implement targeted interventions, and evaluate improvement in compliance.

ET AL AUTHORS :

6. Dr. Muhammad Zubair - General Practitioner- muhammadzubair1103@gmail.com

A closed-loop quality improvement audit with a repeated cross-sectional design was conducted in the Psychiatry Department over 2 months. Fifty patients were included: 25 pre-intervention and 25 post-intervention phases. Pre-intervention data were collected retrospectively from patient records for physical examination (general + systemic), vital signs, BMI/weight, ECG, standard laboratory tests (CBC, LFTs, RFTs, serum electrolytes, fasting lipid profile, fasting glucose, viral markers), and special/indicated investigations (pregnancy test, urine drug screen, TFTs).

Documentation of findings in clinical notes was also assessed. Interventions included staff education sessions, standardized admission checklists, reminders during ward rounds, and coordination with laboratory and ECG services. Post-intervention data were collected prospectively using identical criteria to measure improvement.

Pre-intervention (n=25): Physical examination was documented in 72%, vital signs in 80%, ECG in 52%, and BMI/weight in 60%. Laboratory investigations showed completion rates of80% for CBC and LFTs/RFTs, 84% for serum electrolytes, 68% for fasting lipid profile and glucose, and 72% for viral markers. Pregnancy testing was completed in 7.7% of eligible females, urine drug screening in 0% of indicated cases, thyroid function tests in 20%, and documentation of findings in 56%.

Post-intervention (n=25): Physical examination improved to 92% (+20%), vital signs to 96% (+16%), ECG to 80% (+28%), and BMI/weight to 88% (+28%). Completion of CBC and LFTs/RFTs improved to 96% each (+16%), serum electrolytes to 92% (+8%), fasting lipid profile and glucose to 84% (+16%), and viral markers to 88% (+16%). Pregnancy testing in eligible females increased to 85% (+77.3%), urine drug screening to 75%, thyroid function testing to 80% (+60%), and documentation of findings to 92% (+36%).

Baseline compliance with physical health investigations within 24 hours of psychiatric admission was variable, with significant gaps in ECGs, metabolic screening, special investigations, and documentation. Following targeted interventions, substantial absolute improvements were observed across all domains, particularly in ECG performance, metabolic monitoring, pregnancy testing, thyroid function testing, and documentation quality. This audit demonstrates that structured educational and system-based interventions can significantly enhance physical healthcare delivery in psychiatric inpatient settings. Ongoing re-audit is recommended to sustain improvements and ensure patient safety.

To evaluate the quality and timeliness of Internal Medicine (IM) referrals, documentation, and follow-up for psychiatric inpatients with medical comorbidities; to identify gaps in liaison between Psychiatry and Internal Medicine; to implement targeted interventions; and to assess improvement following these interventions.

A closed-loop clinical audit was conducted over a 4 month period in the Department of Psychiatry, Gulab Devi Teaching Hospital, Lahore. Two audit cycles were completed. A total of 35 psychiatric inpatients with identified medical comorbidities were included in each phase (pre- and post-intervention). Data were collected retrospectively from admission clerking notes, inpatient progress notes, and IM referral records.

Audit standards were based on good clinical practice for the management of medical comorbidities in psychiatric inpatients. Parameters assessed included: identification of medical comorbidities, IM referral made, documentation of indication for referral, attachment of relevant vital signs or laboratory investigations, timeliness of referral, documentation of IM review, documentation of IM management plans, and implementation of IM recommendations.

Interventions included introduction of a standardized IM referral proforma, targeted reminders to psychiatry junior doctors regarding referral and documentation, reinforcement of combined verbal and written handover of IM advice, and use of a ward-round checklist toensure review and implementation of IM recommendations. Post-intervention data were collected using the same methodology.

Pre-intervention (n=35):

IM referrals were made in 65.7% of eligible patients. Documentation of referral indication was present in 78.3%, and relevant investigations were attached in 60.9%. Same-day referral occurred in 39.1%. IM review was documented in 42.9%, IM management plans in 37.1%, and IM recommendations were implemented in 31.4%. Complete referral-review-action loops were achieved in 28.6% of cases.

Post-intervention (n=35):

IM referral rates increased to 88.6% (+22.9%). Documentation of referral indication improved to 93.5% (+15.2%), and attachment of relevant investigations to 87.1% (+26.2%). Same-day referrals increased to 71.0% (+31.9%). Documentation of IM review improved to 80.0% (+37.1%), documentation of management plans to 74.3% (+37.2%), and implementation of IM recommendations to 71.4% (+40.0%). Complete referral-review-action loops increased to 68.6% (+40.0%).

This audit identified significant baseline gaps in liaison, documentation, and follow-up of medical comorbidities in psychiatric inpatients. Following simple, structured interventions implemented over a 3–4 month period, substantial improvements were observed across all domains. These findings highlight the effectiveness of low-cost, system-based measures in strengthening Psychiatry–Internal Medicine collaboration and improving patient safety. Continued re-audit is recommended to sustain improvements.

This clinical audit aimed to assess and quantify patient wait times across all localities within the TEWV Trust, benchmarking these durations against Trust and National averages. Timely care for individuals with dementia is critical, not only for patients and their families but also for broader community health outcomes. Early diagnosis is essential for providing customized support, facilitating effective treatment options, enabling proactive planning, and preventing crises. Reducing the wait time between referral to a Memory Assessment Service (MAS) and the subsequent diagnosis and care plan is crucial, as delays can significantly burden the NHS and adversely affect the long-term mental health of patients and their caregivers. According to the National Audit of Dementia for 2023/2024, wait times have risen sharply from 124 days in 2021 to 151 days, with only 10% of patients obtaining a diagnosis within six weeks of referral.

The audit was conducted over a four-week period from September 28 to October 28, 2024. A random sampling method was employed to select 149 patients referred to 15 memory services throughout the TEWV Trust. Data were collected through the analysis of referral letters, initial assessments, diagnostic appointments, case notes, and correspondence from CITO. Analysis was performed using a custom tool developed in Excel.

The analysis yielded average access times, diagnostic wait times, and overall wait times ranging from 30 to 207 days, 3 to 147 days, and 92 to 323 days, respectively. Notably, none of the Mental Health Service for Older People (MHSOP) services within the TEWV Trust met the national benchmark for overall wait times of six weeks. Furthermore, only 25% of the services succeeded in providing a diagnosis within the 6 to 18-week timeframe, while the remaining 75% experienced wait times extending to 18-52 weeks. A comparative analysis revealed that the average wait times (access, diagnostic, and overall) within the Trust exceeded those of the National averages.

The audit underscored substantial discrepancies between the various memory services’ performance and the National recommendations of a six-week wait. Among the services assessed, only one was marginally compliant with a 92-day mark, falling short of the National benchmark of 42 days. This evaluation not only identified critical challenges faced by the services but also presented a series of recommendations to address these gaps.

The purpose of this audit was to evaluate and improve staff awareness and confidence in signposting patients to services both within and outside the NHS. It aimed to transition from a fragmented information landscape to an integrated “one-stop-shop” directory. By centralising resources into a sustainable, living database, the project sought to bridge knowledge gaps, foster Trust-wide collaboration, and ensure patients receive tailored support across all five boroughs.

A Trust-wide baseline survey was distributed to all staff, capturing data on professional roles and geographical boroughs to identify specific resource gaps. Targeted surveys were sent to medical staff to pinpoint clinical areas and service types where signposting confidence was lowest. Both quantitative and qualitative methods were used to gather initial baseline data and further suggestions to integrate resources better. This data informed the design of a Microsoft Lists database, prioritizing the most “under-resourced” areas and ensuring the platform met the practical needs of frontline staff.

Baseline data confirmed a high demand for resources, with 71.5% of staff signposting patients at least weekly. Key barriers included unclear referral pathways (77.8%), poor service awareness (70.4%), and outdated information (59.3%). Pre-intervention, staff lacked confidence in signposting for housing (78.7%), employment (67%), and finances (57.1%), with significant unawareness regarding legal aid (89.3%) and food banks (67.9%). Internal service literacy was also low, with over half (60.7%) unaware of Trust rehabilitation services. Consequently, 60.7% of staff requested the interactive digital directory.

Post-intervention, confidence in signposting to employment, housing, and finance services all rose to above 56%. Staff reported marked increases in awareness for domestic abuse and carer support (both 93.8%), legal aid (75%), and debt advice (68.8%). While awareness of external resources improved, gaps persisted for internal rehabilitation (62.5% unaware) and forensic services (43.8% unaware). Qualitative feedback confirmed the directory successfully consolidated information, though staff recommended expanding the database through closer collaboration with community teams and social prescribers across all five boroughs.

The collaborative digital directory represents a low-cost, high-impact solution to streamline patient signposting. Future interventions will focus on expanding the project team and recruiting “resource champions” from various teams to ensure the directory remains dynamic and sustainable. This model serves as a scalable blueprint for enhancing health literacy of staff for services that exist both within and outside NHS services.

- Evaluating the current practice for management of insomnia in inpatient settings.

- Assessment of the current use of CBT- Insomnia for the treatment of sleep disorders in inpatient settings.

- Comparing the current practice with the NICE guidelines.

A retrospective review of electronic medical records of 45 patients who were currently admitted in the inpatient unit over a period of two weeks of data collection.

For each patient, documentation was examined to determine:

• Whether insomnia was reported or observed

• Whether sleep difficulties were noted in clinical records

• Whether nonpharmacological interventions (e.g., sleep hygiene) were offered

• Whether behavioural therapy (CBTI), which is considered the first line of treatment.

treatment for chronic insomnia was offered or signposted

• Whether hypnotic medication was prescribed, and if so:

Type of medication

Documentation of indication

Presence of review or stop dates

Out of the 45 current in-patients audited during the initial assessment of electronic records, 26 (58%) complained of sleeping difficulties; an additional 4 patients were observed to have sleeping difficulties according to the records. This makes the totalprevalence of insomnia 30 (66.6%). Of these patients, 23 (76.6%) had proper documentation of insomnia in their notes. As management, non-pharmacological interventions such as sleep hygiene discussion were done in 11 out of 30 (36.6%), and no patients (0%) were offered or signposted towards CBT-I. Pharmacological interventions of offering hypnotic medications were offered to 26 out of 30 (86.6%). The hypnotic medications offered included Z-drugs and/or in combination with benzodiazepine and antihistamines. None of the patients (0%) adhered to all criteria of NICE guidelines and Local Trust Policy (classifying insomnia according to duration of symptoms, trial of non-pharmacological intervention before using medications, clear indication documented before starting hypnotics, periodic review and documentation of stop date for said medications)

This audit highlights the need for a structured and consistent approach to managing insomnia across the hospital. Establishing a simple, standardized care pathway–prioritizing non-pharmacological strategies and applying a cautious, clearly justified approach to hypnotic prescribing–has the potential to enhance patient safety, minimize the risk of hypnotic dependence, and promote higher-quality clinical care. Ensuring insomnia is managed systematically and in line with NICE recommendations will support more effective and sustainable outcomes for our patients.

Prolonged length of stay (LoS) on acute psychiatric inpatient wards is associated with increased clinical risk, poorer patient experience, reduced patient flow, and higher healthcare costs. National monitoring frameworks focus on average LoS and the proportion of admissions exceeding defined long-stay thresholds. NHS England policy outlines an ambition for average acute adult mental health inpatient stays of approximately 32 days. A UK-focused systematic review identified factors associated with longer psychiatric inpatient stays, including involuntary admission, psychotic diagnosis, older age, and ethnic minority status. Individual studies have also highlighted systemic and social contributors to prolonged LoS, such as out-of-area placements and accommodation-related discharge delays, alongside clinical factors including psychotropic polypharmacy. Local, service-level analyses using routinely collected clinical data can identify patient- and system-level predictors of prolonged LoS, enabling the development of targeted quality improvement initiatives to reduce avoidable extended inpatient admissions.

All inpatient admissions to a female acute ward over a 12-month period (January–December 2025) were analysed, with readmissions included as separate episodes. A multivariable logistic regression was conducted examining factors associated with prolonged LoS (≥32 days, in line with current NHS mental health policy and performance monitoring frameworks, vs <32 days). Data was extracted from electronic health records: age, ethnicity, local vs. out-of-area placement, primary discharge diagnosis, detention under the Mental Health Act, presence of incidents during admission, discharge destination, safeguarding processes raised, and psychotropic polypharmacy (≥2 concurrent antipsychotics or ≥2 psychotropic medications on discharge)

161 records were included in the analysis. Mean LoS was 29.76 days (SD=29.71). Median LoS was 17 days (IQR 9-31). Forty admissions (24.8%) met criteria for prolonged LoS (≥32 days). Adjusting for all other factors included in the model, prolonged LoS was independently associated with detention under the Mental Health Act (aOR 6.07, 95% CI 2.06–17.88; p=0.001), schizophrenia, schizotypal and delusional disorders (aOR 5.55, 95% CI 1.14–27.00; p=0.034), and mood disorders (aOR 4.77, 95% CI 1.01–22.52; p=0.049). Incidents, safeguarding, polypharmacy, out-of-area placement, discharge destination, ethnicity, and age were not significantly associated with prolonged LoS after adjustment (all p>0.05)

Prolonged inpatient length of stay was independently associated with detention under the Mental Health Act and diagnoses of schizophrenia-spectrum and mood disorders. No other patient- or system-level variables remained significant following multivariable adjustment. Targeted early intervention and proactive care planning for high-risk groups may help reduce avoidable prolonged inpatient stays while maintaining patient safety

Antipsychotic medications are widely prescribed in child and adolescent mental health services (CAHMS) and carry recognised metabolic and cardiovascular risks. National Institute for Health and Care Excellence (NICE) guidance outlines minimum standards for physical health monitoring before and during antipsychotic treatment. This audit aimed to assess compliance with NICE-recommended physical health monitoring for children and young people prescribed antipsychotic medication within a CAHMS Head-to-Head (H2H) community service.

A retrospective audit of electronic patient records (Rio) was conducted. All patients under the CAHMS H2H team prescribed antipsychotic medication were identified. Physical health monitoring was assessed at baseline, six weeks, twelve weeks, and at six-monthly intervals thereafter. Six-monthly monitoring was analysed per eligible monitoring window, recognising that patients commenced treatment at different times. Patients admitted to inpatient wards when monitoring was due were excluded. Patients who had not yet reached eligibility for six-monthly monitoring were excluded from six-monthly denominators. Monitoring performed during medication titration or switching was outside the scope of this audit. Descriptive statistics were used to calculate completion rates.

Eleven patients were identified; two were excluded, leaving a final audit cohort of nine patients aged 15–18 years. Complete baseline physical health monitoring was documented in 0% of patients, although 44.4% had at least one baseline parameter recorded. Six-week weight monitoring was completed in 22.2% of patients, and complete twelve-week monitoring (weight, blood pressure/heart rate, and blood tests) in 22.2%. Seven patients were eligible for six-monthly monitoring, contributing a total of 25 eligible six-monthly monitoring windows. Completion rates for individual NICE-recommended parameters across these windows were low (height 20.0%, weight 20.0%, blood pressure/heart rate 16.0%, blood tests 20.0%, waist circumference 0%), with no window containing all recommended measures. Despite this, all patients had evidence of some ongoing physical health monitoring while prescribed antipsychotic medication, although this did not consistently occur within NICE-specified timeframes. No adverse physical health outcomes related to delayed or out-of-window monitoring were identified.

Formal compliance with NICE-recommended monitoring schedules was low when assessed against strict guideline timeframes. However, all patients received ongoing physical health monitoring and remained clinically safe. These findings highlight the challenges of implementing rigid monitoring schedules within CAHMS and support the need for systems that promote consistent, well-documented monitoring while accommodating real-world clinical and family circumstances.

This audit aimed to assess current practice within NHS Borders Mental Health for Older Adults Service (MHOAS) regarding the use of neuroimaging in memory assessment clinics. Specifically, it sought to determine the proportion of patients with suspected dementia who had a documented decision and rationale regarding neuroimaging, and the proportion who underwent neuroimaging as part of their assessment. This was compared with findings from a previous audit conducted in 2014.

Patients referred to NHS Borders Older Adult teams with suspected dementia between January and March 2024 were identified from administrative referral records. A retrospective review of initial cognitive assessment letters was undertaken between February and August 2025. Data collected included whether there was documented consideration and rationale for neuroimaging, and whether neuroimaging was subsequently performed. The agreed audit standard was that all patients with suspected dementia should have a documented decision and rationale regarding neuroimaging, and that the majority should undergo imaging unless a clear clinical justification was recorded.

Fifty-one patients were included in the audit. Documented consideration of neuroimaging was present in 45 patients (88.2%), representing a substantial improvement compared with 59% in the 2014 audit. Neuroimaging was performed in 27 patients (53%), compared with 18% in 2014. Of the 24 patients who did not undergo neuroimaging, eight (33%) had already received neuroimaging within the preceding two years, and repeat imaging was deemed clinically unnecessary. In the remaining cases, the most common documented rationale for not performing neuroimaging was that the diagnosis was already clear and that imaging was unlikely to add diagnostic value or alter management.

This audit demonstrates a marked improvement over the past decade in both the documentation and utilisation of neuroimaging within the NHS Borders memory assessment clinic. Current practice is more closely aligned with national NICE and SIGN guidance, with appropriate clinical reasoning documented where neuroimaging is not performed. The findings suggest that neuroimaging is being used proportionately and appropriately, balancing guideline recommendations with principles of Realistic Medicine.

An audit of our 16 bedded male medium secure rehabilitation ward)during January - May 2025 identified that e-cigarette and smoking history was not recorded. Gap in availability of guidanceon how to take this history was identified.

We adapted standardised history and dependence checklists for our health setting for any new admissions. We then reaudited (August 2025 – December 2025) to assess if documentation of smoking and e-cigarette history had improved for any new admissions.

We had 2 new admissions in the re-audit period. We also retrospectively interviewed the other 14 patients on the ward as per the action point from our original audit.Two of these patients did not have capacity to engage and one patient was away on leaves from the ward making interview impractical.

The use of the adapted interview ensured that 2 admissions in the reaudit period had a thorough smoking and vaping history documented. The average age in our cohort of 13 included patients including the new admissions was 41 years. Majority had a diagnosis of Schizophrenia.All patients had a history of smoking.

The average age of trying first cigarette was 13.3 years old with the majority starting smoking with friends. All but one patient used to smoke daily. The average age of starting smoking daily was 15 years old. Most had a family history of smoking and nine reported smoking inside the home. Retrospective assessment of smoking dependence using the Modified Version of the Fagerstrom Tolerance Questionnaire demonstrated that 5/12 had a moderate dependence and 7/13 had a substantial dependence. Three of the four patients who actively attempted to stop smoking were successful. Eight only stopped smoking when held in prison or admitted to hospital. The majority did not have concerns of smoking affecting their health at the time.

10/13 had used e-cigarettes with majority starting in hospital (5) or prison (3). Assessment of dependence using the E-cigarette Fagerström Test of Cigarette Dependence demonstrated that eight had a high dependence. One patient had successfully quit e-cigarette citing that motivation to quit was ‘flavours are horrible’ and used an inhalator. Two patients were independently reducing e-cigarette by reducing strength of liquid used, both citing health concerns for vaping. The majority (8/13) did not express health concerns from e-cigarette use.

There is need for education of health impact of cigarettes /e-cigarettes and support for patients who are trying to quit e-cigarettes.

This audit evaluates the prescribing and monitoring practices of sodium valproate, particularly in females of childbearing potential. Sodium valproate is a medicine that is commonly used in the treatment of bipolar disorder and epilepsy, and less commonly migraine prophylaxis. Valproate is an effective treatment for bipolar disorder, however there are significant risks that come with the use of valproate medication including the risk of teratogenic effects should pregnancy occur.

The audit aims to assess compliance with the Pregnancy Prevention Programme (PPP), share findings ahead of the June 2025 national audit, and highlight updated initiation steps post-April 2024.

The audit standards were derived from national guidelines including the Royal College of Psychiatrists CR210 and MHRA Prevent Programme. They are also a replica of the standards measured in the National POMH Valproate Audit. The purpose of auditing the standards is to review compliance prior to the next POMH Valproate audit which will take place in June 2025.

The audit reviewed documentation of prescribing rationale, annual reviews (therapeutic benefit, adverse effects, medication adherence), and PPP compliance including Annual Risk Acknowledgement Forms (ARAFs).

The sample included 22 female patients aged 12–55 currently prescribed valproate. These patients were identified by the Clinical Director of Pharmacy. Sample characteristics such as age and ethnicity were also explored.

• Rationale for prescribing was documented in 20 out of 22 cases (91%).

• Only 23% of patients had all elements of the annual review documented.

• ARAF compliance was poor:

- 9 non-compliant cases where pregnancy was possible.

- 10 non-compliant cases where pregnancy was not possible.

• Common issues included missing or incorrectly completed ARAFs and lack of documentation of Patient Guide distribution.

The audit revealed significant gaps in compliance with PPP requirements and documentation standards. There was confusion around when ARAFs are needed, especially for long-standing patients and those post-menopausal. Baseline checks prior to initiation (BMI, FBC, LFT) were not consistently documented. The findings suggest a need for improved education and communication among prescribers.

The audit highlights the need for better adherence to national guidelines in prescribing and monitoring valproate. Key areas for improvement include annual review documentation, proper completion of ARAFs, and baseline physical health checks. Recommendations include targeted education for consultants and improved documentation practices to ensure patient safety and regulatory compliance.

Authors: Dr. Ahmad Maaen Aalater, Dr. Nirvana Swamy Kudlur Chandrappa, Dr. Faycal Walid Ikhlef, Dr. Suhair Mohammed Yousuf. Dr. Dina ElGhar, Dr. Zeeshan Aqeel Usman Sheikh, Dr. Majid Al-Abdulla,

To evaluate and compare prescribing patterns, safety practices, and clinical monitoring for patients with Alcohol Use Disorder (AUD) and Opioid Use Disorder (OUD) patients across two audit cycles at Umm Slal Treatment and Rehabilitation Center (USTRC) and to identify areas for sustained quality improvement.

Two retrospective audits were conducted using inpatient records from 89 patients in 2022 and 79 patients in 2024 diagnosed with AUD or OUD. Extracted variables included medication indications, dose titration and adjustment, contraindications, adverse drug reactions (ADRs), drug-drug interactions, and completion of baseline investigations. The 2024 cycle was benchmarked against the prior audit to assess changes in prescribing safety and documentation.

In 2024, 46 patients had AUD and 19 had OUD, with most patients aged 20–29 years. Documentation of appropriate medication indications improved (AUD 72%; OUD 78.9%). Dose titration and dose adjustment remained consistently high (98–100%), and contraindications were appropriately avoided in nearly all cases. Baseline medical testing improved but remained incomplete, with 8.7% of AUD and 10.5% of OUD patients missing liver or renal function results. Adverse Drug Reactions (ADRs) were documented in 18% of AUD and 5.3% of OUD cases, predominantly extrapyramidal symptoms and sedation. Drug interactions were identified in approximately one-third of prescriptions, with 25-29% classified as higher-risk interactions requiring closer monitoring. Documentation gaps and limited multidisciplinary ADR reporting persisted across cycles.

As one of the first longitudinal prescribing-safety audits within a mandated addiction treatment service in the region, this study demonstrates strong adherence to dosing safety while identifying ongoing vulnerabilities in documentation quality, baseline testing, and interaction monitoring. Sustained staff education, structured electronic documentation fields, and continuous re-audit are essential to strengthening medication safety and supporting high-quality addiction care in compulsory treatment settings.

This audit aims to review the prescribing of melatonin in adults with intellectual disability (ID) to understand current patterns of melatonin use within this population and to assess whether prescribing practice follows existing clinical guidelines. In addition, the audit seeks to compare the current findings with those from previous audits conducted in 2018 and 2021 to provide a longitudinal overview of changes in melatonin prescribing over time.

A retrospective audit was conducted to assess the use of melatonin in adults with intellectual disability and insomnia. From a total population of 322 patients, a sample of 50 patients was selected using systematic random sampling. The inclusion criteria focused on adult patients with intellectual disability prescribed melatonin by the Intellectual Disability Psychiatry Team at Leicestershire Partnership Trust. Patients in transition from the Child and Adolescent Mental Health Services (CAMHS) and those under adult Community Mental Health Teams (CMHT) were excluded. The audit covered the period from January 2022 to December 2024, with data collected from patient records and GP correspondence. Data collection focused on melatonin initiation, dosing, and prior sleep hygiene, with reviews of effectiveness and side effects during the first and most recent 12 months. The later review also assessed withdrawal or dose reduction where appropriate.

Insomnia was the indication for prescription in all 50 patients, with 42% (21/50) having severe, 26% (13/50) moderate, and 32% (16/50) mild Intellectual Disability. The initiation dose was 2mg in 62% (31/50). The current dose is over 10mg (12mg) in 2% (1/50). While all were reviewed post-initiation (within 2 weeks to 1 year), only 40% (20/50) had a review within 2 months. Sleep hygiene advice was undocumented in 80% in the first year and in 88% (44/50) in the past year. There was no review of side effects in 70% in the first 12 months and 51% in the last year. Insomnia had resolved for ≥6 months in 21% (10/50), but 50% (5/10) of these had no trial of dose reduction.

This audit demonstrates some improvement in adherence to prescribing guidelines for melatonin in individuals with intellectual disability, particularly regarding indication, starting dose, and regular reviews of effectiveness. However, it also highlights ongoing gaps in best practice, including timely initial reviews, consistent monitoring of side effects, provision of sleep hygiene advice, and opportunities for deprescribing. These findings underscore the need for more structured and comprehensive approaches to monitoring and documentation.

• • To monitor adherence to the General Medical Council professional standards in prescribing unlicensed medications for patients open to the Stanley Treatment and Intervention team.

• • To identify areas of unlicensed prescribing that require improvement in order to communicate this with prescribers to raise awareness of the professional standards and reinforce them.

• • To ensure good practice in decision-making around treatment choice in conjunction with parents and carers

• • To allow use of unlicensed or off-label medicines in line with recognised clinical practice and/or published evidence

• • To minimise risk associated with unlicensed and off-label use of medicines.

A search was conducted on clinic letters by medical staff in the Stanley Treatment and Intervention Team in community mental health between 1 July 2024 and 31 October 2024. We randomly chose 27 clinic letters.

To complete this audit, we reviewed all 27 patient’s electronic record to identify unlicensed medication use practice using the audit tool.

The total number of patients included in this audit was 27.The number of patients who were initiated on unlicensed medications was 2 out of 27 . Out of these, 2 patients records had clear documentation of discussion of the use of unlicensed medication with the patient, 2 patients records had a clear documentation of the rationale for prescribing a medicine off-label or prescribing an unlicensed medicine and 2 patients records had a clear documentation of the benefit vs risk of unlicensed medication use.

Subsequently, 2 patients records had documentation of clear, accurate and legible record of all medicines prescribed, 2 patients records had clear documentation that sufficient information about the medicines were given to patient, or their parents or carers. Lastly, there were no patients considered to be in a vulnerable group such as children and adolescents, women of childbearing age and elderly patients.

The Stanley Treatment and Intervention Team in community mental health was found to be 100% compliant with the General Medical Council standards. Compared to a previous audit in the inpatient ward, we identified this was due to improved documentation, open discussions with patients and clearly documented rationale. We suggest practices to have a set proforma to support doctors identifying a rationale, prescribing and documenting commencement of unlicensed medications.

Depression is common amongst young adults and is frequently managed in primary care. Antidepressant medications are commonly initiated or adjusted, however the early stages following this are associated with an increased risk of suicidality in those aged 18-25 years, with the highest risk being observed within the first 28 days of treatment. NICE guidelines therefore recommend close monitoring of this group, including review within one week of initiation or dose increase, followed by further review no later than four weeks. The aim of this audit was to assess compliance with NICE guidelines for follow-up after initiation or dose increase of antidepressant medication in those aged 18-25 years in a primary care setting

A retrospective audit was conducted in a primary care setting. Electronic medical records were used to identify patients aged 18-25 who were either newly prescribed or had a dose increase of an antidepressant between October 2025 and January 2026. 95 eligible patients were identified, of which 55 were randomly selected. The data collected included the timing and mode of follow-up. The standards that were measured were if patients had been reviewed within one week and within four weeks of antidepressant initiation or dose increase.

3/55 patients (5.5%) were seen within one week and again within four weeks, thus fully compliant with the guidelines. However, only 4/55 patients (7.3%) were reviewed within one week and 8/55 (14.5%) were followed up within four weeks. 35 patients were reviewed during the study period, but not within the recommended guideline timeframes. 12 patients had no documented follow up review since medication initiation. Where reviews occurred, they were most commonly conducted via telephone consultation.

This audit identifies opportunities for improvement in adherence to NICE guidelines for follow-up of antidepressant treatment in young adults within primary care. Given the prevalence of antidepressant prescribing and recognised vulnerability of this age group, untimely follow-up may represent a patient safety concern at a population level. System based interventions to support routine early review may improve adherence, such as automatically booking a 1-week follow-up telephone review at the time of antidepressant initiation or dose increase. Followed by implementing clear pathways for urgent review and escalation if suicidal ideation is identified during follow-up.

Pro re nata (PRN) medication is often used on mental health wards to manage agitation, restlessness and risky behaviours. It is important that these medicines are prescribed according to the guidelines and reviewed regularly to ensure patient safety. This audit aims to assess patterns of PRN medication use on mental health wards in Luton and Bedfordshire and to determine whether PRN medications are actively reviewed and discontinued when no longer required.

We retrospectively reviewed the case records of 25 randomly selected in-patients across General Adult, Old Age and CAMHS wards. Data were collected on patient demographics, diagnosis, legal status, PRN prescriptions, utilisation and administration practices.

The audit showed a high prevalence of PRN medication use, with 84% of patients reviewed prescribed PRN medication. Promethazine and lorazepam were the most frequently prescribed PRN medications, either alone or in combination.10 out of 21 patients were prescribed both promethazine and lorazepam.

There was noticeable variation in PRN utilisation with 6 out of 21 patients requiring frequent PRN administration (more than 20 doses since admission). PRN prescribing appeared appropriate to clinical presentation as approximately 84% of patients requiring higher-frequency PRN use had psychotic symptoms or emotionally unstable personality disorder.

PRN administration adhered to best practice guidance with oral medication regularly offered prior to IM administration.

Areas for improvement were identified: 5 out of 21 patients had PRN prescriptions that were no longer clinically indicated but remained active. PRN protocols were not consistently updated following changes in legal status for 2 patients.

• • Introduce regular PRN medication reviews during ward rounds and at defined intervals.

• • PRN medications that have not been used for a specified period should be reviewed and discontinued where clinically appropriate.

• • PRN protocols should be promptly reviewed and updated following any change in a patient’s legal status.

• • Patients requiring frequent PRN medication should receive a multidisciplinary review to explore underlying causes and consider alternative management strategies.

• • Improve documentation of PRN indications, review dates and clinical rationale to support safe prescribing.

The primary aim was to assess the quality of recording mental capacity assessments by the Chesterfield MHLT to ensure compliance with legal and ethical obligations. The audit aimed for 100% documentation of capacity assessments during all mental health reviews. Additionally, the project targeted a minimum Grade 2 standard (moderate detail) in documenting the four functional stages of capacity for all patients, ensuring that narrative and context regarding a patient’s capacity component were thoroughly recorded.

A retrospective review of 30 randomized electronic patient records (electronic system) was conducted for the Chesterfield MHLT for cases identified between January and February 2025. Data was analysed to determine the presence of broad capacity assessments and, crucially, to evaluate the quality of documentation regarding the four functional stages: Understanding, Retaining, Weighing-up, and Communicating information. A standardized grading scale (Grade 0-3) was utilized to measure the depth of narrative and the presence of direct patient quotes in the documentation

While a broad assessment of capacity was recorded in 90% of cases, the documentation quality regarding specific domains was inadequate. Only 37% of cases explicitly documented the specific decision being assessed, such as consent to medication or admission, representing a critical gap in compliance. Furthermore, the detailed assessment of the functional stages frequently failed to meet the required standard. For the functional domains of “Understanding” and “Communicating,” 50% of cases showed no evidence (Grade 0) of documentation. Similarly, 40% of cases showed no evidence of documentation for “Weighing-up” information, highlighting a significant discrepancy between broad capacity recording and the required detailed documentation of the assessment process

This audit highlights that while capacity is often broadly recorded, the specific, detailed assessment of how patients understand, retain, weigh up information, and communicate their decisions is frequently absent or insufficient. To enhance compliance, we recommend integrating mandatory MCA forms into the core assessment template on electronic and enforcing explicit, decision-specific documentation. A re-audit is planned in six months to measure the impact of these changes on documentation quality and patient autonomy.

Guided by the Model for Improvement, this project aims to increase the completion of core assessments and capacity-to-consent documentation in MHA referrals made by the MHLT to at least95% within six months. The ultimate objective is to enhance resource efficiency, ensure compliance with the MHA Code of Practice, and guarantee that formal detention is initiated only when legally and clinically justified.

A baseline diagnostic analysis of referrals from the Mental Health Liaison Team (MHLT) at Chesterfield Royal Hospital revealed that 33% (10/30) of MHA referrals did not result in detention. Critically, 90% of patients without a recorded core assessment and 70% without documented capacity were ultimately admitted informally or discharged. This diagnostic phase indicated a direct correlation between missing documentation and a lack of clinical necessity for formal detention, suggesting that a lack of structured assessment acted as a barrier to identifying less restrictive alternatives.

The project involved mapping the current MHLT referral process, identifying a lack of a structured, mandatory protocol as a key driver for poor-quality referrals. A driver diagram was developed to focus on staff competency and referral mechanics. Two PDSA cycles are currently being implemented:

• • System Mechanics: Introduction of mandatory digital fields in the referral pathway requiring confirmation of a core assessment, capacity assessment, and documented consideration of informal admission.

• • Staff Competency: Delivery of structured teaching sessions to MHLT staff regarding MHA principles and the introduction of visual aids prompting documentation prior to referral submission.

Based on the diagnostic phase, which showed that formal assessment was more frequently omitted in referrals that ultimately did not require detention, we expect a substantial improvement in referral quality by ensuring these steps are taken pre-referral. We are currently implementing these changes and monitoring process measures. A follow-up audit will be conducted to formally measure the increase in documentation compliance and the subsequent reduction in referrals not resulting in detention, aiming to demonstrate improved resource efficiency and adherence to the MHA Code of Practice.

This ongoing QI initiative indicates that structural changes to referral mechanisms, paired with targeted staff education, can be effective in improving documentation fidelity. By enhancing the decision filter for referrers, this project aims to ensure that MHA assessments are initiated only when legally and clinically justified

The audit evaluated the diagnosis and management of mild cognitive impairment (MCI) across the older adult community mental health teams of a large and rural mental health trust. In the absence of specific NICE guidelines for MCI, the standards used in this audit were based on the current older adult (OA) memory assessment and management service (MAMS) protocol, the Manchester Consensus guideline recommendations and NICE guidance NG16 and NG97.

The aims of this audit were to assess compliance with guidelines, screening processes, diagnostic accuracy, patient and caregiver education, follow-up and monitoring as well as record keeping.

This was a baseline retrospective audit of 80 patients who received a diagnosis of MCI from older adult community mental health teams (CMHTs) between January 2023 and January 2024. 10 patients were reviewed from each of the 8 CMHT teams. Electronic RiO records were reviewed for documentation. Patients with a diagnosis of MCI outside of this period were excluded.

Of the 80 patients reviewed, 13 were excluded. 67 patients (100%) were assessed using standardised cognitive assessment tools. 52 (78%) had functional impairment documented. 47 (70%) were screened for depression. Of those eligible, 10% had a documented medication review. 42% received information about lifestyle and risk reduction advice. 14 patients (21%) had cardiovascular risk reduction advice shared within GP letter. 67 (100%) were not prescribed antidementia medication. Forty-six patients (69%) received a follow-up review. Reasons why 13 patients (19%) were not followed up remain unaccounted for. 42 patients (91%) recalled had monitoring of cognitive function and daily living activities over time. Of the recalled, 35 patients (76%) had an updated IQCODE or detail of functioning impairment evidence in RiO notes. 14 patients (21%) had their diagnosis changed to dementia at the follow-up review. 11 patients (16%) were informed about and offered access to partaking in research.

Compliance with the standards was variable. Strengths included compliance with using standardised cognitive assessment tools as well as avoidance of inappropriate prescribing of antidementia medications. There was also a high rate of reviews re-assessing cognition. Key gaps included medication reviews, depression screening, patient lifestyle and risk reduction advice, and research opportunities. Actions implemented included sharing audit findings across OA CMHTs and creation of a MAMS how-to guide for clinicians. The how-to guide includes a MAMS assessment checklist and a standard information pack for patients and carers. A follow-up audit is planned one year after the MAMS how-to guide is instated.

Antipsychotic-induced hyperprolactinaemia is a common adverse effect associated with dopamine-blocking medications. Persistently raised prolactin is linked to sexual dysfunction, infertility, and importantly, reduced bone mineral density and osteoporosis. Concerns were raised that prolactin monitoring within the service was inconsistent and that raised levels were not always acted upon, posing potential long-term risks.

• • Assess whether patients prescribed antipsychotics had prolactin levels appropriately monitored, during my psychiatry placement at the Early Intervention team in Adult psychiatry.

• • Determine whether elevated prolactin prompted clinical action.

• • Identify gaps in monitoring practice and associated risks to bone health.

• • Provide recommendations to improve standards of care.

A retrospective audit of referrals over a six-month period was performed usingRiOelectronic records.

• • Patients not on antipsychotics were excluded.

• • For eligible patients, the following were reviewed:

  1. Antipsychotic medication.

  2. Whether prolactin was checked.

  3. Whether levels were normal or raised.

  4. Documentation of any medication adjustment or follow-up.

• • Comments were added to highlight missed monitoring opportunities or incomplete documentation.

• • Total referrals reviewed: 43

• • Excluded (not on antipsychotics): 20

• • Included for audit: 23

Key Findings:

• • 6/23 (26%)hadno prolactin test despite being on antipsychotics.

• • 15/23 (65%) had normal prolactin results.

• • 2/23 (9%) had raised prolactin, with one severe elevation (4155.6 mU/L).

Only 1 patient had clear medication adjustment in response to raised prolactin

Implications for Bone Health:

• • Persistent or unmonitored hyperprolactinaemia increases osteoporosis risk.

• • No consistent documentation linking raised prolactin to bone-health outcomes (e.g., DEXA, vitamin D).

Overall, the team demonstrates good awareness and management of prolactin-related issues, with most patients receiving appropriate monitoring and normal results. When significantly raised prolactin levels were identified, clinicians acted promptly with medication review and plans for follow-up, reflecting good clinical practice.

The key learning point is the value of maintaining this strong standard while improving documentation clarity and ensuring timely follow-up of repeat prolactin testing. No major pathway changes are required; instead, small refinements can further strengthen already effective care.

The QIP identified only one patient with raised prolactin who had not yet received a medication adjustment.

The primary aim of this project was to assess the current knowledge and confidence levels of medical employees regarding the management of transgender patients within the Kent and Medway Mental Health NHS Trust (KMMH). Against a background of recent legal changes and scarce guidelines, we hypothesised that despite likely clinical exposure to this demographic, staff confidence and awareness of specific policies would be low. The results are intended to drive the development of a dedicated Trust policy and training curriculum.

This project was designed as a service evaluation utilising an anonymous electronic questionnaire distributed to medical staff by the medical education team. The survey consisted of five questions addressing clinical experience, self-reported confidence, training history, and awareness of gender reassignment processes and relevant guidelines. Qualitative data were also collected through free-text comments. Data collection and analysis focused on quantifying the gap between patient contact and provider preparedness.

A total of 43 completed responses were received from over 300 medical staff. The data revealed that while the vast majority of staff (83.7%) had been involved in the care of transgender patients, confidence remained low. Only 41.9% of respondents felt “quite confident” managing these patients in a mental health setting, with 58.1% reporting they were “not confident”.

Gaps in education and governance were prominent. Eighty-six per cent (86%) of respondents stated they had received no training in the management of transgender patients. Furthermore, 60.5% were unaware of current gender reassignment processes in the United Kingdom (UK), and 79.1% were unaware of any national guidelines or hospital policies regarding healthcare for this group. Qualitative feedback supported these figures, with staff requesting specific training on pronouns, legal frameworks, and “user perspectives” from the trans community.

The audit demonstrates a significant disparity between the high frequency of clinical contact with transgender patients and the low levels of staff training and confidence. The widespread lack of awareness regarding existing guidelines indicates an urgent need for the formalisation of Trust policies and the implementation of targeted educational workshops. Improving staff knowledge is critical to mitigating risk and ensuring effective, respectful care for transgender service users.