Medium Secure Unit Research Articles

Trauma History in a Medium-Secure Adult Male Forensic Mental Health Setting

Forensic services have shifted their focus to the importance of forensic practice becoming more trauma informed. Trauma exposure is pervasive in forensic mental health populations and has been found to negatively impact the course of severe mental illness (SMI) and increase risk of violence. This study aimed to explore the trauma histories of adult male inpatients in a medium-secure psychiatric hospital, and examine childhood and adulthood trauma as predictors of diagnoses, self-harm, suicidality, hospital re-admissions, substance use, and nature of offense. The case files of 85 male patients in a medium secure unit in the UK were reviewed. Eighty-seven percent of patients had a schizophrenia diagnosis and 86% had extensive trauma histories, the most common trauma type being physical violence in childhood (44.7%). One patient had a PTSD diagnosis. Logistic regressions demonstrated that cumulative childhood and adulthood trauma significantly increased the odds of self-harm. Cumulative childhood trauma exposure was found to decrease the likelihood of having a schizophrenia diagnosis. There is a serious under-recognition of the extent and consequences of trauma exposure; trauma histories are likely greater than the findings of this study and existing literature suggests. Implications for clinical practice, trauma-informed care (TiC), and future research are proposed.

Introduction of the DUNDRUM Triage Urgency Tool to a Medium Secure Unit in Bed Crisis

Introduction of the DUNDRUM Triage Urgency Tool to a Medium Secure Unit in Bed Crisis

Comparative analysis of characteristics among young people discharged from adolescent medium secure psychiatric hospital

BackgroundSpecialised forensic mental health provision for young people with mental disorders and high-risk behaviours has developed significantly in the UK. Despite this, research on the young people within secure settings remains limited. Adolescents in secure settings exhibit higher levels of mental disorders and have complex needs. This study aims to compare the demographic characteristics of patients discharged from an adolescent medium secure unit (AMSU) to different discharge destinations: community, another hospital, or custodial setting. MethodsA retrospective study was conducted using data from 155 patients admitted to a UK AMSU from 2008 to 2021. Demographic data, clinical information and Millon Adolescent Clinical Inventory (MACI) scores were extracted from electronic health records. A descriptive statistical method was used to report observational differences in patient characteristics between discharge locations. Statistical analysis included Chi-squared tests and AVOVA testing. ResultsPatients discharged to different settings exhibited distinct demographic and clinical characteristics. Those discharged to custodial settings were predominantly male and often transferred from custodial settings. Those discharged to other hospitals were mostly females with a diagnosis of Borderline Personality Disorder. The community-discharged group had a higher frequency of admissions from other hospitals under civil sections. Multiple variables were found to be statistically significant in relation to discharge location including gender and age at discharge. Findings of the MACI were not statistically significant in relationship with discharge location. ConclusionsThe study enhances understanding of healthcare transitions from AMSUs. The influence of diagnoses, particularly personality disorders, and their connection to admission duration is explored, as is the influence of this on transitioning patients across care settings. The impact of trauma-informed, attachment focussed models of care in regards transitions from AMSUs is also examined. Despite diversity in discharge locations, self-reported personality questionnaires show consistent outcomes, demonstrating psychological similarities across groups. Further research is needed to understand post-discharge trajectories enabling targeted interventions and improved care pathways.

A qualitative study exploring patient experiences of art therapy in a female medium secure unit

ABSTRACT This qualitative study is the first evaluation of patient experiences of art therapy within female secure mental health services. Data was collected using semi-structured interviews and analysed using thematic analysis in 10 patients with severe and enduring mental health conditions in a female medium secure unit in South London. Four themes (expression, connectedness, coping and sense of empowerment) and nine subthemes (the art therapist, the artwork, sense of belonging, building relationships, escapism, managing emotions, control, reflection, and achievement) were identified. These themes demonstrated the participants’ positive personal experiences of art therapy. Our results add to the body of evidence supporting the positive benefits of art therapy within inpatient mental health units. Escapism and achievement were highlighted as important themes that are often less valued in the professional literature. This provides new insight, and contribution that should be considered by clinicians to help to shape the future delivery of art therapy interventions within inpatient mental health settings. We hope this encourages others to study this topic further. Future research may wish to focus on whether there are measurable improvements in wellbeing from art therapy within forensic inpatient care.

Medium secure mental health care for young people: decisions to detain

Medium secure units are one component of secure mental health care for young people across the UK. No research has previously examined the appropriateness of admissions. This is a retrospective cohort study of all patients admitted to one unit by examining clinical notes for demographic, mental health and criminological variables. Descriptive data was statistically analysed to then characterise the cohort, audit against admission criteria and examine changes over time. There were 149 admissions. All patients admitted were male, most were 17 years old and from racialized groups. Most were detained under forensic sections with a primary diagnosis of psychosis. Four of five admissions met all 4 admission criteria. There were notable changes in use of forensic sections and risk over time. Our cohort differs from previous historical and contemporaneous cohorts in terms of diagnosis, legislation determining admission and ethnic breakdown. Our analysis relies on an interpretation of existing admission criteria but it suggests that not all admissions were appropriate, raising important practical, ethical and cost benefit questions. We suggest greater transparency about admission decisions to ensure that patients are admitted to the least restrictive setting needed and that national service planning is responsive to changes in demand.

How Do Patients, Carers and Mental Health Nurses Experience Their Contact With the Forensic Multidisciplinary Team in a Medium-Secure Unit? a Thematic Analysis

AimsClinical teams oversee the care of patients within secure psychiatric inpatient settings. They are made up of a number of professions, including psychiatrists, psychologists, occupational therapists, social workers and nurses. The effective collaboration of the different members of the clinical team is vital for its functioning. However, so is the team's interface with other key stakeholder groups, namely nursing teams, service users and carers. Understanding the needs and priorities of these groups regarding their relationships with the clinical team is also important to recognise and in the provision of good quality care. To understand the experiences, priorities and needs of stakeholder groups in their relationship with the clinical team. Gaining feedback from multiple sources (service users, carers, nurses) will help facilitate functioning of the clinical team in the delivery of excellent care to service users.MethodsEthical approval was granted by the host NHS trust. Between October 2019 and October 2021, three focus groups were conducted using a semi-structured interview to gather responses from carers, nurses and service users (6 participants in each group) respectively. The interviews were recorded and transcribed. Thematic analysis was used to code each transcript and themes were drawn from the coded data.ResultsDominant themes emerged from the three data sets. Consistent themes between groups included communication, hierarchy/power and representation. There were also differences in themes identified, with the carer group bringing the theme of education/ knowledge, and nursing group raising the value of human relationships, including compassion. The theme of transparency emerged strongly for the service user group.ConclusionThis study offers an interesting perspective on what distinct stakeholder groups want and value in their relationship with the clinical team. Gaining feedback from multiple sources (service users, carers, nurses and members of the MDT) can better inform a team about its functioning and help improve performance. Developing a tool to aid the systematic collection of multi-source feedback is the next step of this project, facilitating the voices of key stakeholder groups to be heard.

Co-producing a physical activity intervention in two forensic psychiatry settings in the UK: The IMPACT study

IntroductionIn the UK there are 3500 individuals detained in medium secure forensic psychiatry units. Service users in such settings have complex and serious mental illness (SMI), often with co-morbid physical health problems and a life expectancy of at least 10 years shorter than the general population. They often have low levels of physical activity. There is little evidence about physical activity interventions for medium secure service users in the United Kingdom.ObjectivesOur objective is to co-produce, with medium secure service users, the content and delivery of an intervention to increase physical activity. We shall assess feasibility, acceptability and pilot data collection methods for outcomes relevant for a future randomised controlled trial.MethodsThis is a 24-month mixed-methods project that will follow the Medical Research Council (MRC) framework Developing and Evaluating Complex Interventions. The study has 4 phases.- Phases 1-2 will gather information required to co-develop an evidence based intervention in Phase 3.- Phase 4 will assess the intervention in a feasibility study, evaluating and testing the intervention for a future pilot study.Study settings: Two NHS Medium Secure In-Patient Psychiatric Hospitals in the UK.ResultsThis paper presents the findings from the Phase 1 questionnaire and focus groups with service users and hospital staff that identified the barriers and facilitators to physical activity in such settings. The results are then discussed in relation to the Phase 2 qualitative results that explored stakeholders’ and service users’ opinions into how to increase physical activity among medium secure service users by identifying potential elements for inclusion in a physical activity intervention, to gain insight into how we can establish engagement of this group with the intervention, maintain commitment, avoid drop-out and develop the intervention design. All findings are presented using the Capability, Opportunity, and Motivation Model of Behaviour (COM-B model), which is widely used to identify what needs to change for a behaviour change intervention to be effective.ConclusionsThe findings of Phases 1-2 are allowing the team to move forward with Phase 3 that is currently developing an intervention to increase physical activity for adult inpatient service users in the medium secure units. This phase will be guided by the MRC framework and the COM-B model to define the target behaviours and select the most suitable intervention components (functions and techniques) and implementation approach.Disclosure of InterestNone Declared

The utilisation of services by patients with psychosis who engage in antisocial behaviours

ABSTRACT Three pathways of antisocial behaviour and psychosis have been described. Three subgroups within a typology have been categorised as (i) schizophrenia preceded by conduct disorder (SZ+CD), (ii) offenders with schizophrenia and no childhood history of antisocial behaviour who begin offending at illness onset (SZ+AS), and (iii) offenders with schizophrenia (SZ). There are no studies investigating how the subgroups utilise services. This study aimed to examine the concurrent validity of typology and examine differences in service utilisation. The sample consisted of 77 male patients admitted to low- and medium-secure units in the United Kingdom. The subgroup of patients was determined from data collected from health records. Analysis assessed the difference in aetiological variables amongst the typology and examined the relationship of subgroup service utilisation. This study provided further evidence of distinguishing characteristics emphasising typology heterogeneity and found differences in service utilisation. The SZ+CD subgroup was more likely to have used services preceding a diagnosis of psychosis. Following the onset of psychosis, the SZ+AS and SZ subgroups had a higher proportion that used general adult psychiatry services. Those patients within the SZ+AS and SZ subgroups had a higher use of general adult services after psychosis onset. Understanding about how these subgroups utilise services will enable clinicians to develop effective management plans that address the distinct characteristics of offenders with psychosis.

Predictive Validity of the HCR-20v3 Compared to the HCR-20v3 with the FAM in Women

Recent findings have highlighted unique risk factors for female-perpetrated violence as well as limitations in its risk assessment. To address these shortcomings, the Female Additional Manual (FAM) was designed as a complementary tool for the gender-neutral framework of the Historical, Clinical, Risk Management-20 (HCR-20). Little research has been undertaken exploring the predictive validity of the FAM, particularly when used with the most recent version of the HCR-20 (HCR-20v3), leaving equivocal evidence in regards of its use in clinical practice. The present study compared the predictive validity of the HCR-20v3 with and without the FAM for inpatient violence. The sample consisted of 42 female forensic psychiatric patients in a low to medium secure unit in the UK. Results revealed a significant difference in the predictive validity of the HCR-20v3 compared to the FAM when assessing for physical violence and no significant differences between the instruments’ validity in predicting nonphysical and any violence. In line with existing literature, the HCR-20v3 was an overall good predictor of violence. While the FAM was less accurate than the HCR-20v3 at predicting physical violence, it achieved moderate to large effect size in predicting each category of violence. The findings provide a degree of support for using the HCR-20v3 when assessing the risk of violence in women but do not demonstrate improved predictive power when adding the FAM.

"My life isn't my life, it's the systems": A qualitative exploration of women's experiences of day-to-day restrictive practices as inpatients.

WHAT IS KNOWN ON THE SUBJECT?: Sometimes someone needs to be in hospital because they are struggling with their mental health and need some extra support but being in hospital can also be a difficult experience. There are a lot of restrictions in place in hospital, like locked doors, rules to follow and not much choice about what happens to you. Other research has found that these restrictions can feel difficult and stressful for people and so more research is needed about this. We wanted to know what being in hospital felt like for women in particular. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: We interviewed women who were in hospital because of their mental health about what it was like for them in hospital. The women told us that they felt powerless while they were in hospital. They sometimes felt like they were being punished and this could affect their mood and could lead to them hurting themselves. They also said that they were not always listened to by staff, and they found it difficult being away from their family and friends while they were in hospital. The women also told us that being in hospital could sometimes help them to feel safe. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Women should be looked after in hospital in a way that helps them to feel in control of what happens to them. They should be supported to be able to go outside the hospital on leave, to keep in touch with their family and friends, and they should be listened to by staff. A project called "safewards" has suggested some ways for helping to make hospital wards safer. They have suggested that everyone should be clear about what the rules are when they go into hospital and ways that staff could communicate more clearly with the people they are working with. Our research supports using these techniques. ABSTRACT: Introduction Inpatient care often involves restrictive interventions such as seclusion and restraint and restrictive practices that limit the person's freedom, rights and daily activities. Restrictive practice has not been the explicit focus in previous research; however, it often appears as an important theme, with participants identifying it can have a detrimental effect on their well-being. More research specifically on this topic in an inpatient setting is, therefore, needed. Women might be particularly vulnerable to adverse effects of restrictive practices compared to men as women generally occupy less powerful positions in society and more often experience abuse. Aims The study aimed to explore women's experiences of routine restrictive practices in mental health inpatient settings. Methods Twenty-two women who were currently inpatients on mental health wards were interviewed about their experiences of restrictive practices in hospital. Interviews were analysed using thematic analysis. Results An overarching theme emerged of powerlessness. Four key sub-themes were also identified: restrictions perceived as punitive, having no voice, impact of restrictions on relationships and restrictions providing safety and support. Discussion Although restrictive practices were found to provide the women with a sense of safety, they were also found to impact upon the women's well-being, leading to increases in self-harm and over-reliance on restrictions. Implications for practice This research highlights the importance of gender-informed inpatient services for women that foster independence, empowerment and allow women to have their voices heard. Safewards interventions such as clear mutual expectations and soft words could contribute to mitigating the impact of restrictive practices.

Implementation of Traffic Light System on food sold at Brockfield House Medium secure unit to help improve healthy food options

IntroductionPublic Health England published a report in 2017 on Obesity in Secure Mental Health units. A key finding was that not only is obesity and overweight more prevalenr in the population detained within mental health secure units (reported rates of up to 80%) than in the general population (around 60%), patients appear to be more at risk of weight gain when they are detained.Objectives 1.To implement a traffic light system on food and confectionaries sold at the shop at a Medium secure hospital. 2. Provide healthier food options at the shop by using traffic light system as a visual aid 3. To achieve weight reduction and promote healthy life style choices in patients admitted to our medium secure Forensic unitMethods1.Buying a new till system which is able to quantify what type of food is sold 2.Labelling food sold using traffic light system 3. Calculate the types of food sold following a three- month period after implementation.Results/Intended Outcome Traffic light system provides a visual aid to patients in choosing healthier food Patients in our medium secure unit achieve a reduction in their weight Traffic light system can be replicated/ adopted by other secure hospitalsConclusionsThe purpose of this research is to implement a traffic light system on food sold at a shop in our medium secure unit and that this will help improve food choices in the unit.DisclosureNo significant relationships.

Implementation of Traffic Light System on Food Sold at Brockfield House Medium Secure Unit to Help Improve Healthy Food Options

AimsPublic Health England published a report in 2017 on Obesity in Secure Mental Health units. A key finding of the review was that not only is obesity and overweight more prevalent in the population detained within mental health secure units (with rates of up to 80% reported) than in the general population (around 60%), patients appear to be more at risk of weight gain when detained. The report found evidence that there is a high risk of weight gain following admission, stemming from the combined effects of incarceration, ease of access to high calorific food, and the potential lack of access to recommended levels of physical activity. This project aims to; 1. Implement a traffic light system on food and confectionaries sold at the shop at a Medium secure hospital. 2. Provide healthier food options at the shop by using the traffic light system as a visual aid 3. To achieve weight reduction and promote healthy lifestyle choices in patients admitted to our medium secure Forensic unit.Methods1.Buying a new till system which is able to quantify what type of food is sold.2.Labelling food sold using a traffic light system.3.Calculate types of food sold following a three-month period after implementation.Results1.Traffic light system provides a visual aid to patients in choosing healthier food.2.Patients in our medium secure unit achieve a reduction in their weight.3.Traffic light system can be replicated/ adopted by other secure hospitals.ConclusionThe purpose of this research is to implement a traffic light system on food sold at a shop in our medium secure unit. It is hoped that by providing visual aids, patients have a means of easily identifying healthier food options. Choosing healthier food we hope will consequently result in weight reduction and overall improved lifestyle choices.

An Audit Cycle Highlighting the Rate of Chlamydia Screening in a Forensic Child and Adolescent Mental Health Unit in Birmingham

AimsChlamydia, a sexually transmitted bacterial infection caused by Chlamydia Trachomatis can result in long-term complications for affected individuals. The National chlamydia screening programme recommends screening at-risk young persons, however for the vulnerable patients at the Forensic Child and Adolescent Mental Health Service (FCAMHS), there has been no audit to determine the completion rate. This audit aim to (1) Determine the demographics of young persons on admission (2) To determine the rate of chlamydia screening as well as the percentage of patients who qualified for a Chlamydia screening(3) To determine the rate of documentation for completed tests.MethodsThis was a retrospective study. The medical electronic records of patients who met the inclusion criteria was searched. All the three mixed-sex adolescent forensic wards (2 medium secure units and one low secure unit) at FCAMHS Ardenleigh, Birmingham were sampled.All patients that were on admission aged above 15 years of age were recruited.A total sample size of 19 was obtained for the initial audit and 12 for the re-audit.Data collectionData were collected by the author for the initial-audit and re-audit by searching the clinical progress notes, the investigation results and the physical health rethink forms. An excel software was used for analysis.ResultsDemographicsThere were 11 males (57.9%) and 8 females (42.1%) in the initial auditIn the re-audit, there were 7 males (58.3) and 5 females (41.7). Some of the patients were still on admission at the time of the re-audit, hence the percentages were calculated differently. The mean age and average length of admission was also calculated.Chlamydia screeningIn the initial audit, the percentage of patients tested for Chlamydia was 11.5%, even though 36.8% of patients met the criteria for Chlamydia screening. In the re-audit, 25.0% were tested, and 41.7% met the criteria for Chlamydia screening.Physical health (Rethink) formsThe physical health form was completed for majority of patients 73.7% in the initial audit although, this was not compatible with screening rates. Before the re-audit was concluded, the physical health forms were no longer in use.ConclusionThe audit highlighted an overall improvement in the rate of screening following recommendations from initial audit. The inclusion of Chlamydia screening in admission processes could be useful in improving sexual health.

Attention Deficit Hyperactivity Disorder in a Male Medium Secure Unit

AimsThe worldwide prevalence of Attention Deficit and Hyperactivity Disorder (ADHD) in the adult population is estimated to be 2.5%. Prevalence studies have shown rates to be consistently around ten times higher in the prison population, but there is less known about secure psychiatric hospital populations. ADHD has relevance as a predictor for offending, for challenging behaviours when incarcerated, for lower quality of life and high costs for both the NHS and prison systems. This service evaluation aimed to establish estimated prevalence of ADHD within one male medium secure unit.MethodsA cross sectional review of computerised medical records for all service users on the male medium secure forensic unit took place, to identify those who met inclusion criteria. Service users who were too acutely unwell or had an established or pending diagnosis of ADHD were excluded.The Brief Barkley Adult ADHD Rating Scale (B-BAARS), a 5 minute screening questionnaire, was given to service users to complete. Anonymised responses were converted to electronic format and the compiled results analysed.ResultsThere were 125 service users at the time of information gathering, with 112 eligible according to inclusion and exclusion criteria. 2 of the excluded service users already had an ADHD diagnosis. 70 service users out of those approached, agreed to take part in the screening (62.5%). 2 out of 70 (2.9%) service users met criteria for a possible diagnosis of ADHD.ConclusionUsing the B-BAARS, 2.9% of service users on the male medium secure forensic unit reported clinically significant symptoms suggestive of a diagnosis of ADHD. This estimate is significantly lower than other studies in prison settings. When combined with the figure for service users with a pre-existing diagnosis, however, the figure is still higher than in the general population (5.5% compared to 2.5%), and illustrates that screening tools can have a useful function in forensic settings.There may have been methodological issues with this evaluation, including the self-reported nature of symptoms, the comparatively high level of functioning required to complete the questionnaire and the low response rate amongst the service users.This evaluation serves to increase awareness about ADHD in the forensic population in general. It also highlights the value of this simple screening tool, or one similar, to clinical teams on the forensic wards. The screening tool could be further utilised in low secure and women's services to establish if results are similar amongst these populations.

The Ligature Assessment Tool: the development of a structured tool to improve quality of reporting of ligature incidents

Of all deaths by suicide on psychiatric wards, 75% are due to hanging or strangulation by ligature. The act of tying a ligature is complex self harm risk behaviour and can be fatal. There is no consistent framework available to ensure that essential risk information is accurately captured following a patient tying a ligature. This leads to a variable quality of incident reports being generated in inpatient psychiatric wards, which can be challenging for the MDT to interpret second hand and understand the ligature risk in that case. Effective psychiatric care is underpinned by accurate and detailed documentation; thus comprehensive recording of ligature incidents is essential for recognising trends and risk factors, and in building a 'ligature tying profile'. A 'Ligature Assessment Tool' was developed to ensure that certain aspects of a ligature risk incident were recorded in a systematic way on the incident reporting system. The tool consists of 15 criteria and is in a semi-structured format. This was rolled out in a regional female medium secure unit. There was clear improvement in the quality of reports, with an increase in the detail included. For two patients, a 'ligature tying profile' was identified. Staff felt that the tool improved their documentation and was highly usable. Further work is ongoing; there is interest in use of the tool in general adult services and also in the national high secure service for women.

Transition outcomes for young people discharged from adolescent medium secure services in England: A qualitative study exploring adolescents’ and carers’ experiences

BackgroundYoung people in secure services present with multiple vulnerabilities; therefore, transition periods are especially challenging for this group. In this study, we followed up young people discharged from adolescent medium secure services to adult and community settings with the aim to explore transition experiences and outcomes.MethodsParticipants were recruited from 15 child and adult mental health services in England. We conducted qualitative semi-structured interviews with 13 young people, aged 18–19 years, moving from adolescent medium secure units 2–6 months post-transition, and five carers 1–3 months pre-transition. Thematic analysis was performed to identify predetermined or data-driven themes elicited from face-to-face interviews.ResultsThe findings indicated poor transition outcomes for young people with the most severe mental health symptoms and those who committed serious offences. Three overarching themes were identified: (1) unsettling environmental factors within adult services; (2) experiences of transition management and preparation and (3) parental experiences of transition process and engagement with adult services.ConclusionThe findings of this study indicate that young people and carers value ongoing involvement in the transition process by well-informed parallel care. They also highlight the need for a national integrative care model that diverges from the traditional ‘one-size-fits-all’ approach.

Elderly offenders at Wathwood Hospital: perspectives and practicalities

AimsThe following project explores where Wathwood Hospital stands in provision of services to its elderly patients.BackgroundThe only dedicated forensic medium secure unit for elderly offenders in England is the St. Andrews medium secure unit in Northampton with only 17 beds. Due to the limited beds, other units must accommodate elderly patients, which raises the question whether these units can provide the appropriate services for this very vulnerable population.MethodInclusion Criteria:Male>55 years of ageAdmitted from 2012 onwards (from when database was maintained)Data were gathered using patient electronic records including index offence, mental disorder, physical health comorbidities and discharge destinations. Patient identifiable data were anonymized to protect their identities.A staff survey was also conducted to find their perspective on managing elderly patients and whether Wathwood Hospital had the appropriate resources for elderly offenders in their area of work.ResultA total of 220 referrals were searched with only 9 patients >55 years. Index offenses, mental disorder diagnoses, physical comorbidities including cognitive assessments in the form of memory tests and brain imaging were also collated for identified patients from electronic patient records.Index offences included violence against person, arson, homicide, robbery, threatening behaviour and dangerous driving and affray. Diagnoses included learning disability, delusional disorder, paranoid schizophrenia, bipolar affective disorder, alcohol dependence, personality disorder and depressive disorder.Patients had multiple comorbidities such as diabetes, COPD, hypertension, coronary artery disease and musculoskeletal problems. Out of the nine admitted patients, only six had an ACE with an average score of 70.83. Five patients had brain imaging, with two normal results and the others showing some degree of atrophy and ischemic changes.Discharge destinations included medium secure units, low secure unit and prison. One patient unfortunately died during admission and four are still inpatients.A staff survey conducted showed their perspective on the challenges in managing elderly patients and whether Wathwood Hospital had the appropriate resources for them to work with elderly offenders in their area of work. All results will be explained through tables and graphs.ConclusionIt's evident that there are challenges in managing elderly patients in units not specifically designed to manage them. This is also due to the lack of geriatric training and resources available to allied health care professionals to carry out their respective work. It's therefore crucial we formulate more inclusive strategies to address these challenges.

Vitamin D monitoring and management within men's secure services

AimsTo audit the investigation, identification and treatment of Vitamin D deficiency within Men's Secure Services.BackgroundVitamin D and/or vitamin D deficiency has been suggested to play a role in the pathogenesis of mental illness. There is evidence that Vitamin D inadequacy is pandemic among rehabilitation patients in inpatient settings. Patients within secure hospitals are similarly considered to be at high risk, due to their limited solar exposure during often lengthy admissions. It has been suggested that these patients should be considered an ‘at-risk’ cohort, for whom Vitamin D supplementation should be routine. Men's secure services in Birmingham comprise of two medium secure units and a low secure rehabilitation unit. Here we present an audit of Vitamin D monitoring and treatment completed in 2019.MethodA three year retrospective review of electronic patient records, for all inpatients admitted within men's secure services as of 1 September 2019 (n = 188). Standards were based on the Trust accepted guidelines for management of Vitamin D deficiency.ResultKey findings included:- The majority of inpatients were Caucasian (43%) and African-Caribbean (24%). Ages ranged from 18 to 70, with a mean age of 39.Approximately two-thirds (65%) had been in hospital for over a year, of which 44% had been admitted for more than 3 years. The average length of admission was 885 days.Only 47% of patients had their Vitamin D level checked within the study period.Of those checked, 24% were tested within 1 month of admission. The mean duration between admission and Vitamin D testing was 464 days.Results ranged from 10.3 to 118.5nmol/L. A high rate of Vitamin D deficiency was identified (54%), whilst a further 16% had ‘inadequate’ levels.23% of those identified as requiring treatment did not receive any supplementation, whilst 59% of those with sufficient Vitamin D were prescribed treatment.Only 48% had their levels rechecked following treatment; of these, only 59% now had an adequate Vitamin D status.ConclusionThis audit demonstrates limited Vitamin D monitoring within male forensic inpatients. There was a high prevalence of Vitamin D insufficiency in this population, yet a substantial proportion of patients with identified deficiency were not prescribed any treatment. Ongoing monitoring and review of treatment effectiveness was poor. We argue that more consideration should be given to this population, with robust guidelines introduced for the treatment of this specific ‘at-risk group’.

Is pregnancy status being assessed within women's secure services?

AimsTo establish rates of pregnancy testing on admission of women within a blended secure service.BackgroundWomen with psychiatric illness are known to be at increased risk of pregnancy, often due to engagement in risky sexual behaviours such as having a higher numbers of sexual partners and engaging in sexual activity whilst under the influence of drugs or alcohol. Awareness of pregnancy at the point of admission to psychiatric hospital would inform ongoing care plans to manage the pregnancy in the safest, least restrictive environment and inform future prescribing decisions, to minimise the risk of teratogenicity associated with some psychotropic medications. Ardenleigh in Birmingham is a blended female secure unit. No pregnancy screening guidelines for this population currently exist. This audit sought to establish current rates of pregnancy testing at the point of admission with a view to developing future guidelines.MethodA retrospective case note audit of electronic records of all patients admitted to Ardenleigh blended women's service as of 1st September 2019 (n = 26). The expected standard for pregnancy testing within one month of admission was set as 100%.ResultKey results include: The majority of patients (67%) were aged under 35 years (range 20–56). The most common ethnicities were Caucasian (42%) and African-Caribbean (38%). Almost half (46%) had a primary diagnosis of paranoid schizophrenia.Two women were known to be pregnant at the point of admission. Only 54% of women with an unknown pregnancy status were screened for pregnancy within one month of admission.Rates of screening were particularly poor in women aged under 25 years (43%) and between 36 and 45 (0%).Women not screened for pregnancy were typically admitted from other hospital settings, including AWA services (27%) or other medium secure units (55%). 2 women admitted from prison were not tested (29%)Of those tested, the majority were checked using urine hCG (92%).None of the women tested were found to be pregnant.ConclusionOverall pregnancy testing on admission to the unit was poor, with only 54% of service users screened. Less than 100% compliance could result in serious consequences for both the woman and unborn baby if a pregnancy is not discovered. Updating the admission checklist for Ardenleigh to include pregnancy testing may prove beneficial. It is recommended that a re-audit is completed 6 months following checklist introduction.

Long admission waiting list at the Orchard clinic-why?

AimsThe Orchard clinic is one of the three medium secure units in Scotland. This project was completed: To gain an understanding of the causes of the Orchard clinic's long admission waiting list.To use this information to improve current clinical pathways, service development and further research and development.MethodTo study the longitudinal traffic flow through the clinic from January 2017 to December 2019, data were collected for this time retrospectively from electronic minutes of fortnightly bed management meetings at the Orchard clinic.This was cross checked with the Orchard clinic's record of admissions and discharges during this time and approved by the Forensic Research and Audit Group, NHS Lothian.ResultNovember 2018 onwards, a surge of 90% was observed in the admission waiting list.Looking at the trends of traffic flow through the clinic during this time, the following observations were made:1. More admissions than discharges, especially November 2018 onwards.2. New referrals for medium secure care at the Orchard clinic peaked twice during this time.3. Delayed discharges peaked in July 2018 and further in January 2019 running parallel to the surge in admission waiting list thereafter.4. 42% patients on the delayed discharge list belonged to other health boards awaiting local low secure/community placements.ConclusionDelayed discharges were identified as a constant parallel to the long waiting list and hence identified as the main factor contributing to it. Out of area (non-NHS Lothian) admissions were noted to be linked to these delayed discharges.Regular peaks in new referrals was also noted to be contributory.