Civil and forensic patients in secure psychiatric settings: a comparison.

Aims and method To evaluate differences between male patients in secure psychiatric settings in the UK based on whether they are detained under civil or forensic sections of the Mental Health Act 1983. A cohort of patients discharged from a secure psychiatric hospital were evaluated for length of stay and frequency of risk-related incidents. Results Overall, 84 patients were included in the study: 52 in the forensic group and 32 in the civil group. Civil patients had more frequent incidents of aggression, sex offending, fire-setting and vulnerability, whereas forensic patients had more frequent episodes of self-harm. Clinical implications Secure hospitals should ensure treatment programmes are tailored to each patient's needs. Civil patients require greater emphasis on treatment of their mental illness, whereas forensic patients have additional offence-related treatment needs. Regular liaison between forensic and general adult services is essential to help ensure patients can return to appropriate settings at the earliest opportunity in their recovery.

End-of-life care in psychiatry: 'one chance to get it right'.

End-of-life care has been given increasing importance within healthcare settings. In June 2014, the Leadership Alliance for the Care of Dying People published One Chance to Get it Right. This nationally accepted guidance replaces previous end-of-life care pathways such as the Liverpool Care Pathway and outlines how dying patients should be managed irrespective of setting. Increasingly, patients with mental health problems are entering their final days of life within psychiatric in-patient or acute hospital settings, and psychiatrists need to be aware of the new guidance and ready to implement it within psychiatric practice.

Clozapine re-trial in a patient with repeated life threatening pneumonias.

BACKGROUND AND AIM OF THE WORK: There has been an increasing amount of evidence to suggest a link between Clozapine and pneumonia. Whilst an exact mechanism for disease causation has not been identified excess salivation, impaired swallowing and abnormalities within the immune system have all been implicated. Within forensic services there is often a need to treat complex patients with Clozapine, even when a past history of pneumonia is present. METHODS: We present a case report on a forensic inpatient who has suffered repeated episodes of Clozapine associated pneumonia and highlight methods for good practice. RESULTS: Where appropriate, Clozapine can still be used in complex patients who have suffered previous pneumonias and have additional risk factors for chest infections, provided that robust risk reduction, infection surveillance and treatment interventions are employed. CONCLUSIONS: Practical measures can be employed to enable safe treatment of forensic patients with Clozapine, this includes risk factors for chest infections being carefully controlled such as asthma, Chronic Obstructive Airways Disease or diabetes. Patients should be carefully monitored for signs of infection by way of regular physical examinations and appropriate tests when required. Should signs of pneumonia arise the dose of Clozapine may need to be reduced and the infection aggressively treated with antibiotic medication.

Clozapine-associated pneumonia and respiratory arrest secondary to severe constipation.

Clozapine is often the drug of choice within patients suffering from treatment-resistant paranoid schizophrenia. It has a complex side effects profile which includes potentially fatal agranulocytosis. Clozapine has also become increasingly associated with a range of other side effects including constipation and pneumonia. We report on a case of clozapine-induced severe constipation leading to a silent presentation of pneumonia with a subsequent respiratory arrest. To our knowledge, this is the first case report of pneumonia secondary to severe constipation occurring in the absence of respiratory aspiration of feculent vomitus. We suggest a new pathological mechanism by way of severe constipation leading to diaphragmatic dysfunction and subsequent clozapine-induced pneumonia. In addition, implications for clinical practice are outlined.

Completion of risk assessment and monitoring within forensic psychiatry.

There is a clear need for high standards of risk assessment and monitoring within forensic psychiatry. This has been highlighted by a number of high profile homicide enquires which have called for better standards of multidisciplinary risk assessment and monitoring. There are no national standards for risk assessment. We conducted a study to audit electronically the completion rate of a service-designed risk assessment document within Fromside, a medium secure unit in the UK. The completion rates for key sections of 64 risk assessment documents were assessed. Only 48 of the 64 (75%) documents were electronically available. The completion rates ranged from 59/64 (92%) for the retrospective risk review to 46/64 (72%) for relapse indicators. Only 35/64 (55%) risk documents were updated within the last three months. We found that the use of risk profile documents has helped achieve good standards of risk assessment, however greater priority needs to be given to ongoing monitoring. We recommend that consideration is given to the development of national guidelines for multidisciplinary risk assessment and monitoring.

An audit of basic record keeping standards: lessons learnt from the Royal College of Physicians.

This paper describes an audit of the basic standard of record keeping for inpatient clinical records. Following an initial audit, the Royal College of Physicians' inpatient record keeping standards 6 and 7 were adopted. The standard was then reassessed in a second audit. During the first audit, 189 medical entries were assessed and 274 were assessed on repeat audit. A significant improvement was achieved in many areas including recording of time (19-82%), name of author (60-89%), location of patient (58-94%) and identity of the most senior doctor present (68-89%), (p<0.001). The Royal College of Physicians' record keeping standards through the use of audit can lead to considerable improvement in the standard of record keeping within psychiatric practice.