Competence in patients with mental illness is an issue of growing importance. We present a matrix that provides a new tool to separate the elements involved.

This matrix is compatible with, and makes explicit, the Richardson Committee's suggestions concerning the incorporation of a test of capacity in Mental Health Act assessments.

We suggest that use of this matrix may offer practical help to clinicians in arriving at a clear understanding of each clinical situation and guide good practice in the use of the Mental Health Act, particularly in problematic cases.

This paper describes a project to make all the patient letters held on secretaries' computers available 24-hours a day to improve patient care and risk management. Following a system audit a solution using existing resources was constructed.

The implementation of a uniform coherent patient letter naming and filing convention (the CLinically Useful Enquiry System) allowing rapid access to letters to support effective care without massive cost or disruption.

This process can be quickly, simply and cheaply replicated in any organisation with a network supporting e-mail and has the additional benefit of making transition to a future paperless system fast and economical.

To develop a guideline that would encourage a systematic approach for both psychiatrists and general practitioners in the provision of safe, effective and consistent management of patients who are prescribed lithium. A multi-disciplinary working group developed the guideline following literature review and consultation with lithium clinics and specialist centres nationally.

The Lothian lithium guidelines include three sections: (a) a lithium treatment plan; (b) advice for clinicians on managing lithium levels; and (c) pointers for counselling patients on lithium. The treatment plan is a key document in the guidelines which, once completed, ensures continuity of care with the transfer of patient-specific information.

This development has provided the opportunity for primary and secondary care services to work together in producing a guideline that will improve patient care and minimises risk.

To evaluate the first 2 years of a new adolescent unit.

One-hundred and eighteen cases were admitted, with a broad range of diagnoses. Median length of stay was 33 days and 82% of admissions were urgent, of which 70% were admitted on the day of referral. A later study of 27 consecutive cases showed a mean improvement of 25% in the Children's Global Assessment Scale and 40% in the Child and Adolescent version of the Health of the Nation Outcome Scales scores.

It is possible to provide an in-patient service for adolescents that includes all-hours emergency access, as well as catering for the full range of severe mental illness and a wide variation in length of stay.

To analyse violent and threatening behaviour occurring within an in-patient service. We surveyed recorded incidents over a 6-month period.

Ninety-six incidents were recorded. The patients involved were assessed as being aware of their actions. Police were contacted in five cases. No charges were pressed.

We believe that violence and threatening behaviours are excessively tolerated in learning disability units. Reasons for this include a staff culture of accepting offending behaviour and an unwillingness or inability to involve the police.

There is increasing evidence-based knowledge in the drug treatment of psychotic and behavioural symptoms in dementia, but drugs do not possess a formal licence for these indications. Drug companies, health authorities, NHS trusts and medical defence unions were asked for their advice on the medico-legal implications for the prescribing clinician.

Drug companies, health authorities, medical defence unions and NHS trusts are aware of out-of-licence prescribing and leave ultimate accountability with the clinician. A suggested best practice is that of obtaining the patient's consent.

Out-of-licence prescribing for psychotic and behavioural symptoms in dementia is widespread. This patient group may be unable to grant consent. The accountability of individual clinicians should be supported by more adequate medico-legal frameworks.

Specialist registrars (SpRs) in psychiatry spend only 3 years in this grade, with 1 day a week allocated to research. In view of this sizeable proportion of time designated for research, we undertook a postal survey of the experiences of and attitudes towards research of SpRs in developmental psychiatry.

A high proportion of respondents were involved in research at the time of the study, although half described difficulty starting and a third described difficulty taking the day. The majority of respondents believed research to be important and about three-quarters found it enjoyable.

While research remains a mandatory part of training it is important that trainers ensure that research time is protected.

Three cases are described to illustrate the elective use of etomidate in electroconvulsive therapy (ECT) anaesthesia.

Use of etomidate is described in an individual who was treated with an electrical stimulus at the maximum level for the ECT machine in use; in a person who had severe side-effects with an alternative induction agent; and in a person with severe cardiac disease.

The anaesthetic drug should be tailored to the individual needs of the person being treated with ECT. Clinics should involve local anaesthetic departments in reviewing their anaesthetic practice.