Despite the higher prevalence of learning disabilities among some minority ethnic communities and the greater burden of care, families from minority ethnic communities with a member who has learning disabilities are doubly disadvantaged as a result of racial discrimination and culturally inappropriate forms of care and service provision. This paper looks at the issue of discrimination, as well as the generally negative attitudes towards people with learning disabilities, and synthesises these into the concept of ‘double jeopardy’. It concludes by proposing ways of developing cultural competence in the delivery of care to this population.

In her article, O'Hara (2003, this issue) has concisely addressed the multitude of complex issues relating to ethnicity in people with learning disabilities, to their carers and to provision for services. The article brings out the interplay between culture, race, ethnicity and learning disability, using an interactional model.

Since the Woolf reforms were incorporated into legal practice in civil cases in England and Scotland, there has been a distinction between expert and professional witnesses. A common feature is the appointment of an agreed expert to give evidence on aspects of a case that require expert testimony. These changes do not apply in criminal cases nor in other jurisdictions such as the Republic of Ireland. However, all witnesses, whether professional or expert, must be objective, since their role is to assist the court. There is little or no training of clinicians in how to become an expert and suggestions for improving this are discussed. Practical aspects of accepting a brief from a solicitor are considered.

Thorough preparation is essential before going into the witness box as an expert witness. This involves, among other things, rereading all the case notes and other relevant documentation and being familiar with recent research in areas related to the case. Areas of probable disagreement between experts should be discussed during consultation with counsel, since cross-examination is likely to focus on these. A specific protocol applies in the courtroom, especially when in the witness box. The approach to examination-in-chief is outlined and the tactics used during cross-examination are described, as these can be used to undermine the evidence of the witness.

Patricia Casey's papers (2003a, b, this issue) cover the situation regarding expert witnesses in England and Wales and in Ireland. The situation in Scotland is outlined below.

Those who possess expertise or experience of a scientific or technical nature are often called to give evidence as a witness in a court or tribunal (in Scotland, he or she is known as a ‘skilled witness’). In so far as the expert witness expresses an opinion, that evidence is, strictly speaking, an exception to the hearsay rule. However, since the 16th century, the courts have admitted opinion evidence from anyone, not just a ‘professional’, who can assist the court on a scientific or technical matter which is an issue in the case and is beyond the knowledge of the court or tribunal. Frequently, the expert witness will be giving evidence as to fact as well as opinion. For example, the forensic pathologist who conducts a post-mortem examination will be able to give a factual description of the condition of the body and, at the same time, give an expert opinion on the cause of death. The forensic psychiatrist will similarly describe what has been determined about the patient on examination of his or her symptoms and express an opinion on the patient's mental health. There will be cases where the expert is supplied with factual data on which to express an expert opinion.

Mental health problems are the most significant cause of morbidity in prisons. Over 90% of prisoners have a mental disorder. The prison environment and the rules and regimes governing daily life inside prison can be seriously detrimental to mental health. Prisoners have received very poor health care and, until recently, the National Health Service (NHS) had no obligations to service this group, which was the Home Office's responsibility. The NHS is expected to take responsibility eventually, following a new health partnership with the Prison Service. NHS psychiatrists will have to be much more active in the development and delivery of health care to prisoners who now have the right to equal health care. There are positive developments but concerted and determined action is required to bring prison health care up to acceptable standards.

Psychiatrists have always been concerned about the mental health of prisoners. If they did not devote much energy to their treatment, it was only because they had more-pressing problems, including how to squeeze ten patients into nine beds. In any case, it was someone else's job to look after prisoners. Luke Birmingham's article (Birmingham, 2003, this issue) could not be more timely, as this situation has now changed. With the publication of The Future Organisation of Prison Healthcare (Prison Service & NHS Executive Working Group, 1999), and the creation of a joint Department of Health and Home Office task force, the Government has made it clear that the problem of mentally disordered offenders belongs to the National Health Service (NHS). There is a plan, there is a partnership and there are targets. Can those of us who have been worrying about prisoners with mental illness sit back and relax, as the solution unfolds?

Adequate sexual expression is essential to many human relationships and provides a sense of physical, psychological and social well-being. Epidemiological and clinical studies show that depression and schizophrenia are associated with impairment of sexual function and satisfaction, even in untreated patients. Most antidepressant and antipsychotic drugs have adverse sexual effects but it is difficult accurately to identify the incidence of treatment-emergent dysfunction, as disturbances can be reliably detected only from systematic enquiries made at baseline and during treatment. Growing awareness of the adverse effects of psychotropic drugs has led to attempts to use adjuvants or substitute treatments to resolve sexual dysfunction. More studies of the effects of antidepressant and antipsychotic drugs on sexual function are needed.

This paper considers how death and dying are presented in literature. A wide range of texts, principally but not exclusively from the English language tradition, is used to illustrate themes. Broad categories are suggested for the study of death: some authors give personal accounts of their impending death or their sense of bereavement; some use literature to structure and order our thoughts about death; and some treat death as a literary device, using it, for example, as a symbolic representation of the decay of society. It concludes that the biggest obstacles that health professionals and patients face as they attempt to understand death in literature are concerned not with a lack of appropriate emotional depth, but with difficulties either in understanding the conventions of literature or in coming to terms with the cultural gaps imposed by time and place.

Why? … because. This commentary to John Skelton's paper (Skelton, 2003, this issue) addresses the question, ‘Why should I, a busy consultant serving a population of 40 000 in north Lincolnshire and having considerable difficulty in keeping up with the latest developments about antipsychotic drugs, use my precious time for CPD reading about death and dying in literature?’ The answer is two-fold: death and dying is intrinsically an important and relevant subject for psychiatrists; and literature gives useful opportunities for modelling, comparing, contrasting and experimenting with circumstances removed from the patient's immediate situation but still recognised as ‘real life’. Great literature demonstrates authenticity. If the experiences described are true to life, perhaps the strategies that were used in this literary work, or are suggested through their absence, may be effective in your patient's (or even your own) predicament. Literature, or ‘the humanities', can enhance good practice in medicine (Evans & Greaves, 1999).

John Skelton's paper (2003, this issue) reminds us that literature can put into words thoughts and feelings which we might otherwise be unable to think or articulate. This is an important attribute and one which we can make use of in our attempts to help patients and families faced with life-threatening illness. It might also help those who have been bereaved to find meaning in what seems like a meaningless experience.

The pace of development and implementation of good information management systems has been disappointingly slow and the potential benefits of using patient information for secondary purposes have not been fully realised. The secondary use of patient data might be at the level of individual practitioners or teams, or at a local-service, regional or national level. Using patient data for purposes other than direct patient care requires an understanding of the principles of case-mix, standards for recording data, the limits of accuracy of data collected in routine practice and of the principles of data security and confidentiality. The alternatives to secondary use of information are to manage the mental health service without information about the people who use it or to gather this information through channels that run in parallel to the process of clinical care.

There are many potential pitfalls in the identification and enlistment of suitable candidates for psychiatric research. The challenges of recruitment are highlighted, detailing impact of study design, characteristics of participants, including demographics and personal preferences, investigator characteristics and collaboration with clinicians. Techniques used in recruitment are discussed, including financial incentives, assertive tracking and communication methods. Ethical issues, methods of data collection, and control participants are also considered. Key issues are: early consideration of the impact of study design on the recruitment process; the participant's perspective; close collaboration with colleagues; the investigator's good interpersonal, communication and organisational skills; and feedback to collaborators, associated clinicians and participants.