NICE guidelines recommend that patients started on antidepressants aged 18–25 years are reviewed 1 week after initiating treatment to check response. All other patients should be reviewed within 2 weeks. The audit aimed to evaluate if these guidelines are being met in Primary Care now that most mental health appointments have changed from face to face to telephone consultations post COVID-19.

Notes of 60 patients that had been started on an SSRI across the period of January 2022 – December 2022 at a North West based Primary Care practice were analysed. Time from initial consultation to medication review with a general practitioner (GP) and/or contact with a Mental Health Practitioner (MHP) within the practice were recorded. Consultation notes from MHPs were analysed for reference to tolerability of medication to assess if the patient's new treatment was discussed as part of support appointments.

Median time for initial follow-up of patients aged 18–25 years was 3 weeks demonstrating 8% compliance with NICE guidelines. Median time for initial follow-up for those >25 was 4 weeks, demonstrating 19% compliance with NICE guidelines. Of those that did not receive a follow-up with a GP within the suggested time frame, 20% met with a MHP for support with their condition and had side effects of new medication referenced in the notes. Within 4 weeks, 58% of patients had an appointment with a MHP where medication was mentioned. Median follow-up for anxiety disorders was 4.5 weeks compared to disorders of depression at 4 weeks. Patients new to the SSRI were followed up at a median of 3 weeks compared to 4 weeks for those that had completed a course previously.

Current follow-up of patients at the practice is not compliant with NICE guidelines. A practice meeting will be held to identify improvements to the patient follow-up process and look at the barriers patients face when arranging follow-up appointments. More than half of audited patients met with a MHP for support within 4 weeks of SSRI initiation. This highlights an opportunity to assess patients that are already meeting with practice staff when GPs have been unable to review them within the time frame. A pro-forma will be developed for MHP to utilise to specifically ask about medication. A repeat audit of both GP and MHP appointments will be completed in 6 months.

Recent reports and inquiries indicate that the potential, identified from the early days of the asylum era, for residents of psychiatric institutions to be subject to abuse has not been eradicated. The findings and recommendations of individual inquiries are often so specific to their unique context that it can be difficult to draw general principles that have wider operationalizability. The aims of this study are to thematically analyse available inquiry reports into health care institutions from the mid-20th century to the present using a ‘generalisable’ framework in order (i) to identify the key themes underpinning the concerns raised, and (ii) to analyse how themes change (or persist) over time.

Inquiries relating to concerns about the institutional care of patients over the past 70 years were identified. In this pilot study, a selection of available reports were subject to thematic analysis to address the first phase of the study (identifying themes underpinning concerns).

Four overarching themes were identified. The first three themes reflect the different levels of system analysis. Thus, the first theme, ‘the proximal dynamic,’ describes the nature of the interaction between staff and patients which is influenced by staff experience, attitude, and actions. The second theme, ‘the organisational dynamic’, comprises processes, policy and culture particularly, but exclusively, within the provider organisation. The third level of analysis, ‘the system dynamic’ theme, includes the influence on the concerns raised of the way the health system is configured (e.g. commissioning arrangements, and use of 'out-of-area' placements). The fourth theme, which cuts across the first three, is ‘the response to concerns’ which ranges from identifying early warning signs to responding to overt expressions of concerns (including whistleblowing).

Using thematic analysis to examine past inquiries into poor institutional care of patients, this study has identified a thematic structure which (i) emphasises that problems arise in a ‘dynamic’ that can be located at three levels of analysis (proximal, organisational and system) and (ii) includes a cross-cutting theme of the way concerns are responded to. This structure can be used as a learning framework for the current provision of inpatient services that has the potential to improve care in institutions, but this will require empirical testing.

Rampton Hospital is the High Secure Hospital of Nottinghamshire Healthcare NHS Foundation Trust's Forensic Service. It is one of three such hospitals in England, following Security Directions set out by the Department of Health. Patient management occurs through the implementation of strict policies and procedures. Policy requirements highlight the need for MDT post-incident discussion of restrictive interventions, and in particular, of Rapid Tranquilisation (RT). This primary audit aimed to ascertain current practice and if necessary, suggest interventions to ensure that patient-care remains safe, effective, and well-led.

To establish current practice with regards to the discussion of individual cases of RT in MDT settings, specifically in Ward Round, we commenced a retrospective data collection from electronic notes covering all directorates within the High Secure estate between May and June 2022.

From these notes, we tried to ascertain whether the following policy standards were being met:

• • A de-brief with the patient should take place as soon after the incident as is practicable and reasonable, ideally within 72 hours.

• • The MDT meeting post RT episode should explicitly discuss the episode, and consider medication and any triggers of periods of acutely disturbed behaviour.

• • There were 81 data sets to explore.

Not all data sets were viable. Out of those analysed, less than 10% were found to have met the aforementioned ideal policy standards of having had a reflective discussion within 72 hours with both the patient and as an MDT, exploring the episode itself and its antecedents.

There are several interesting factors to consider from the results obtained. We postulate that the frequency of episodes of RT makes meeting the policy standard problematic; pragmatically, there is a significant time barrier to exploring these incidents in detail and the various teams, operating in dynamic and high-risk environments, may find it difficult to coalesce in order to debrief appropriately.

Furthermore, the reflections may actually be happening, but the burden of documentation mean that these are not being recorded formally in a way that can be measured.

There are limitations to the searches of electronic notes and we did not have access to Incident Reports, often completed at the time of these episodes; further information may have been uncovered if they were available.

Despite this, there is room for interventions that inform staff of this need and to provoke improvements in current practice.