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.

AimsThere remain a number of barriers to patients taking HIV tests, and prevalence of HIV in patients with severe mental illness can be higher than those without. Patients in forensic settings may be at even greater risk. National standards state that in areas of high and extremely high prevalence of HIV, testing should be offered routinely on admission to hospital. A review of compliance with these standards took place across low and medium secure male forensic wards in West London, followed by implementation of targeted interventions to increase testing rates. A reaudit was later completed to assess if changes had resulted in lasting effectsMethodA retrospective review of computer records took place to identify all inpatients residing on the low and medium secure wards on the day of data collection. Their pathology records were checked to ascertain if HIV test results were available. If no test was documented here, then patient psychiatric records were searched for documentation of the test being offered.After the initial audit, education of patients and staff regarding the benefits of HIV testing took place, HIV testing was incorporated into primary healthcare routine admission screening and separate consent forms were eradicated.The reaudit took place with data collection occurring in an identical manner.Result183 patients were initially identified across 5 low and 7 medium secure male wards, and 184 on reaudit. The initial audit found that only 30.6% (56/183) of patients had either been offered an HIV test or had a result recorded on the pathology system, but this rose to 82.6% (154/184) on reaudit. After the interventions, 43.4% of all patients had HIV test results available, compared to 23.5% initially. Even where no test result existed, the number of tests offered rose from 7.1% to 39.1% of all patients.ConclusionThis study shows that simple measures to normalise HIV testing and make it part of routine admission screening had dramatic implications for the number of patients being offered an HIV test.There is still room for improvement, however, with 17.4% of patients having neither test results available, nor documentation that a test was offered. This could be a result of poor general engagement with health care services, and would benefit from thorough documentation and assertive outreach.

AimsThis project aimed to assess the use of handcuffs in a secure forensic mental health hospital.BackgroundHandcuffs are used by secure forensic psychiatric wards where patients need to leave the ward and require added restrictive measures for their own or other's safety. The decision to use handcuffs is made by the multi-disciplinary team, with the input of the unit's clinical security team and is assessed based on individual risk and need. This study investigated the frequency, duration and purpose of handcuff use in one secure forensic mental health unit, encompassing 8 male medium secure wards, 5 male low secure wards, 1 adolescent secure ward,1 female low secure ward and 5 female medium secure wards.MethodHandcuff use was recorded contemporaneously by ward staff in a specialised handcuff proforma. This data were then compiled to assess the number of instances of use, the mental health section applicable to the patient, the reason the patient needed to leave the unit, and the duration of use (including the time period for which the handcuffs were removed during the visit, if applicable.) Data from these forms over an 18 month period were analysed.ResultOver the 18 months, there were a total of 347 uses of handcuffs, with an average of 18.3 occurrences per month. In 55 cases, the patients were detained under a civil section, with the remaining instances occurring in patients detained under forensic section. 47% were unsentenced prisoners.The most common destination for patients was the general medical hospital, which accounted for 49% of all visits. Court was the second most common destination, with 39% of uses.The average duration spent in handcuffs was 3.3 hours. The average time that the handcuffs were taken off during the transfer was 1.2 hours.ConclusionThrough ongoing education and supervision by the clinical security team, handcuff use in this forensic service was limited to essential situations, most often to allow treatment of physical health issues off-site. A large proportion of instances involved unsentenced prisoners and court attendances, where the risk of absconsion might be particularly high. Duration spent in handcuffs was kept to a minimum, with cuffs being removed where possible. The service strives to continue such good practices and to identify further ways to reduce handcuff use, such as using video-conferencing as an alternative court attendance.

AimsCentral and North West London's Clinical Ethics Committee (CEC) offers a non-judgmental space to discuss ethical concerns and challenges and provide ethical guidance. This project aims to publicise these ethical dilemmas and guidance to inform decision making trust-wide.BackgroundA Clinical Ethics Committee (CEC) encompasses a diverse range of figures, from psychiatrists and general practitioners to members of the clergy and experts by experience. The CEC in Central and North West London have been meeting regularly since 2003 to provide ethical assistance to a wide range of medical, surgical and psychiatric teams. Complex ethical cases are presented by the treating team, allowing a subsequent discussion of the ethical theories and frameworks within the case with the committee members. This synthesis of information can then assist the treating team in the shaping of ethical based solutions to their dilemmas.The committee wished to encourage ethical based clinical thinking within the trust and enable others to learn from the valuable insights already provided by the CEC over the years.MethodCase notes, recorded from the last 17 years of meetings of the Clinical Ethics Committee were reviewed. 98 cases were identified between 2003-2019. The contemporaneous case reports were then anonymised and indexed into one easy to use file. This file was published on the local intranet and publicised to staff.ResultThe cases were compiled into a PDF document which is available for all staff members within the trust on the intranet. This resource is open to all clinical staff, and serves the dual purpose of encouraging ethical-based thinking and also promoting the ethics committee to those who might be in need of assistance.ConclusionClinical decisions can be complex and nuanced, often complicated by multiple viewpoints and ways of thinking. The database demonstrates the use of ethical dimensions by the ethics committee to inform decision making in a series of varied clinical and management dilemmas. The project required careful consideration around preservation of confidentiality as well as overcoming the logistical barriers of trust-wide dissemination. The result is a document that will allow ethical based decision-making to be embedded into everyday practice.