1. Introduction  Restricted patients  The importance of the RMO annual report  Most reports are of a high standard  Reminder: risk assessments!

2. Restricted Patient Annual Report Completion Jan-July 2014 Dr Jackie Drummond ST6 in Forensic Psychiatry 22 nd May 2015

3. Background  Responsible Medical Officers (RMOs) are required to provide Annual Reports for restricted patients (CORO, TTD, HD)  Memorandum of Procedure (MoP) (2010) contains a template  Some Annual Reports not aligned to template, have unclear opinions or opinion is not supported by any justification  Since 2012, RMOs have been notified by the Restricted Patient Team if their report is deemed not to meet the standards outlined in the MoP  RMOs given 4 weeks to amend, and if not satisfactory the Restricted Patient Team will contact their Medical Director  Audit completed at the request of the PMO and Restricted Patient Team to evaluate whether or not RMOs were using the template and how complete reports are

4. Method  All annual reports submitted in first 7 months of 2014  Files obtained  Compared content and layout of annual reports to MoP template  Recorded  Timeliness of reports  Whether data was present or missing, using Microsoft Excel  Did RMO appear to be using the MoP template?

5. Sample  154 reports  10 NHS health boards, 3 private providers  Security levels  High – 45  Medium – 41  Low/other ward – 42  CD – 26  Orders  CORO – 132 (inc. CD)  TTD – 20  HD – 1  TTD + ICO – 1

6. Results  Reports on time/overdue  On time – 84  Late – 68  Unknown – 2 (date received not clear from file)  Late reports  Range from 1-52 days late

7. Results  Assessed completion of 25 items as detailed in MoP template (excluding patient name and DoB) Patient detailsDiagnosis and Treatment Risk ManagementOpinion and Recommendations 1. CHI/Hosp. no8. Diagnosis16. Date RMP updated 24. Legal tests 2. Legal status9. Mental state17. Amber/red incidents 25. Level of security 3. Index offence10. Activities18. Adverse incidents 4. Date of original order 11. Progress19. Change in level of risk 5. Date of renewal12. Treatment20. Media/victim issues 6. Date of tribunal13. Compliance21. Drug and alcohol issues 7. MAPPA level14. Changes in circumstances 22. Dates and results of testing 15. Response to SUS23. CPA minutes

8. Results  Section 1 - Patient details  All reports contained patient name and DoB YesYes (in body of text) No% of reports with data missing CHI/Hosp. no146085.1% Legal status14841 (+1 wrong)1.3% Index offence115162314.9% Date of original order 1347138.4% Date of renewal 9725535.7% Date of tribunal 29311876.6% MAPPA level10424831.2%

9. Results  Section 2 – Diagnosis and treatment YesYes (in body of text)No% of reports with data missing Current Dx1183331.9% Current mental state 904715 (+ ‘stable’ x2) 11% Activities81433019.4% Progress since last report 1014853.2% Treatment76582013% Compliance60692516.2% Changes in circumstances 61563724% Response to SUS (where applicable) 47453628.1%

10. Results  Section 3 – Risk Management YesYes (in body of text) No% of reports with data missing Date RMP updated88-6642.9% Amber/red incident details 59425334.4% Other adverse event details 60732113.6% Change in level of risk 55158454.5% Media/victim issues62256743.5% Issues with D&A66493925.3% Dates and results of testing 62197347.4% CPA minutes enclosed? 108-4629.9%

11. Results  Section 4 – Opinion and Recommendation

12. YesExplained?No% of reports with data missing Mental disorder153Yes in 45, Dx only in 106, no in 2 10.65% Serious harm138Yes in 107, no in 3116 (inc. 4 TTDs) 10.4% Medical treatment*153Yes in 140, no in 1210.65% Significant risk*151Yes in 128, no in 2321.31% CO(TTD/HD) necessity*152Yes in 128, no in 2410.65% RO necessity (where applicable - 132)* 130Yes in 111, no in 1910.76% Detention in hospital (N/A in 26 CDs - 128) 121Yes in 106, no in 1575.5% Special security (N/A in 26 CDs - 128) 79Yes in 53, no in 264938.3% Other security (N/A in 71 CD/special security – 86) 65Yes in 50, no in 151820.9%

13. Results  Legal tests – 22 reports (14.4%) did not address all legal tests. 1 report had page missing from file  Level of security – 19 inpatient reports (14.8%) did not mention either category of security level  Use of the Annual Report template as provided in the MoP  Exactly as per template – 48  Yes but with fewer headings – 44  Yes but with more headings – 13  Does not appear to follow template – 49  Overall, use of template apparent in 68.2%

14. Patient detailsDiagnosis and Treatment Risk ManagementOpinion and Recommendations 1. CHI/Hosp. no8. Diagnosis16. Date RMP updated 24. Legal tests 2. Legal status9. Mental state17. Amber/red incidents 25. Level of security 3. Index offence10. Activities18. Adverse incidents 4. Date of original order 11. Progress19. Change in level of risk 5. Date of renewal12. Treatment20. Media/victim issues 6. Date of tribunal13. Compliance21. Drug and alcohol issues 7. MAPPA level14. Changes in circumstances 22. Dates and results of testing 15. Response to SUS23. CPA minutes

15. Assessment of Completeness Patient detailsDiagnosis and treatment Risk management

16. Discussion  Majority of clinicians appear to be using Annual Report template (68.2%)  Just over half of Annual Reports are received on time (54.5%)  Most reports contain most of the information required!  Items which are most frequently missing are tribunal date, date of Risk Management Plan update, changes in level of risk and dates and results of alcohol/drug tests  49 reports state all test negative but no dates provided (although for purpose of audit information was considered to be present if report indicated that testing had been completed)

17. Discussion  Legal test which was most frequently not addressed was the ‘serious harm test’  The section which is least fully completed is the Risk Management section  Mean % completion  Section 1 – Patient details - 75.3%  Section 2 – Diagnosis and Treatment - 85.4%  Section 3 – Risk Management - 63.6%  Section 4 – Legal tests and Security Level - 85.4%  MoP is in process of being revised – an opportunity for RMOs to provide feedback on the Annual Report template!

18. Conclusion  Quality of Annual Reports remains variable, but overall the majority of reports contain most of the required information!  The standard template appears to have been adopted by most clinicians  The least fully completed section is Risk Management  It is helpful to provide some explanation of how the legal tests are considered to be met (or not)  A well written Annual Report is of value to the clinician as well as the Restricted Patient Team – a worthwhile time investment when facing a potentially difficult tribunal!