Nottinghamshire Healthcare NHS Foundation Trust
NHS / Health Body
Action Taken
Nottinghamshire Healthcare NHS Foundation Trust has taken immediate actions including a teaching session on Psychogenic Polydipsia within the ‘Trustwide 2-day Physical healthcare Training’, sharing learning from Michelle’s inquest, and reviewing cases of polydipsia in secure settings. The Trustwide Nutrition and Hydration Policy is also under review to specifically reference psychogenic polydipsia. (AI summary)
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Dear Miss Bower
Regulation 28 Response - Michelle Whitehead November 2023
Please find below the Organisational response to the received Regulation 28 Report to Prevent Deaths following the death of Mrs Michelle Whitehead, the inquest of which was concluded on the 21st of September 2023. We offer our sincere condolences to Mrs Whitehead’s family and will ensure we also update Mr Whitehead with regards to actions in support of this.
1. The Trust’s Rapid Tranquilisation policy has not been sufficiently embedded through learning and development to ensure that all staff have a good working knowledge of the requirements for safely monitoring patients following the use of sedative medications. I heard evidence that ward staff had all received training on the policy as part of their initial induction, but all staff in this case had consistently failed to follow the policy, including senior ward leaders and medical staff, who informed the court that they were simply not aware of the necessary safeguards to monitor a patient’s consciousness level after administering tranquilisation medications, or how to do so when the patient was thought to be sleeping.
Response:
The Trust’s mandatory training requirements for Rapid Tranquilisation includes:
• All medical and nursing staff working in clinical areas that perform Rapid Tranquilisation must attend face to face training session every three years. As an annual refresher, an
21 November 2023
Private and Confidential
The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA
e-learning update or training video is required to be completed to ensure awareness of current issues in Rapid Tranquilisation and any procedural updates.
• Trainee Nursing Associates, Nursing associates and healthcare assistants, as important members of the ward team, are required to complete the e-learning package or training video annually to raise their awareness of the issues. They may also attend the face-to- face training as optional.
• It is also acknowledged that local training is delivered by Clinical Leads to support the face to face offer and understanding of the tools used in practice.
Our Learning and Development team oversee training delivery for Rapid Tranquilisation sessions to all staff in line with the mandatory requirements, face to face sessions are delivered by our Pharmacy colleagues. In addition to this, the Rapid Tranquilisation video is played following all Hospital Life Support (HLS) training sessions to ensure all staff who are required to complete an annual HLS refresher will also receive an update on rapid Tranquilisation.
The policy changes that have since been made will be reflected within the training offer to ensure all staff are aware of the additional monitoring requirements. We recognise that staff did not understand the policy standards as necessary and whilst training will be amended to reflect the subsequent changes relating to monitoring, a full training review in line with the learning from the inquest will be undertaken in relation to Rapid Tranquilisation to ensure we have the correct approaches in place post induction. For example, a review of the e- learning package to Health Care Support workers to ensure competency assessment features as part of this process.
To ensure training is embedded into practice, as an immediate action we have shared resource across our Forensics and Adult Mental Health care groups of the expertise of a Quality Improvement lead role who will be supporting the Trust is working with wards and services to embed the standards within the policy and ensuring that staff are familiar with this policy and expectations. This will include review of individual cases of RT post observation and staff case-based discussion learning. This is now in place and will remain under review with the learning and improvements monitored through Quality Oversight group.
The above resource will additionally be delivering bite-size teaching across the In-Patient units with a focus on post Rapid Tranquilisation Observations including NEWS2 and escalation.
All training that is offered will be amended in line with the policy changes outlined below regarding the post observation period.
The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA
There is a learning space for Junior Doctors within the Organisation will which be utilised to share the learning related to the use of Rapid Tranquilisation, ensuring those are sighted on the policy and the related changes.
Amendments to the policy as outlined further in this letter will be communicated Trust Wide in our Chief Executive briefing. Leaders will be tasked with cascading through team meetings, through supervision and overseeing the changes in practice. Associated monitoring tools are also in the process of being updated to understand compliance in practice.
2. The Trust’s Rapid Tranquilisation policy is not sufficiently clear on what action should be taken if a patient is considered to be unconscious during the period of monitoring or is felt to be asleep. The current iteration of the policy (revised after Michelle’s death) does not make it clear that any suspected unconsciousness should result in the immediate summoning of a doctor and alerting the ambulance service via 999. Further, the revised policy does not make it clear which vital sign observations should be undertaken and recorded if a patient is thought to be asleep in the period post rapidly tranquilisation and until the patient is ambulatory. This is despite the policy listing reduced consciousness and respiratory depression as known risks of sedative use, which can lead to death.
Response:
Immediate actions The Trust have responded to the concerns raised regarding the clarity within the Rapid Tranquilisation policy about the escalation requirements relating to known risks associated with the use of medication with Rapid Tranquilisation. The relevant section within the policy concerning escalation of a deteriorating patient has been amended to specifically respond to the risks of reduced consciousness, monitoring when a patient is asleep post rapid tranquilisation and the use of NEWS2 escalation.
In response to the learning, the Trust have revised our policy recommendations regarding the Rapid Tranquilisation post monitoring physical health monitoring, with consideration and focus to a patient who is asleep. The policy standard now states that for every patient who has received Rapid Tranquilisation, physical health monitoring must include NEWS2 observations every 15 minutes for the first hour and then hourly until the patient becomes ambulatory. If the patient is asleep post administration, the patient will be woken to assess the level of consciousness and to complete NEWS2 observations, every 15 minutes until ambulatory, or for a minimum of 3 hours with escalation as clinically indicated. The rationale for 3 hours of 15 minutes NEWS2 is derived from the peak concentrations of the medications used as part of Rapid Tranquilisation, recognising this is the period of increased risk of adverse effects. The use of continuous pulse oximetry to measure levels of oxygen saturation should be used
The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA
whenever possible, in addition to direct line of sight observations every 15 minutes. This is in addition to the requirements for more frequent and intensive monitoring being necessary for those patients with additional risk factors including seclusion, intoxication of illicit substances and where there is a relevant medical diagnosis which may place the patient at greater harm.
This is in addition to the expectation that all patients are continually observed by a competent staff member until ambulatory.
The use of NEWS2 monitoring includes the expectation that the observations include heart rate, blood pressure, respiratory rate, oxygen saturation, the use of ACVPU and temperature.
The above changes are to be reflected, with immediate effect, within the training offer provided for Rapid Tranquilisation as outlined in above section. In addition, Within the Trust Hospital Life Support training, the use of ACVPU scale for assessment of reduced consciousness is included, this has been strengthened to include the considerations and ability to differentiate a patient that is asleep versus a patient with reduced consciousness.
The changes made to this policy have been supported through the Trust senior medical colleagues and agreement for the significant policy changes to be communicated through the Associate Medical Directors into the Care Groups, the policy changes will be shared at the Medicines Optimisation Groups and Restrictive Practice groups which have a triumvirate representation.
Ongoing Monitoring and continued quality improvement.
Compliance with the application of this policy in practice will be monitored through the data collected from the Rapid Tranquilisation weekly ward-based audits. The oversight for this data is through the Care Group Restrictive Practice Groups with escalations and assurances reported to the Trust Medicines Optimisation Group. This work will be led by the Associate Director of Nursing Leads.
As outlined in the response above to the first concern within the report, to ensure training is embedded into practice, as an immediate action we have shared resource across our Forensics and Adult Mental Health services of the expertise of a Quality Improvement lead role who will be supporting the Trust in working with wards and services to embed the standards within the policy. This will include review of individual cases of Rapid Tranquilisation and the post monitoring phase. These reviews will be held with staff involved, following a case-based discussion learning method. This approach will ensure greater compliance with the policy expectations, improve staff confidence with embedding this in practice and increase oversight of the challenges. This is now in place and will remain under
The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA
review with the learning and improvements monitored through Care Group Quality Oversight group and Medicines Optimisation group.
The Trust recognise the need to continually engage with staff to understand the challenges faced when adhering to the expectations of the application of NEWS2. Staff focus groups for the use of NEWs2 will begin in December 2023 providing the opportunities to be clear on challenges faced in practice and appropriate actions.
The NEWS2 and Non-Contact Observations templates on RiO have been amended to create an alert for ward staff that when these observations are carried out due to Rapid Tranquilisation there is a mandatory requirement to change the frequency of observations as per the policy. This change will support the changes in practice and act as a reminder to clinicians as to the monitoring requirements.
In December 2022, our Learning and Development team began a roll out of a two-day Physical Health training package for Mental Health clinicians. The aim of the course is to support staff with the knowledge and skills to assess, monitor and manage the physical health needs of patients. The programme is based on recommendations by Health Education England (NHS England) Physical Healthcare competency Framework for Mental Health and Learning Disability Settings. The course content has also taken on board findings from clinical incident reviews, training needs survey and Trust physical healthcare objective agenda. With regards to this response, relevant sections within this include the assessment of the deteriorating patient including NEWS2 and SBARD, Medicine and the risk factors associated with antipsychotic medications. Since the introduction of this programme, a total of 233 staff have received this training.
3. The Trust’s current policy appears to depart from National guidance – NICE issued Rapid Tranquilisation Guidance in Notice NG10 in May 2015
The Trust advised me during the inquest that their policy was in line with other local mental health Trusts. However, a review of NICE guidance and other Mental Health Trust policies, available via a brief internet search, demonstrates differences in the advised monitoring protocols. I have shared with the Trust both the NICE guideline and a copy of the publicly available policy issued by a London Trust in February 2022 for comparison. The Trust should take urgent action to ensure their guidance is in line with National guidance, or where it departs, ensure there is sound clinical reason for doing so.
Response:
During the development of the Trust Rapid Tranquilisation Policy significant and extensive review of other Organisation’s policies took place in order to assist with benchmarking appropriate monitoring protocols this included national literature and evidence base. It is
The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA
acknowledged that there is significant variance in the monitoring protocols in place across similar Organisations.
Following subsequent review in the learning from this serious event, amendments to the Policy have been made and clarity has been added to the relevant sections that required ensure adequate safeguards are in place to manage the risks associated with the use of Rapid Tranquilisation.
During this review, consideration from the Trust Clinical Policies Group has taken place as to the need for primary evidence base and national body recommendations to form the basis of approval of Policies prior to the considerations of benchmarking against other Organisations.
4. Psychogenic Polydipsia – there appears to be no guidance, either locally or nationally, on the management of this condition, despite the research literature demonstrating that 50% of reported cases of over-hydration appear to be linked to psychosis. The Mental Health Commission for Scotland issued a report on the final day of Michelle’s inquest, related to the death of another mental health patient, Mr D, making recommendations for all NHS bodies to ensure staff have information to detect and manage acute physical health scenarios including polydipsia and water intoxication.
The Trust should take urgent action to ensure their staff are able to detect and manage this rare but potentially fatal condition. I shall include the Department for Health and Social Care, NHS England, NICE and the Royal College of Psychiatrists as recipients of this report, for information sharing purposes, as it may inform future discussion about the management of two important but separate features of metal health care that each carry a risk of death, namely, (a) the use of Rapid Tranquilisation and (b) the detection and management of Psychogenic Polydipsia.
Response:
Immediate actions The Trust have included a teaching session within the ‘Trustwide 2-day Physical healthcare Training’ for mental health staff on the symptoms, risk, and necessary escalation of overhydration including Psychogenic Polydipsia as a core training section. The sharing of the learning from Michelle’s inquest has and will continue to be shared to raise awareness in relation to Psychogenic polydipsia within staff groups. This includes within the Trustwide Dietitians Professional Advisory Group, physical healthcare staff and medical teams though continued professional development sessions, journal clubs, and Trustwide Physical Healthcare meetings as well as inclusion within the Trustwide Learning the Lessons Safety Bulletin circulated to all staff.
The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA
The learning from Psychogenic Polydipsia will be shared at the next Junior Doctor Journal Club as a conduit to ensuring that senior clinicians are familiar with this condition, are able to detect and consider the risks associated with this.
Short term actions The Trustwide Nutrition and Hydration Policy is currently under review – psychogenic polydipsia will be specifically referenced within the overhydration section, including risks, signs and symptoms and escalation – this review has commenced and planned to be finalised by the end of February 2024.
Following the learning from the inquest, the Trust have identified of a number of cases of polydipsia within our secure settings. A clinical case review of these patients will be undertaken to ensure the management of these patients is appropriate and support any learning and guideline development. The case reviews will be undertaken in December 2023, the learning from which will inform further actions necessary.
Regulation 28 Response - Michelle Whitehead November 2023
Please find below the Organisational response to the received Regulation 28 Report to Prevent Deaths following the death of Mrs Michelle Whitehead, the inquest of which was concluded on the 21st of September 2023. We offer our sincere condolences to Mrs Whitehead’s family and will ensure we also update Mr Whitehead with regards to actions in support of this.
1. The Trust’s Rapid Tranquilisation policy has not been sufficiently embedded through learning and development to ensure that all staff have a good working knowledge of the requirements for safely monitoring patients following the use of sedative medications. I heard evidence that ward staff had all received training on the policy as part of their initial induction, but all staff in this case had consistently failed to follow the policy, including senior ward leaders and medical staff, who informed the court that they were simply not aware of the necessary safeguards to monitor a patient’s consciousness level after administering tranquilisation medications, or how to do so when the patient was thought to be sleeping.
Response:
The Trust’s mandatory training requirements for Rapid Tranquilisation includes:
• All medical and nursing staff working in clinical areas that perform Rapid Tranquilisation must attend face to face training session every three years. As an annual refresher, an
21 November 2023
Private and Confidential
The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA
e-learning update or training video is required to be completed to ensure awareness of current issues in Rapid Tranquilisation and any procedural updates.
• Trainee Nursing Associates, Nursing associates and healthcare assistants, as important members of the ward team, are required to complete the e-learning package or training video annually to raise their awareness of the issues. They may also attend the face-to- face training as optional.
• It is also acknowledged that local training is delivered by Clinical Leads to support the face to face offer and understanding of the tools used in practice.
Our Learning and Development team oversee training delivery for Rapid Tranquilisation sessions to all staff in line with the mandatory requirements, face to face sessions are delivered by our Pharmacy colleagues. In addition to this, the Rapid Tranquilisation video is played following all Hospital Life Support (HLS) training sessions to ensure all staff who are required to complete an annual HLS refresher will also receive an update on rapid Tranquilisation.
The policy changes that have since been made will be reflected within the training offer to ensure all staff are aware of the additional monitoring requirements. We recognise that staff did not understand the policy standards as necessary and whilst training will be amended to reflect the subsequent changes relating to monitoring, a full training review in line with the learning from the inquest will be undertaken in relation to Rapid Tranquilisation to ensure we have the correct approaches in place post induction. For example, a review of the e- learning package to Health Care Support workers to ensure competency assessment features as part of this process.
To ensure training is embedded into practice, as an immediate action we have shared resource across our Forensics and Adult Mental Health care groups of the expertise of a Quality Improvement lead role who will be supporting the Trust is working with wards and services to embed the standards within the policy and ensuring that staff are familiar with this policy and expectations. This will include review of individual cases of RT post observation and staff case-based discussion learning. This is now in place and will remain under review with the learning and improvements monitored through Quality Oversight group.
The above resource will additionally be delivering bite-size teaching across the In-Patient units with a focus on post Rapid Tranquilisation Observations including NEWS2 and escalation.
All training that is offered will be amended in line with the policy changes outlined below regarding the post observation period.
The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA
There is a learning space for Junior Doctors within the Organisation will which be utilised to share the learning related to the use of Rapid Tranquilisation, ensuring those are sighted on the policy and the related changes.
Amendments to the policy as outlined further in this letter will be communicated Trust Wide in our Chief Executive briefing. Leaders will be tasked with cascading through team meetings, through supervision and overseeing the changes in practice. Associated monitoring tools are also in the process of being updated to understand compliance in practice.
2. The Trust’s Rapid Tranquilisation policy is not sufficiently clear on what action should be taken if a patient is considered to be unconscious during the period of monitoring or is felt to be asleep. The current iteration of the policy (revised after Michelle’s death) does not make it clear that any suspected unconsciousness should result in the immediate summoning of a doctor and alerting the ambulance service via 999. Further, the revised policy does not make it clear which vital sign observations should be undertaken and recorded if a patient is thought to be asleep in the period post rapidly tranquilisation and until the patient is ambulatory. This is despite the policy listing reduced consciousness and respiratory depression as known risks of sedative use, which can lead to death.
Response:
Immediate actions The Trust have responded to the concerns raised regarding the clarity within the Rapid Tranquilisation policy about the escalation requirements relating to known risks associated with the use of medication with Rapid Tranquilisation. The relevant section within the policy concerning escalation of a deteriorating patient has been amended to specifically respond to the risks of reduced consciousness, monitoring when a patient is asleep post rapid tranquilisation and the use of NEWS2 escalation.
In response to the learning, the Trust have revised our policy recommendations regarding the Rapid Tranquilisation post monitoring physical health monitoring, with consideration and focus to a patient who is asleep. The policy standard now states that for every patient who has received Rapid Tranquilisation, physical health monitoring must include NEWS2 observations every 15 minutes for the first hour and then hourly until the patient becomes ambulatory. If the patient is asleep post administration, the patient will be woken to assess the level of consciousness and to complete NEWS2 observations, every 15 minutes until ambulatory, or for a minimum of 3 hours with escalation as clinically indicated. The rationale for 3 hours of 15 minutes NEWS2 is derived from the peak concentrations of the medications used as part of Rapid Tranquilisation, recognising this is the period of increased risk of adverse effects. The use of continuous pulse oximetry to measure levels of oxygen saturation should be used
The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA
whenever possible, in addition to direct line of sight observations every 15 minutes. This is in addition to the requirements for more frequent and intensive monitoring being necessary for those patients with additional risk factors including seclusion, intoxication of illicit substances and where there is a relevant medical diagnosis which may place the patient at greater harm.
This is in addition to the expectation that all patients are continually observed by a competent staff member until ambulatory.
The use of NEWS2 monitoring includes the expectation that the observations include heart rate, blood pressure, respiratory rate, oxygen saturation, the use of ACVPU and temperature.
The above changes are to be reflected, with immediate effect, within the training offer provided for Rapid Tranquilisation as outlined in above section. In addition, Within the Trust Hospital Life Support training, the use of ACVPU scale for assessment of reduced consciousness is included, this has been strengthened to include the considerations and ability to differentiate a patient that is asleep versus a patient with reduced consciousness.
The changes made to this policy have been supported through the Trust senior medical colleagues and agreement for the significant policy changes to be communicated through the Associate Medical Directors into the Care Groups, the policy changes will be shared at the Medicines Optimisation Groups and Restrictive Practice groups which have a triumvirate representation.
Ongoing Monitoring and continued quality improvement.
Compliance with the application of this policy in practice will be monitored through the data collected from the Rapid Tranquilisation weekly ward-based audits. The oversight for this data is through the Care Group Restrictive Practice Groups with escalations and assurances reported to the Trust Medicines Optimisation Group. This work will be led by the Associate Director of Nursing Leads.
As outlined in the response above to the first concern within the report, to ensure training is embedded into practice, as an immediate action we have shared resource across our Forensics and Adult Mental Health services of the expertise of a Quality Improvement lead role who will be supporting the Trust in working with wards and services to embed the standards within the policy. This will include review of individual cases of Rapid Tranquilisation and the post monitoring phase. These reviews will be held with staff involved, following a case-based discussion learning method. This approach will ensure greater compliance with the policy expectations, improve staff confidence with embedding this in practice and increase oversight of the challenges. This is now in place and will remain under
The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA
review with the learning and improvements monitored through Care Group Quality Oversight group and Medicines Optimisation group.
The Trust recognise the need to continually engage with staff to understand the challenges faced when adhering to the expectations of the application of NEWS2. Staff focus groups for the use of NEWs2 will begin in December 2023 providing the opportunities to be clear on challenges faced in practice and appropriate actions.
The NEWS2 and Non-Contact Observations templates on RiO have been amended to create an alert for ward staff that when these observations are carried out due to Rapid Tranquilisation there is a mandatory requirement to change the frequency of observations as per the policy. This change will support the changes in practice and act as a reminder to clinicians as to the monitoring requirements.
In December 2022, our Learning and Development team began a roll out of a two-day Physical Health training package for Mental Health clinicians. The aim of the course is to support staff with the knowledge and skills to assess, monitor and manage the physical health needs of patients. The programme is based on recommendations by Health Education England (NHS England) Physical Healthcare competency Framework for Mental Health and Learning Disability Settings. The course content has also taken on board findings from clinical incident reviews, training needs survey and Trust physical healthcare objective agenda. With regards to this response, relevant sections within this include the assessment of the deteriorating patient including NEWS2 and SBARD, Medicine and the risk factors associated with antipsychotic medications. Since the introduction of this programme, a total of 233 staff have received this training.
3. The Trust’s current policy appears to depart from National guidance – NICE issued Rapid Tranquilisation Guidance in Notice NG10 in May 2015
The Trust advised me during the inquest that their policy was in line with other local mental health Trusts. However, a review of NICE guidance and other Mental Health Trust policies, available via a brief internet search, demonstrates differences in the advised monitoring protocols. I have shared with the Trust both the NICE guideline and a copy of the publicly available policy issued by a London Trust in February 2022 for comparison. The Trust should take urgent action to ensure their guidance is in line with National guidance, or where it departs, ensure there is sound clinical reason for doing so.
Response:
During the development of the Trust Rapid Tranquilisation Policy significant and extensive review of other Organisation’s policies took place in order to assist with benchmarking appropriate monitoring protocols this included national literature and evidence base. It is
The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA
acknowledged that there is significant variance in the monitoring protocols in place across similar Organisations.
Following subsequent review in the learning from this serious event, amendments to the Policy have been made and clarity has been added to the relevant sections that required ensure adequate safeguards are in place to manage the risks associated with the use of Rapid Tranquilisation.
During this review, consideration from the Trust Clinical Policies Group has taken place as to the need for primary evidence base and national body recommendations to form the basis of approval of Policies prior to the considerations of benchmarking against other Organisations.
4. Psychogenic Polydipsia – there appears to be no guidance, either locally or nationally, on the management of this condition, despite the research literature demonstrating that 50% of reported cases of over-hydration appear to be linked to psychosis. The Mental Health Commission for Scotland issued a report on the final day of Michelle’s inquest, related to the death of another mental health patient, Mr D, making recommendations for all NHS bodies to ensure staff have information to detect and manage acute physical health scenarios including polydipsia and water intoxication.
The Trust should take urgent action to ensure their staff are able to detect and manage this rare but potentially fatal condition. I shall include the Department for Health and Social Care, NHS England, NICE and the Royal College of Psychiatrists as recipients of this report, for information sharing purposes, as it may inform future discussion about the management of two important but separate features of metal health care that each carry a risk of death, namely, (a) the use of Rapid Tranquilisation and (b) the detection and management of Psychogenic Polydipsia.
Response:
Immediate actions The Trust have included a teaching session within the ‘Trustwide 2-day Physical healthcare Training’ for mental health staff on the symptoms, risk, and necessary escalation of overhydration including Psychogenic Polydipsia as a core training section. The sharing of the learning from Michelle’s inquest has and will continue to be shared to raise awareness in relation to Psychogenic polydipsia within staff groups. This includes within the Trustwide Dietitians Professional Advisory Group, physical healthcare staff and medical teams though continued professional development sessions, journal clubs, and Trustwide Physical Healthcare meetings as well as inclusion within the Trustwide Learning the Lessons Safety Bulletin circulated to all staff.
The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA
The learning from Psychogenic Polydipsia will be shared at the next Junior Doctor Journal Club as a conduit to ensuring that senior clinicians are familiar with this condition, are able to detect and consider the risks associated with this.
Short term actions The Trustwide Nutrition and Hydration Policy is currently under review – psychogenic polydipsia will be specifically referenced within the overhydration section, including risks, signs and symptoms and escalation – this review has commenced and planned to be finalised by the end of February 2024.
Following the learning from the inquest, the Trust have identified of a number of cases of polydipsia within our secure settings. A clinical case review of these patients will be undertaken to ensure the management of these patients is appropriate and support any learning and guideline development. The case reviews will be undertaken in December 2023, the learning from which will inform further actions necessary.