Dr R L – Consultant Forensic Psychiatrist
I have prepared expert psychiatric reports and given expert witness evidence in Court on the instruction of the defence, CPS, Probation and at the direction of the Court, covering issues such as fitness to plead, insanity, diminished responsibility, capacity to form intent, mental illness, disposal, and the imposition of civil orders. I also have prepared a large number of reports on parents involved in Child Protection cases and Care proceedings. I have also been trained in and have extensive experience of assessing Risk of Harm to others. The principle tools I use are the Hare Psychopathy Checklist Revised version (PCL-R) and the Historical Clinical Risk Assessment (HCR 20). I have been approved by the Secretary of State under Section 12 (2) of the Mental Health Act 1983 as having special experience in the diagnosis and treatment of mental disorder since 1999.
B. Med. Sci. (Hons) 1987 Nottingham
B.M., B.S. 1990 Nottingham
T (GP) 1994 U.K.
M.R.C.G.P. 1995 U.K.
M.R.C.Psych 1999 U.K.
C.C.S.T. (Forensic Psychiatry) 03/03 U.K.:
Diploma in Cognitive Analytic Therapy 2006 UEA, UK
Aug 1990 – Jan 1991 Medical House Officer, Derbyshire Royal Infirmary, Derby, England
Feb 1991 – July 1991 Surgical House Officer, Nottingham City Hospital, Nottingham, England
Senior House Officer (Training posts)
Aug 1991 – Jan 1992 General Medicine & Rheumatology, Princess Alexandra Hospital, Harlow, England
Feb 1992 – July 1992 General Medicine, Oncology & Radiotherapy, Derbyshire Royal Infirmary, Derby, England
Aug 1992 – Jan 1993 General Medicine & Endocrinology, Derbyshire Royal Infirmary, Derby, England
Feb 1993 – July 1993 Obstetrics & Gynaecology, Nottingham City Hospital, Nottingham, England
Vocational Training Scheme for General Practice (Peterborough)
Oct 1993 – Mar 1994 Registrar in General Practice, Market Deeping Health Centre, Lincolnshire
Apr 1994 – Sep 1994 Registrar in General Practice, St. Mary’s Medical Centre, Stamford, Lincolnshire
Oct 1994 – Jan 1995 Registrar in Rheumatology (locum post), Derbyshire Royal Infirmary, Derby
Psychiatric Rotations (Basic Specialist Training)
Peterborough Training Scheme
Training Supervisor – Dr Hasha Fernando
Feb 1995 – April 1996 Psychotherapy Training (Psychoanalytical psychodynamic)
Dr Nicola Blandford, Psychotherapist
1 patient: 40 hourly sessions. Weekly supervision
Feb 1995 – July 1995 Psychiatry for the Elderly
Dr Birgit Nilakantan, Consultant Psychiatrist
Peterborough District Hospital, Peterborough
Aug 1995 – Jan 1996 Adult Psychiatry / Drugs and Alcohol
Dr Hugh Kilgour, Consultant Psychiatrist
Peterborough District Hospital, Peterborough
Feb 1996 – May 1996 Adult Psychiatry with a special interest in Forensic Psychiatry
Dr Simon Barnett, Consultant Psychiatrist
Peterborough District Hospital, Peterborough
Wellington Training Scheme, New Zealand
Training Co-ordinator – Dr Joanna Macdonald
May 1996 – June 1996 Child, Adolescent and Family Psychiatry
Dr. Peter Zyminisky, Consultant Psychiatrist
Wellington, New Zealand
June 1996 – Dec 1996 Liaison Psychiatry
Dr. Stokes Taylor, Consultant Psychiatrist
Lower Hutt, New Zealand
Dec 1996 – June 1997 Acute Community Psychiatry
Dr Alison Brown, Consultant Psychiatrist
Lower Hutt, New Zealand
June 1997 – Dec 1997 Child, Adolescent and Family Psychiatry
Drs Susan Perry & John Lambe
Lower Hutt, New Zealand
Dec 1997 – May 1998 In patient Unit, Adult Psychiatry
Drs Victor Morcos & Sheila Gordon
Te Whare Ahuru,
Hutt Hospital, New Zealand
Returned to the UK
June 1998 – Sep 1998 Rehabilitation Psychiatry (locum post)
Dr Steve Fallows & Dr Harry Andrews
The Rutland Unit, Leicester
Leicester Training Programme
Clinical Tutor – Dr Alan King
Sep 1998 – Jan 1999 Forensic Psychiatry
Dr Adarsh Kaul
East Midlands Medium Secure Unit, Leicester
Feb 1999 – Jan 2000 General Adult Psychiatry
Dr. Andrew Briggs
Stamford Resource Centre, Stamford, Lincolnshire
Feb 2000 – Mar 2000 General Adult Psychiatry (Academic Unit)
Professor Michael Reveley
Leicester General Hospital, Leicester
East Anglian Higher Training Scheme In Forensic Psychiatry
(Specialist Registrar posts)
(3 year rotation)
Mar 2000 – Mar 2001 Forensic Psychiatry in Medium Security
(First year) Clinical supervisor: Dr Girish Shetty
The Norvic Clinic, Regional Medium Secure Unit of East Anglia, Norwich
Staff: 3 Consultants: Dr Ann Stanley, Acting Clinical Director
Dr Girish Shetty
Dr Chris Jones
Also the following Consultants have responsibility for some beds in the Norvic Clinic:
Dr Bodham Solomka (also covers 11 low secure beds in St Clement’s hospital, Ipswich)
Dr Olivia Guly (also 9 medium secure beds and 4 PICU beds in Coastlands, Great Yarmouth)
Dr Barbara Rudzinski (also 9 Rehabilitation beds in Heron Lodge, Hellesdon Hospital)
The following Consultants have clinical input to the Norvic Clinic:
Dr Hadrian Ball, Medical Director (does 1 day clinical work a week)
Dr Val Hawes, Consultant to DSPD project in HMP Whitemoor
3 SpRs, 1 Staff Grade, 2 SHOs, 5 CPNs, 2 Social Workers, 2 Clinical Psychologists, 1 Art therapist, 1 Dance & Movement therapist, 3.5 Medical Secretaries
Beds: 56 [including Meadowlands (18) and Highlands (5)]
In-patients have access to physiotherapy and occupational therapy.
Mar 2001 to April 2001 Special Hospital Experience
Clinical supervisor: Dr Kim Page
Rampton High Security Hospital
I spent two months in Rampton hospital attached to Dr Kim Page who works in the male mental illness directorate. My aim was to not just gain valuable clinical experience with this group of patients but also obtain an understanding of how the hospital operates in accepting, treating and discharging patients. To this end, I attended the hospitals referral meeting and assessment panel. I was involved in three assessments of patient referrals with three different Consultants and prepared reports for two of the cases. Although my time in Rampton hospital was brief, I felt I did obtain some understanding of how a special hospital ‘works’.
May 2001 – April 2002 Forensic Psychiatry in Medium Security
(Second year) Clinical supervisor: Dr Ann Stanley
The Norvic Clinic, Regional Medium Secure Unit of East Anglia, Norwich
May – July 2002 Locum Consultant Forensic Psychiatrist
Park House, Huntingdon
Staff: 0.6 Consultant, 1.5 CPNs, 0.5 SW, 0.2 Clinical Psychologist, 0.5
For 3 months, I worked in this locum Consultant post covering the clinical duties of Dr Adrian Grounds who had been seconded to the Department of Health to complete some research. It was a part time post (3 days a week) which allowed me to continue with my research and CAT work.
The forensic service in Huntingdon is very small and limited. There are no in-patient beds and no junior medical staff. The service mainly provides consultation and advice. In view of the fact that there were no forensic beds, a model of co-working with the General Adult services had been developed. The forensic team did manage a number of community patients with the agreement that if they required admission, the ‘patch’ team would provide their care. For this arrangement to work there needed to be very good working relationship between the general adult services and the forensic team which there was. In addition, there were no secure beds in our area. There was a contract with George Mckenzie house (a PICU and low secure unit) in Cambridge to provide Huntingdon with some in-patient facility. The Regional Secure Unit covering the area is the Norvic Clinic in Norwich. When a ‘forensic patient’ required admission it required much negotiation with these different units. I gained much valuable experience doing this.
In addition, a service was provided to the local prison (HMP Littlehey) in the form of one session per week. This is a Category C prison and does not have a Health Care centre. It mainly accommodates prisoners who are near to discharge but also has a number of ‘lifers’.
August 2002 – Feb 2003 Forensic Psychiatry in Low Security and in the
(Final year) Community
Clinical Supervisor: Dr Alan Smith
Addenbrooke’s & Fulbourn Hospitals, Cambridge
Staff: 1 Consultant, 1 SpR, 1 SHO, 3 CPNs, 1 SW, 1 Clinical Psychologist, 1 Secretary
Beds: 9 low secure on George Mckenzie house, Fulbourn Hospital
4 open on Burnett ward, Fulbourn Hospital, Cambridge
(In-patients have access to Occupational therapy)
In my final training post I continued to build on and consolidate my previous experience. As before I clinical responsibility for the care for some in-patients and out-patients. This necessitated the preparation of reports for MHRTs, Managers Meetings and for the Home Office. I also completed a number of assessments on referrals from a wide variety of places. As a result I visited various prisons [including HMP Highpoint (women side) in Suffolk and HMYOI Glen Parva in Leicester] and other psychiatric units such as the Wellerwing unit in Bedford. I also undertook a number of psychaitric reports for Magistrate’s and Crown Courts.
After completing my forensic training and obtaining my CCST, I took the opportunity to widen my experience by undertaking some locum posts before taking up a substantive post:
March & April 2003 Locum Consultant Forensic Psychiatrist in Challenging Behaviour Unit
Fairoak House, St James Hospital, Portsmouth
Staff: 1 Consultant (this post), 1 Staff Grade, 1 I Grade Senior Nurse, 2 G Grade
Nurses, 3 F Grade Nurses (one of whom is an outreach nurse), 12.1 E G Grade nurses, 23.2 Support Workers, 1 Senior 1 OT, 1 Activity
Co-ordinator, 1 B Grade Psychologist, 1 CBT Specialist, 1.8 Admin staff
Beds: 14 beds on Fair Oak unit and 8 beds in Cheriton house (slow rehab):
all are classified as low secure.
Out patients: There were a small number of outpatients.
The Challenging Behaviour Service is a tertiary service which is part of, and mainly takes referrals from General Adult Psychiatry. It also has important liaison roles with the forensic services, prisons, courts and social services who also make referrals. It is not a mentally disordered service although this group makes up a proportion of the workload.
Fair Oak operates a specialist assessment and advice service, as well as supervision and skilled treatments for those with serious challenging behaviour whose needs are not fully met within general Adult Mental Health settings.
May 2003 onwards Locum Consultant General Adult Psychiatrist
Agenoria House, Wisbech & The Fermoy unit, Kings Lynn
The Wisbech CMHT is based in Agenoria house. There is 1 consultant (this post), 1 Staff Grade Psychiatrist, 4 CPNs and 3 Social Workers, 1 Psychologist (currently vacant), 1 Occupational Therapist, 2 Community Support workers and 2 secretaries. The Wisbech CMHT is an integrated team. It has excellent working relationships with local groups such as MIND and Richmond Fellowship. 2 members of the Community Drug Team are also based in Agenoria house affording good opportunities of joint working in the field of dual diagnosis.
The in-patient beds are at the Fermoy Unit on the Queen Elizabeth site in Kings Lynn. Beds for the Wisbech sector are located on 2 wards. Churchill ward is a 30 bedded acute admission ward including a 4 bedded High Dependency area. Mountbatten ward has 25 beds. In addition, the Fermoy unit houses the outpatient department and a Day Service Area.
September 2003 Consultant Forensic Psychiatrist
NHS Medium Secure Unit
This is a full time Consultant post and I am employed by an NHS Trust. My duties are split between working as the NHS Consultant Forensic Psychiatrist and as the Consultant Forensic Psychiatrist to the Women’s service of the Trust.
I am one of five Forensic Consultants and our work is divided up into 5 geographical areas The area I cover has 44 beds: 20 beds in medium security 20 beds in low security ; 4 beds in a rehabilitation hostel within the hospital grounds . We provide a service and regular sessions to HMP Lewes. The service runs a prison inreach service there as well as ac court diversion scheme. There is a small community team with each of the three areas having a CPN and social worker working with each of the three consultants. We work closely with other agencies such a police, probation and housing and member of the MDT sits on the local RAMS and MAPPA panels.
The consultants are supported by 2 staff grade doctors and 1 Senior House Officer. We also have usually 2 Specialist Registrars attached our service. One is a Forensic trainee from the Maudsley rotation and one for the General Adult Psychiatry rotation in Eastbourne. There is an active teaching program with a weekly academic meeting held at the Department of Psychiatry in Eastbourne District Hospital.
Women’s Service for an NHS Trust
I am the Consultant Psychiatrist responsible for the women’s service. The women’s service opened a six-bedded women’s wing in May 2004. This mainly treats women with Personality Disorder and operates a non-medical model. This has been highly challenging and interesting work with some very damaged patients who have not been helped by mainstream psychiatric services.
The ethos of the women’s unit is one of maximising an individual’s potential to live as independently and in the least restrictive conditions of security as possible, with an emphasis on relational rather than physical security. Specific treatment options will therefore take place in the broader context of a therapeutic milieu, in which staff will aim to maintain a respectful and non-judgemental, but consistent and boundaried, approach in the face of the frequent difficulties in inter-personal dynamics which residents are likely to present. To this end, there will be an emphasis on communal living and the development of more meaningful relationships and residents will be encouraged to participate and be supported in daily de-briefing sessions and a weekly group. Residents will also be encouraged to be involved in the day to day running of the unit and decisions therein, with the aim of maximising their ability to take responsibility and develop self-efficacy. Residents will be expected to participate in a weekly house meeting.
Specific treatment options will include medication, individual and group psychological therapies and family therapy to address identified needs. She will also have access to complementary and creative therapies as well as self-care, occupational, educational and leisure activities.
Cognitive Analytical Therapy (CAT)
I have also trained and qualified as a Cognitive Analytic Therapist. I have offered this therapy to NHS patients. I have completed over 200 hours of individual therapy with patients either in the form of 16 or 24 sessions per patient. The majority of my patients have been women with personality disorder predominantly Emotionally Unstable Borderline type. I receive regularly supervision from Dr John Bristow, a CAT Psychotherapist and qualified Supervisor.
September 2000 2 year Diploma course in Cognitive Analytic Therapy (CAT). This was a part time course comprising academic teaching, skills workshops, supervised clinical practice, course work and assessed assignments. There is an essential clinical component consisting of supervised therapy for 8 cases in total. CAT is a brief therapy usually limited to 16 ‘hour long’ sessions done weekly.
September 2000 2nd bi-annual conference for developmental Neuropsychiatry and Learning Disability. It focused primarily on Asperger Syndrome and was chaired, on one day, by Dr. Lorna Wing.
November 2000 Annual Specialist Registrar Forensic Psychiatry Conference in Newcastle. The conference focused on sex offenders –
assessment and treatment. Workshops were held which were facilitated by Professor Don Grubin.
November 2000 Medico-Legal Report Writing and Giving Expert Evidence for Psychiatrists. Run by Professional solutions sponsored by the college.
February 2001 Annual Royal College of Forensic Psychiatry division Conference in Brighton.
May 2001 Interviewing Skills Workshop. Norfolk & Norwich Institute for Medical Education
July 2001 I successfully completed the first year of the Diploma in CAT passing all written work. I completed 36 hours of therapy.
July 2001 Open day at the DSPD (Dangerous and Severe Personality Disorder) pilot site in HMP Whitemoor
August 2001 One day workshop on patients with dangerous and severe personality disorders run by Professor Conor Duggan.
November 2001 Annual Specialist Registrar Forensic Psychiatry Conferences in Leeds. This particularly looked at expert witness skills and preparation of medico-legal reports.
January 2002 Hare Psychopathy Checklist-Revised (PCL-R) Training Workshop run by Professor Hare in Cardiff.
May 2002 HCR 20 Training workshop. This was a 2 day course run by Mats Dernevik and Forensic Psychologist Todd Hogue of Rampton Hospital who is also an advisor to the DSPD project.
July 2002 I successfully completed the second year of Diploma in CAT have passed all written assignments. I completed 64 therapy hours.
Currently I am due to complete my remaining therapy hours by March 2003.
September 2002 Changing roles – preparing to be a consultant. 3 day management course run by Addenbrooke’s NHS Trust
November 2002 Recent Trends in Forensic Mental Health. A one day national conference held in Chelmsford, Essex
November 2002 Annual SpR Conference, “Forensic Psychiatry and the Media. 2 day conference in Nottingham
January 2003 Faculty of Forensic Psychiatry Residential Annual Meeting
A 3 day conference which took place in Glasgow. I presented a poster of my research findings
October 2003 Lecture: Bipolar Disorder: Current Concepts and Evidence Based Treatment by Professor RN Mohan
November 2003 Community Training Day held at Powder Mill Hotel, Battle
Covering 3 topics
1. Sex Offender Treatment Programmes by the Thames Valley Team, Sussex Probation Area
2. Gender Dysphoria by Dr J Barrett, Gender Identity
3. Treatment of Substance Misuse by Dr Hugh Williams
January 2004 Faculty of Forensic Psychiatry Residential Annual Meeting
A 3 day conference which took place in Southampton
March 2004 Annual Cognitive Analytic Therapy conference
A 2 day conference held in London.
22 – 24 April 2004 Joint Meeting – Forensic Faculty, Royal College of Psychiatrists/Tri-State Chapter, American Academy of Psychiatry and the Law, New York City, 22-24 April 2004
24 – 26 May 2004 Gender Awareness Training with specific reference to women’s mental heath needs
July 2004 Mental Health Act Refresher course for section 12 (2) approved doctors, Brighton University
November 2004 1 Day workshop on Conflict resolution and Leadership Skills,
Powdermills Hotel, Hastings
1-3 December 2004 Risk Assessment Training course using the HCR – 20 and PCL – SV (Psychopathy Check List Shortened Version)
Broadmoor Hospital, Berkshire
13 January 2005 Consent, Capacity Workshop Radicliffs LeBrasseur, Specialist Mental Health Solicitors
February 2005 Faculty of Forensic Psychiatry Residential Annual Meeting
A 3 day conference which took place in Belfast
March 2005 Annual Cognitive Analytic Therapy conference
A 2 day conference held in London.
17 March 2005 Symposium IV – Latest advances in Psychiatry
One day conference held in The Royal College of Medicine, Regent’s Park London
June 2005 The Next Generation in Antipsychotic Therapy
A 2 day conference in Selsden park hotel with speakers including Prof Tim Crow from Oxford
27 June 2005 Women’s Enhanced Medium Secure Service Stakeholder Meeting, Mayfair conference Centre, Marble Arch London
February 2006 Faculty of Forensic Psychiatry Residential Annual Meeting
A 3 day conference which took place in Newcastle
23 March 2006 Symposium V: Latest Advances in Psychiatry
Key note speaker Professor Sir David Goldberg
Royal College of Obstetrics & Gynaecology, Regents Park, London
May 2006 Section 58 Mental Health Act 1983. Consent to Treatment & Capacity Act
Millview Hospital, Hove
February 2007 Faculty of Forensic Psychiatry Residential Annual Meeting
A 3 day conference which took place in Prague
3rd May 2007 Prevention and Management of Violence and Aggression
1 Day breakaway training course
12th June 2007 Long Acting Injections in Psychosis – An overview
The Hydro Hotel, Eastbourne
20th June 2007 OSCE examiner for Medical Students
Brighton and Sussex Medical School
4th July 2007 Bipolar Disorder : Time for a rethink?
The Sundial, Herstmonceux, East Sussex
12th July 2007 Fixed threat assessment Centre
Dr David James, New Wellington Hotel, Tunbridge Wells, Kent
25th September 2007 What do we want to be? The best that we can?
Sussex Education Centre
6-8 February 2008 Faculty of Forensic Psychiatry Residential Annual Meeting
A 3 day conference which took place in Liverpool
16th May 2008 Witness Skills in the Coroner’s Court
Bond Solon Training
The Start Inn, Alfriston
10th June 2008 The Challenges of Treating Depression – Should we be more aggressive?
The Jurys Inn, Brighton
10th July 2008 Strategies for Successful Outcomes with the Treatment of Schizophrenia
Dr Wilfred Assin
Boship Farm Hotel, Lower Dicker
8 September 2008 Mental Health Act Refresher Course
Westlain Lecture Theatre, Falmer Site, University of Brighton
19 September 2008 HoNOS Secure Training
Woodside Annex, Hellingly
4-6 February 2009 Faculty of Forensic Psychiatry Residential Annual Meeting
A 3 day conference which took place in Barcelona
17th March 2009 Schizophrenia is a changing Illness
Profs Murray, Jones, Kapur & Deakin
Hilton Metropole, London
19/20 March 2009 PCL – R Training
Dr Carol Ireland and Fiona Wilks-Riley,
The Ship Hotel, Brighton
25th March 2009 Latest Advances on Psychiatry Symposium VIII
Royal College of Physicians, Regents Park, London
11 September 2009 Assessing Patient progress in Secure Setting using risk assessment tools (START)
Dr Quazi Hoque
Farmfield Hospital, Farmfield Drive, Charlwood, Surrey
24 September 2009 Neurobiology of Depression
Dr Morgan Haldane, South London & Maudsley Hospitals
The Wild Mushroom, Woodgate House, Westfield
20 Nov 2009 Current Developments in Offender Mental Health Provision
Priory Grange Sturt House, Sturt’s Lane, Surrey,
‘The Bradley Report: Implications for offender mental health services’. –Max Rutherford
‘Prison: Psychiatry’s forgotten frontier’ – Dr Andrew Forrester
25/26 Nov 2009 APPROVED CLINICIANS TRAINING COURSE
Loxdale Centre, Loxdale, Locks Hill, Portslade, East Sussex
27 November 2009 Adult ADHD
Dr Hugo Critchely
The Star Inn, Alfriston
4 December 2009 CREATING A SAFE AND SECURE ENVIRONMENT
ONE DAY TRAINING COURSE
Medium Secure standards
The Quality Network and Department of Health Secure Services
Dr Paul Gilluley
10-12 Feb 2010 Faculty of Forensic Psychiatry Residential Annual Meeting
A 3 day conference which took place in Dublin
10 June 2010 Secure and Forensic Community Service review
The Royal Pavillion, Brighton
24 August 2010 Arson Training Event
Theories, Risk Assessment and Treatment of Fire Setting in Mental Health Settings
Dr Louise Minchin, Consultant Clinical Psychologist
Sussex Partnership NHS Foundation Trust
1 Nov 2010 Dynamics of Attachment of Professional Encounters
Prof Una McCluskey
Sussex Education Centre, Hove
5 Nov 2010 Applied Recovery in Practice
1 day workshop on Recovery
15 Nov 2010 Understanding Diversity
Croydon Park Hotel
4- 6 Feb 2011 Faculty of Forensic Psychiatry Residential Annual Meeting
A 3 day conference which took place in Berlin
The last research I completed was undertaken in 2010 jointly with a 4th year Brighton Medical Student. I have reproduced the abstract below:
The Point Prevalence of Metabolic Syndrome amongst patients on atypical antipsychotic medications in a secure Forensic setting in rural East Sussex. Daniel Howard Baker, 4th Year Medical Student, Brighton and Sussex Medical School, Dr Roderick John Ley, Consultant Forensic Psychiatrist, Sussex Partnership Foundation NHS Trust.
Background: There is increasing concern and recognition about the poor physical health of people with mental disorder. In particular, the incidence of obesity and diabetes are rising which is reflected in the general population. While there have been huge improvements in treatment such as the development of atypical antipsychotic medications, this has come at a cost of possible worsening physical health. The potential relationship between atypical antipsychotic medication and the Metabolic Syndrome is well established. It has been reported that patients with severe mental illnesses such as Schizophrenia live 15 years less than controls without mental illness. There are multiple definitions of Metabolic Syndrome. This in part is because there is still yet to be an internationally agreed unifying factor. (1) (2) However it is generally agreed that Metabolic Syndrome is a constellation of hyperinsulinaemia with insulin resistance and subsequent glucose intolerance, hypertension and dyslipidaemia with hypercholesterolaemia and hypertriglyceridaemia. (3)
Aims: As such, our primary aim was to detect the point prevalence of Metabolic Syndrome amongst a group of psychiatric patients detained in low and medium secure units who are currently taking atypical antipsychotics versus typical antipsychotics. Our secondary aim was to identify the level of monitoring of patients on established and newly introduced atypical antipsychotic regimes. We sought to highlight and make recommendations to Sussex Partnership Trust as to the current levels of monitoring undertaken towards meeting the National Institute of Clinical Excellence (NICE) guidelines.
Methods: Patients were informed as to the potential of second generation antipsychotics to cause Metabolic Syndrome and verbal consent was gained. Patients were systematically screened and underwent venepuncture for full blood count, urea and creatinine, liver function tests, lipid profile including cholesterol and glycosylated haemoglobin (HbA1c) followed by height, weight and waist circumference measurements. Blood pressure was obtained by calculating the mean from three readings for reasons of accuracy.
Results: Data collection will conclude imminently. Once all data subsets are available systematic analysis will occur. Results will be interpreted and patient’s positive for Metabolic Syndrome identified. We have used the World Health Organisation (WHO) 1999 diagnostic criteria as opposed to the European Group for the study of Insulin Resistance (EGIR) or the National Cholesterol Education Programme-Third Adult Treatment Panel (NECP-ATP III). (1) This was sufficiently more flexible in accommodating the definition of obesity, allowing both waist circumference or body mass index. If a diagnosis of Metabolic Syndrome is made patients will be counselled as to the potential consequences of this diagnosis and offered medical management in accordance with NICE guidelines.
Only one patient presented with pre-existing type 2 diabetes mellitus. Whilst the point prevalence of frank Metabolic Syndrome in our small cohort was low the data does reveal elements of pre-diabetes in a large number of participants. None of our patients were within the healthy BMI range: one was morbidly obese; one was obese and three were overweight. 80% of our participants returned abnormal Cholesterol samples. HbA1c levels are largely normal. It is proposed that central (visceral) obesity develops with adipocyte hypertrophy and proliferation, leading to peripheral insulin resistance, hyperinsulinaemia with subsequent hyperglycaemia that causes switching of primary fuels in metabolically flexible end organs to lipids. Weight gain is cited as being the first sign of Metabolic Dysfunction. Some believe this sign, and often symptom, should be treated as a red flag that receives metabolic investigations. Simple anthropometric data could be easily collected on a regular basis if patients decline blood tests. In response to peripheral insulin resistance the β islet cells remain activated to this marginal hyperglycaemia signalling the synthesis and secretion of supraphysiological quantities of insulin. This leads to the formation of amyloid plaques in the islet cells. Our data is highly consistent with trends for developing type 2 diabetes mellitus. In accordance with meeting our secondary aim, we discovered low levels of monitoring for metabolic abnormalities amongst our group of vulnerable patients. This finding is consistent with other literature. This may be due to beliefs of conflicting roles: the psychiatrists believe Metabolic Syndrome is a “physical” disorder and so leave monitoring and treatment to the General Practitioner. The GP however believes that because of the direct implication of antipsy chotic medication and Metabolic Syndrome, this would be screened for and treated by the Psychiatrists, in similarity when patients develop EPS with conventional antipsychotics. Health education and promotion, such quitting smoking, increased exercise and better diet are simple, practical and economic. In reality resource availability predominates. One screening tool other teams have used
is the inclusion of monitoring protocol (proposed by the ADA) within patients drug charts. It is the responsibility of the SGA prescriber to ensure protocol outcomes are up to date. In forensic psychiatry this is a persistent challenge: patients often require stable regimes of metabolically potent SGA yet decline physical health screening.
This research was presented on 4th to 6th February 2011 at the Faculty of Forensic Psychiatry Residential Annual Meeting which took place in Berlin.
In 2002, I completed the first phase of a research project looking into how the Home Office and Mental Health Review Tribunals differ in their criteria for deciding whether detained patients can be discharged. An abstract of the work (see later) done thus far has been submitted and accepted to be included in the proceedings booklet for the Faculty of Forensic Psychiatry Residential AnnuaI Residential meeting in Glasgow on 29 January 2003. I presented my research findings as a Poster presentation at the meeting.
Abstract of Research Project submitted for Faculty of Forensic Psychiatry Residential Annual Meeting (2003)
Conditional discharges granted by the Home Secretary over a 5 year period
To study the characteristics of offenders who received hospital orders with restrictions (‘restricted patients’) and were subsequently granted a conditional discharge (CD) by the Home Secretary (HS).
The case files of all restricted patients who were subsequently granted a CD by the HS between May 1997 and May 2002 were studied.
143 were identified. 130 (91%) files were analysed.
108 (83.1%) were male and 22 (16.9%) female.
Legal classification: 102 (78.5%) Mental Illness; 14 (10.8%) Psychopathic disorder; 6 (4.6%) Mental Impairment; 5 (3.8%) Mental Illness and Psychopathic disorder; 2 (1.5%) Mental Illness and Mental Impairment; 1 (0.8%) Mental Impairment and Psychopathic disorder.
Age at restriction from 18 to 60 (average 34)
Index offence: 20 (16%) manslaughters of which victims were 6 (30%) partners, 6 acquaintances, 4 (20%) mothers, 3 (15%) children, 1 (5%) father and 1 aunt.
A further 20 were convicted of either attempted murder or assaults leading to grievous bodily harm (GBH). 27 (20%) were convicted of Arson and 4 (3%) of sexual offending. 76 (58%) had past convictions. Of which 55 (70%) for violent offences and 7 (9%) for sexual offending.
41 (31.5%) had previous involvement with mental health services.
Restriction orders were terminated in 5 Patients who were repatriated to their home countries, and 5 patients were imprisoned.
The average length of detention prior to CD was 9.43 years (range from 10 months to 40 years).
17 ((13%) were recalled.
The results were compared with those who received restriction orders.
The HS granted discharge to a range of restricted patients. These patients did not differ greatly from those on whom restriction orders were imposed. The HS might discharge more restricted patients than currently if asked. Further research is underway to compare this sample with those granted discharge by MHRTs.
Past Research Experience
Whilst working in Peterborough, I was involved in a multi centre, international trial comparing using Risperidone, low dose Haloperidol or placebo in demented elderly patients who had behavioural problems including psychiatric symptoms. After recruiting patients, I performed a comprehensive battery of rating scales (including a Behaviour Rating scale, EPSE rating scale, CGA) as well as a full physical examination and blood workup. I had to repeat these weekly for several months.
Prior to starting my training in Psychiatry, I have been involved in other research as part of my clinical work. Whilst working in General Practice I undertook an investigation of the prevalence of clinical depression in patients with a diagnosis of chronic fatigue syndrome (or Myalgic Encephalitis). I used 2 rating scales: Beck Depression Inventory and Hamilton Anxiety and Depression Scale. I found 90% were clinically depressed. Half were not on antidepressant and my study led to most of these patients being commenced on treatment. Unfortunately, due to moving to another post, I was not able to do a follow up project to see if any patients had improved but anecdotally, some had.
During my time as a Medical SHO in Derby, I was involved in a trial comparing Maxalon and Stemitil with Ondansetron as an antiemetic in-patients receiving chemotherapy.
As part of my undergraduate degree, I spent a year in the Department of Microbiology in Queens Medical Centre, Nottingham. I completed research looking at the different extracellular proteins produced by the bacteria Staphylococcus aureus. I wrote up a thesis as part of my degree.
I helped run the Royal College of Australian and New Zealand Psychiatrists’ examinations when they were held in Wellington in 1997.
I was the Junior Doctor’s representative for psychiatric trainees when I was on the Leicester Training Scheme. This involved ensuring all posts were within the “New Deal” maximum hours of work and that trainees were able to attend their half-day release training course.
During 2001, I was involved in promoting the Norvic Clinic as a Beacon site. This involved working with other disciplines and agencies to prepare information for others and arranging open days. I also attended a number of MAC (Medical Advisory Committee) meetings and took an active interest in current issues in the Trust.
During my Consultant posts I have attended Consultants and Medical Advisory Committee meetings. This has given me a useful insight and understanding of some of the management problems and difficulties that can arise and importantly how they can be overcome and solved.
I am currently an examiner on the undergraduate medical degree course in Brighton Medical School.
I have been actively involved and enjoyed teaching others throughout my 13 years as a doctor. This has included not just medics, but a range of other health service personnel including nurses, occupational therapists, and physiotherapists.
During my last year as an SpR, I took an active part in the teaching of medical students during their attachment to psychiatry. I delivered lectures on the Mental Health Act and Forensic Psychiatry. I also acted as an examiner in the medical students end of psychiatry attachment exams. I do believe that it is essential for Psychiatry, with all its current recruitment problems, to be trying to excite and interest medical students who will be the doctors of tomorrow.
Currently I directly supervise a Senior House Officer. I participate in the local academic programme run by the Department of Psychiatry. I run a monthly multidisciplinary journal club for the Forensic service.
I have taken the lead in teaching medical students for their specialist attachment in Forensic Psychiatry. As part of this I have trained to be an examiner and took part as an examiner since 2007 for the medical student finals.
I have a particular interest in how other countries manage and treat mentally disordered offenders and have extensively lectured on this subject in the South east of England. In particular I have an interest in the system in operation in USA.