title: STRESS-testing clinical activity and outcomes for a combined prison in-reach and court liaison service: a 3-year observational study of 6177 consecutive male remands.
abstract: BACKGROUND
  People with major mental illness are over-represented in prison populations however there are few longitudinal studies of prison in-reach services leading to appropriate healthcare over extended periods.
  
  
  OBJECTIVE
  We aimed to examine measures of the clinical efficiency and effectiveness of a prison in-reach, court diversion and liaison service over a 3 year period. Secondly, we aimed to compare rates of identification of psychosis and diversion with rates previously reported for the same setting in the 6 years previously. We adopted a stress testing model for service evaluation.
  
  
  METHODS
  All new male remand committals to Ireland's main remand prison from 2012 to 2014 were screened in two stages. Demographic and clinical variables were recorded along with times to assessment and diversion. The DUNDRUM Toolkit was used to assess level of clinical urgency and level of security required. Binary logistic regression was used to assess factors relevant to diversion.
  
  
  RESULTS
  All 6177 consecutive remands were screened of whom 1109 remand episodes (917 individuals) received a psychiatric assessment. 4.1 % (95 % CI 3.6-4.6) had active psychotic symptoms. Levels of self-harm were low. Median time to full assessment was 2 days and median time to admission was 15.0 days for local hospitals and 19.5 days for forensic admissions. Diversion to healthcare settings outside prison was achieved for 5.6 % (349/6177, 95 % CI 5.1-6.3) of all remand episodes and admissions for 2.3 % (95 % CI 1.9-2.7). Both were increased on the previous period reported. Mean DUNDRUM-1 and DUNDRUM-2 Triage Security Scores were appropriate to risk and need.
  
  
  CONCLUSIONS
  We found that a two-stage screening and referral process followed by comprehensive assessment optimised identification of acute psychosis. The mapping approach described shows that it is possible for a relatively small team to sustainably achieve effective identification of major mental illness and diversion to healthcare in a risk-appropriate manner. The stress-testing structure adopted aids service evaluation and may help advise development of outcome standards for similar services.
authors.affiliation: National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin, 14 Ireland.|Department of Psychiatry, Trinity College, Dublin, Ireland.
authors.forename: Conor
authors.identifier: 0000-0003-0505-6997
authors.initials: C
authors.lastname: O'Neill
authors.affiliation: National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin, 14 Ireland.|Department of Psychiatry, Trinity College, Dublin, Ireland.
authors.forename: Damian
authors.initials: D
authors.lastname: Smith
authors.affiliation: National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin, 14 Ireland.
authors.forename: Martin
authors.initials: M
authors.lastname: Caddow
authors.affiliation: National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin, 14 Ireland.
authors.forename: Fergal
authors.initials: F
authors.lastname: Duffy
authors.affiliation: National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin, 14 Ireland.
authors.forename: Philip
authors.initials: P
authors.lastname: Hickey
authors.affiliation: National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin, 14 Ireland.
authors.forename: Mary
authors.initials: M
authors.lastname: Fitzpatrick
authors.affiliation: National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin, 14 Ireland.
authors.forename: Fintan
authors.initials: F
authors.lastname: Caddow
authors.affiliation: National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin, 14 Ireland.
authors.forename: Tom
authors.initials: T
authors.lastname: Cronin
authors.affiliation: National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin, 14 Ireland.
authors.forename: Mark
authors.initials: M
authors.lastname: Joynt
authors.affiliation: National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin, 14 Ireland.
authors.forename: Zetti
authors.initials: Z
authors.lastname: Azvee
authors.affiliation: National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin, 14 Ireland.
authors.forename: Bronagh
authors.initials: B
authors.lastname: Gallagher
authors.affiliation: National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin, 14 Ireland.
authors.forename: Claire
authors.initials: C
authors.lastname: Kehoe
authors.affiliation: National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin, 14 Ireland.
authors.forename: Catherine
authors.initials: C
authors.lastname: Maddock
authors.affiliation: National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin, 14 Ireland.
authors.forename: Benjamin
authors.initials: B
authors.lastname: O'Keeffe
authors.affiliation: National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin, 14 Ireland.
authors.forename: Louise
authors.initials: L
authors.lastname: Brennan
authors.affiliation: National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin, 14 Ireland.
authors.forename: Mary
authors.initials: M
authors.lastname: Davoren
authors.affiliation: National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin, 14 Ireland.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Owens
authors.affiliation: National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin, 14 Ireland.
authors.forename: Ronan
authors.initials: R
authors.lastname: Mullaney
authors.affiliation: Irish Prison Service, Dublin, Ireland.
authors.forename: Laurence
authors.initials: L
authors.lastname: Keevans
authors.affiliation: Irish Prison Service, Dublin, Ireland.
authors.forename: Ronan
authors.initials: R
authors.lastname: Maher
authors.affiliation: National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin, 14 Ireland.|Department of Psychiatry, Trinity College, Dublin, Ireland.
authors.forename: Harry G
authors.initials: HG
authors.lastname: Kennedy
keywords: Clinical pathways; Court diversion; Court liaison; Prison psychiatry; Risk assessment; Screening