MERSEYSIDE 2023

Dear Mrs Micklewright

Thank you for your email. Please see below the wording from the Appendices that were originally sent to you. These have now been copied into the body of this email as requested.

Appendix 1

Please provide ECT information under the FOI act to the following questions: -

Please supply patient’s information ECT leaflet.

Appendix 2 below

Neuromodulation Service (NMS)

FAQs on ECT

General Information Leaflet for Service User and Carers

Purpose

This leaflet explains about Electroconvulsive Therapy (ECT), what you can expect from the Mersey Care Neuromodulation Service and what your role in this treatment partnership is.

The leaflet explains the process of ECT here at Mersey Care. Deciding whether or not to have ECT can be a big decision and we want to help you with this.

It can be hard to read a lot of information when you feel depressed, but as well as this leaflet, you should have a conversation with the doctors and nurses who are looking after you. They will also provide written information including leaflets from MIND and the Royal College of Psychiatrists.

Many people also find that talking with a family member or friend helps them clarify their thoughts and decide how to proceed.

Please do not hesitate let us know if you have any questions or would like us to explain anything about ECT. We are always happy to discuss any queries or concerns you may have.

Introduction

ECT is an approved treatment option for people who suffer with Severe or Difficult to Treat Depression. It involves stimulating the brain with an electric current to cause a small epileptic seizure. It is given under an anaesthetic twice a week in a special treatment suite.

ECT is seen as controversial by some, but it has been scientifically evaluated and researched and is approved for use in the UK and most other countries.

To be considered for ECT, your Consultant Psychiatrist will need to make a referral to the Neuromodulation Service based in the Broadoak Unit, Broadgreen Hospital site, Thomas Drive, Liverpool L14 3PJ.

The service is open Monday to Friday between 8.30 am and 6pm.

GENERAL INFORMATION

What is the Neuromodulation Service?

We are a team of specialist doctors and nurses who provide a number of treatments, including ECT, that involve stimulating the brain. These treatments are mostly used for depression and are offered if the depression is very severe or if other treatments are not helping.

Where is the service based?

ECT is based in a special suite on the ground floor of the Broadoak Unit at Broadgreen Hospital, please report to the receptionist when you arrive.

What should happen before I decide to have ECT?

Before your Consultant refers you for ECT, they will discuss it with you. They will explain the pros and cons of ECT, why they are considering it for you and discuss the alternatives. They will give you written information about ECT to take away and read later. You should take the opportunity to ask any questions you may have. The Consultant will also speak to your family and friends if you wish. They will give you time to decide if you wish to be referred for ECT.

You will be asked to give your consent to the treatment every time you have it. Your consultant will assess if your illness is making it too hard for you to decide.

If at any time change your mind and decide not to continue with ECT, we will always respect your decision.

What if I decide I do not want ECT

If you are able to make an informed decision about ECT and you decide you don’t want it, then it will not be given. Your consultant will speak to

you about other treatment options. ECT is never the only choice, though your consultant may think it is right for you.

For some people, however, their illness is so severe they are unable to make choices for themselves about treatment. If this is the case, ECT can only go ahead under the Mental Health Act with the person being treated in hospital. There will also have to be a second opinion from an independent doctor who must agree that ECT is an appropriate treatment. The independent doctor will speak to other people involved, including family and other professionals.

Once the person is well enough to make a decision, then ECT will only continue if they agree.

BEFORE TREATMENT STARTS

Before being considered for ECT you will have some basic blood tests, a heart trace (ECG) and if needed an x-ray.

As close as possible to the proposed start date of your ECT we’ll send you an appointment to see a Consultant Anaesthetist in the Broadoak Unit. The Consultant Anaesthetist will have access to your medical history and assess your fitness for the treatment. They will also give you a range of information about your anaesthetic and will be happy to answer any questions you may have.

We recommend that if possible, you have a family member or friend with you. If you are an inpatient a member of staff will also attend.

You will be given an appointment card with provisional dates, should you decide to proceed with ECT. At this appointment, you will not be asked to decide if you wish to proceed with ECT or not. You will have at least 24 hours to consider your options and then make a decision.

We would like you to let us know that you wish to proceed with the treatment 24 hours before your first proposed appointment. If you do not call us we will assume you do not wish to proceed and may give the treatment to someone else.

Please call us if you need more time to decide. We are always happy to answer any questions you may have.

TREATMENT DAYS

Do I have to fast on the day of treatment?

Yes. You must avoid eating or drinking anything except small amounts of water for six hours before treatment. From two hours before treatment you must not eat or drink anything at all.

Do I take my usual medication?

The anaesthetist will talk to you about this at your meeting. You should continue to take your normal medication (especially tablets for heart and blood pressure) on the morning of treatment with a small sip of water.

If you are taking medication for diabetes, you should not take this, as you will have been fasting. After the treatment, you should continue with all your normal medication.

Can I have chewing gum or suck sweets?

No. You should avoid these for 6 hours before treatment

Can I bring someone with me?

If you are coming for your treatment from home, you must have a family member or friend with you as you will be having an anaesthetic. It is only possible to give ECT from home if there is someone with you. There must also be someone with you for 24 hours after the treatment in case of anaesthetic problems. Your psychiatric team will discuss this with you and agree who will be the other people involved.

If you are coming from a ward, a member of staff will be with you, and you can have a family member or friend as well.

Can my family member or friend come into the treatment room with me?

Yes. They are welcome to stay with you until you go to sleep after the anaesthetic. They will then be asked to go into the recovery area while your treatment is carried out.

Are there any arrangements about transport?

If you are coming from a ward, this will be sorted out for you

If you are coming from home, you will need to make your own arrangements for yourself and your family member or friend to get to Broadoak. You will need to use the main parking to the right of the entrance to Broadgreen.

Unfortunately at the moment, we aren’t able to arrange this for you. Please note there is a charge for parking at the hospital.

AFTER TREATMENT

How will I feel after the ECT?

As you wake up after the treatment, you will feel woozy and muddled for a while because you have had an anaesthetic and a small epileptic seizure. You may have a headache and aching muscles and feel generally unwell. There will be a specialist recovery nurse there who will be with you until you are fully awake.

Once you are awake, you will walk into our sitting area where we will provide you with a drink and something to eat. You can have a painkiller if you need one. Our staff will do regular checks to see if you are OK. Most people find they are well enough to leave after about 20 minutes or so, but you can take longer if you need it.

What are the side effects of ECT?

Your Consultant will have explained any possible side effects and given you written information about them. Many people find that their memory is affected while they are having ECT, though for most people these memory difficulties settle once the course is over. Please tell your Consultant about any side effects you (or others) have noticed.

How will I be reviewed?

Every week, whilst you are having ECT, you will be seen by a member of your psychiatric team. This will ensure that your consultant knows how you are and can decide if your ECT should finish. You should be reviewed after every two treatments.

How many treatments will I have?

The number of treatments varies between people. We usually give ECT until you are feeling fully better, with a review after every two treatments. You and your consultant should decide together when to stop depending on if you are getting better or if there are any side effects.

Usually there will be signs of improvement after four to six treatments and the average course is around 10 treatments. We usually stop ECT if you are feeling no better after 12 treatments.

How will I know if I am getting better?

We hope that ECT will improve your mental state. Usually it is the patient who tells us they are better but often it is family and friends who first notice an improvement.

What happens once ECT is over?

After your course of ECT, you will continue to be seen by the team who referred you. ECT helps to get people better, but doesn’t treat the reasons for becoming unwell. Most people require a combination of medication and psychological support to keep well after the course.

How do I know if ECT is being done properly?

ECT services are subject to regular detailed review every 3 years by the ECT Accreditation Service (ECTAS). ECTAS is run by the Royal College of Psychiatrists. They set standards of practise and equipment, review ECT clinics and will only accredit clinics if they maintain the national standards.

We have been fully accredited members of ECTAS since it began in 2003.

Useful Websites

Royal College of Psychiatrists Information sheet on ECT https://www.rcpsych.ac.uk/mental-health/treatments-and-wellbeing/ect

MIND Information Sheet on ECT https://www.mind.org.uk/information-support/drugs-and- treatments/electroconvulsive-therapy-ect/about-ect/

MIND guidance on treatments for depression https://www.mind.org.uk/information-support/types-of-mental-health- problems/depression/treatments/

We welcome any comments or suggestions that can help us to improve our service. If you have any comments or questions about ECT treatment, please speak to our team or contact

Neuromodulation Service, Broadoak Unit, West Road, Broadgreen Hospital site, Thomas Drive, Broadgreen, Liverpool L14 3PJ.

Tel: 0151 250 5069

Date for review : July 2024

This document is available in other languages if required

This booklet was produced as a general guide and is in no way meant to be definitive. It will be subject to change and regular update at any point.

This booklet was produced with the invaluable assistance of the Mersey Care service users forum through the Engagement and Experience team

No contract is implied or guarantees given or liabilities accepted, though this document and its information are given in good faith.

Appendix 3

Electroconvulsive therapy (ECT)

Explains what electroconvulsive therapy (ECT) is, when it might be used and what happens during the treatment.

If you require this information in Word document format for compatibility with screen readers, please email: publications@mind.org.uk

Contents

What is electroconvulsive therapy (ECT)?.................................................................... 2

How do I decide whether to have ECT?....................................................................... 3

Consenting to ECT......................................................................................................... 5

What are ECT treatment sessions like?........................................................................ 8

What are the side effects of ECT?............................................................................. 11

What alternatives are there to ECT?.......................................................................... 12

Useful contacts............................................................................................................. 13

What is electroconvulsive therapy (ECT)?

Electroconvulsive therapy, or ECT for short, is a treatment that involves sending an electric current through your brain, causing a brief surge of electrical activity within your brain (also known as a seizure). The aim of the treatment is to relieve the symptoms of some mental health problems.

ECT is given under a general anaesthetic, so you aren't awake during the treatment.

What problems can ECT treat?

The National Institute for Health and Care Excellence (NICE) recommends that ECT is only used to achieve quick, short-term improvements if you have:

severe or life-threatening depression and your life is at risk so you need urgent treatment
moderate to severe depression and other treatments such as medication and talking therapies haven't helped you
catatonia (staying frozen in one position, or making very reptitive or restless movements)
a severe or long-lasting episode of mania.

Repeated ECT is only recommended if you have previously responded well to it, or if all other options have been considered.

ECT is not recommended for ongoing management of schizophrenia, or as a routine treatment for mild to moderate depression.

You can read full guidelines on the NICE website for using ECT to treat catatonia, mania or schizophrenia, and as one of the treatments for moderate or severe depression.

Is ECT effective?

It’s very difficult to know how ECT works, or how effective it is. Many different theories have been suggested, but research hasn’t shown what effects it has or how these might help with mental health problems.

Some people find ECT helpful while others don’t. If you are thinking about having ECT, it’s important that you are given full information about the treatment. See our page

on deciding to have ECT for more information.

Supporting someone else

If you’re worried about someone who may have ECT treatment, our pages on how to cope when supporting someone else and helping someone else seek help give suggestions on what you can do, and where you can go for support.

“It didn't work overnight but as my course of nine progressed I could feel the huge weight of black, black fog lift from my mind.”

Why is ECT controversial?

The use of ECT can be controversial for several reasons:

It was used unethically in the past. ECT was used far more in the 1950s to 1970s than it is today, and it was used without anaesthetic and often without consent. This has sometimes been shown in films and TV shows, which may not reflect how ECT is carried out today.
It can sometimes cause memory loss. This is often short-term, but can be longer- lasting as well. See our page on the side effects of ECT for more information.

Some people are offered ECT without being offered other treatments they may prefer to try first, such as talking therapies for depression.

Professionals disagree about whether to use it. Some healthcare professionals see ECT as a helpful treatment, while others say it should not be used.

How do I decide whether to have ECT?

Deciding whether or not to have ECT can be difficult. Usually you will only be offered it if you are very unwell, so you might find it harder to take in information and make decisions.

You should be given full information about the treatment so you can make an informed decision. Unless you are unable to make the decision for yourself, it is your choice whether you accept the treatment or not.

You may find it helpful to discuss it with a trusted friend or family member, or a mental health advocate. See our information on advocacy in mental health, or

contact POhWER or Rethink Mental Illness to find out about advocacy services in your area.

Why might I consider having ECT?

If ECT improves your mental health, the effects are usually felt quickly.
ECT could be helpful if you have stopped eating and drinking or looking after yourself due to severe depression.
If you have depression after having a baby (postnatal depression), ECT might make it easier to care for and bond with your baby.
ECT may reduce suicidal feelings, although there is no evidence that it prevents suicide.

Why might I decide against ECT?

Any helpful effects are likely to be short-term. ECT can’t prevent future depression, or fix any ongoing stresses or problems that are contributing to how you’re feeling.
Some people have very bad experiences of ECT, for example because they feel worse after treatment or are given it without consent.
You might not want to risk the possibility of getting side effects.

“It was suggested by my psychiatrist as a last resort since my depression was resistive to multiple medications that had been tried and multiple types of talking therapies”

Who should avoid having ECT?

Before a course of ECT treatments, you will need a full medical examination to make sure the treatment is safe for you. You will be asked about:

your medical history – in case you have other health problems that should be treated first, or which mean you shouldn’t have the treatment
whether you are pregnant – ECT can be used in pregnancy, but there may be concerns about giving you anaesthetic while pregnant
any medicine you are taking – some prescribed drugs can affect your response to ECT, meaning the treatment needs to be adjusted

any allergies you have.

NICE guidance

NICE recommends in its guidance on ECT that, before you are offered ECT, doctors should consider:

- the risks of general anaesthetic
- other medical conditions you might have
- possible adverse effects, especially memory loss
- the risks of not having treatment.

Doctors should take extra caution about recommending ECT if you are at higher risk of adverse effects. This includes if you are:

- a pregnant women
- an older person
- a child or young person.

You should be assessed after each ECT session, and you should not receive any more ECT if you:

- have already been helped by the treatment so you don’t need any more

show signs of serious adverse effects, such as memory loss.

If you have had ECT for depression before and it didn’t help, you should only be given it again if:

- you and your doctors are sure that all other possible treatments have been tried
- you have discussed the possible benefits and harms with your doctor and also with a friend or family member, if you want them to be included.

Consenting to ECT

Some of the information on this page is legal information, which applies to adults in England and Wales.

It covers the following:

How do I make an informed choice and give consent?

You have the right to make an informed decision about whether or not to accept the treatment a doctor suggests. To consent properly you need enough information to be able to weigh up the risks and benefits of having it.

You should be given full information, in language you can understand, about:

the expected benefits of the treatment
any side effects and the risk of harm
how the treatment will be given
alternative treatments
the alternative of having no treatment at all.

It can be hard to take in a lot of new information in one go, so you can ask for medical staff to explain it to you more than once if necessary.

You should be given 24 hours to think about your decision.

The ECT Accreditation Service (ECTAS) recommends that you have a friend, relative or advocate with you when you are given the information, so that they can go over it with you again.

Questions for your doctor

If ECT is recommended by your doctor, you or your friend, relative or advocate might want to ask them the following questions:

What is the reason for suggesting ECT?
What are the risks of ECT?
How could ECT help me?
What are the side effects?
Are there any long-term effects?
Have I been offered every available alternative treatment?
What treatment will I be offered in addition to, and after, ECT?
What is the risk that I will feel worse afterwards?
How many treatments are suggested?
How will the dosage be decided?
What can I expect if I refuse this treatment?

What happens if I decide to consent to ECT?

If you agree to the treatment, you will have to sign a written consent form. Once you have signed a consent form, you should be informed that you can change your mind at any stage in the treatment and that, if you do, the treatment will be stopped.

You should also be told how you can tell staff if you have changed your mind. At each stage of the treatment, the doctor should confirm with you that you are continuing to consent.

ECTAS recommends that, if you decide to go ahead with having ECT but your relatives or close friends disagree with this treatment, this should also be recorded in your notes.

See our page on deciding whether to have ECT for more information about making this decision.

ECT and the Mental Health Act 1983

If you are detained under the Mental Health Act 1983, ECT can normally only be given if you consent to it and your approved clinician or a second opinion appointed doctor (SOAD) certifies that you’ve consented, and that you have capacity to do so.

If you are in hospital under sections 4, 5(2) or 5(4) of the Mental Health Act 1983, you cannot be given ECT without your consent, except in an emergency.

If you are on a community treatment order (CTO), ECT can normally be given only if you consent to it and your approved clinician certifies that you’ve consented (and have capacity to do so).

Can I be given ECT without my consent?

You may be given ECT without your consent if you need emergency treatment or if you don't have capacity to consent to it.

Emergency treatment

The Mental Health Act 1983 sometimes allows ECT to be given without your consent in an emergency, but only if the treatment is immediately necessary for any of the following reasons:

If it will save your life.
If it will prevent your condition seriously worsening, and won't have unfavourable physical or psychological consequences that can't be reversed.

If you do not have capacity to give consent

If you don't have capacity to give consent, treatment may be given under the Mental Health Act 1983 or, less commonly, under the Mental Capacity Act 2005.

Under some sections of the Mental Health Act 1983

If you have been detained under certain sections of the Mental Health Act 1983, you may be given ECT without your consent if all of the following apply:

You are detained under the Mental Health Act 1983, except if you are detained under sections 4, 5(2) or 5(4).
You are unable to understand the information about ECT and cannot give informed consent.
You have not previously made an advance decision, or there is not a decision made by an attorney, deputy or the Court of Protection refusing ECT treatment.
A second opinion specialist who is not involved in your care consults with two people who have been professionally involved with your care and also agrees that ECT should be given.

Under the Mental Capacity Act 2005

If you are not detained under the Mental Health Act 1983, you may still be treated without your consent under the Mental Capacity Act 2005. This can only happen if all of the following apply:

- You are assessed as lacking capacity to consent under the Mental Capacity Act 2005.

You have not previously made an advance decision refusing ECT treatment.
It is considered to be in your best interests to receive the treatment.

Before a decision is made on whether ECT is in your best interests, various people need to be consulted, including:

anyone interested in your welfare, such as a carer or close family member
your attorney (if you have appointed one) and deputy (if the Court of Protection has appointed one).

If there is a disagreement over whether ECT is in your best interests, it may be necessary to apply to the Court of Protection to resolve this disagreement.

Advance decisions about ECT

If you are clear you do not wish to receive ECT even if your life is in danger, your advance decision needs to meet special conditions.

ECT should not be given to you if any of the following conditions apply:

You have already made a valid and applicable advance decision refusing ECT.
Your attorney has refused ECT on your behalf under a lasting power of attorney.

A court-appointed deputy, or a court, has refused ECT on your behalf. Your family should also be consulted in all of these cases, if appropriate.

𝒩hat are ECT treatment sessions like?

Do I have to be an inpatient to have ECT?

It’s more common to have ECT as an inpatient in a hospital, which means you will stay in hospital overnight. But outpatient treatment is sometimes possible – this means you won’t have to stay overnight.

If you’re staying in a hospital that doesn’t offer ECT, you’ll need to visit another hospital with an ECT clinic to have the treatment.

If you are an outpatient, you will need to have someone with you to accompany you home, as it’s important that you aren’t alone when leaving hospital. You, or your friend or family member who is with you, should be asked at the hospital to confirm that:

- you will be accompanied home and have someone with you for 24 hours after treatment
- you will not drive during your course of treatment, or until the psychiatrist has told you it’s ok
- you will not drink alcohol for at least 24 hours after treatment, or until you have been told it’s ok

you will not sign any legal documents for at least 24 hours after treatment, or until you have been told it’s ok.

What is the ECT clinic like?

The ECT clinic should have three rooms:

a waiting area, which should be comfortable and provide a relaxing environment
a treatment room, which should have the equipment required for monitoring and for resuscitation in an emergency, as well as the ECT machine
a recovery room.

The clinic should be organised so that the rooms are separate and you can move easily from one room to the next, without people observing you from other rooms. Staff at the clinic will usually include nurses, psychiatrists and anaesthetists.

𝒩here can I find out about the clinic I'm visiting?

ECTAS provides a set standards for the use of ECT in the UK, including how the clinic is set up and how treatment is administered. It also has a list of clinics which meet these standards across different areas of the country.

“I was so surprised after my first treatment that it was nowhere near as bad as I had anticipated it being.”

How can I prepare for ECT?

To prepare for ECT, you should:

wear loose, comfortable clothing
tell the team if you have had cosmetic dentistry such as veneers or implants, or any piercings.

And you should not:

eat or drink anything (except a few sips of water) for at least six hours before treatment, because of the anaesthetic given just before treatment
wear any hairspray, creams, make-up, nail polish, metal hair slides or grips, or piercings.

What happens during ECT?

- Before the treatment starts, you will lie on a bed and your jewellery, shoes and any dentures will be removed and kept safe for you.
- You will be given a general anaesthetic injection, once you are comfortable.

Once the anaesthetic takes effect and you are unconscious, you will be given an injection of muscle relaxant to stop your body from convulsing during the treatment. You will also be given oxygen through a face mask or tube. This is needed because of the muscle relaxant.
Two padded electrodes will be placed on your temples. You will either have one placed on each side of your head (bilateral ECT), or both placed on the same side of your head (unilateral ECT) – there is more information about this below.
A mouth guard will be placed in your mouth, to stop you biting your tongue.
The ECT machine will deliver a series of brief, high-voltage electrical pulses. This will cause you to stiffen slightly, and there may be some twitching movements in the muscles of your face, hands and feet. The seizure should last for 20 to 50 seconds.

“The actual treatment was disorientating and overwhelming... I was overwhelmed by how quickly it was happening.”

What are bilateral and unilateral ECT?

Bilateral ECT means that two electrodes are placed on your temples, one on each side of your head, so the electric current passes across your whole brain.
Unilateral ECT means that two electrodes are placed together on one temple, so only one side of your brain is stimulated.

Both types cause a seizure of the whole brain. Bilateral ECT is more commonly used and is believed to be more effective, but may also be more likely to cause memory problems. Unilateral ECT can have fewer side effects, but may also be less effective.

You may be given unilateral ECT if it has helped you in the past, or if you have had unpleasant side effects after bilateral ECT.

What happens after ECT?

After the seizure, the mouth guard is removed and you will be turned on your side. The anaesthetist will provide oxygen until the muscle relaxant wears off (after a few minutes) and you start breathing on your own again.

You will slowly come round, although you may feel very groggy. You may sleep for a while after treatment.

You will need to recover from the general anaesthetic as well as the ECT treatment itself.

How many treatment sessions might I have?

ECT is usually given twice a week for 3-6 weeks, meaning you might have around 6-12 sessions. You should be assessed after each treatment to see if another one is necessary, or isn’t advisable.

ECT tends to provide short-term improvements, so it can be helpful to try other types of treatments after having it. This could help you make the most of any improvement you have experienced from ECT.

𝒩hat are the side effects of ECT?

Memory loss

Many people experience memory loss after having ECT. Some people find this only lasts for a short time and their memories gradually return as they recover from ECT.

But some people experience more long-lasting or permanent memory loss, including losing personal memories or forgetting information they need to continue in their career or make sense of their personal relationships. Some people also find they have difficulty remembering new information from after they’ve had ECT.

Guidelines say that you should have a standard test of your memory and thinking abilities as part of your assessment before treatment and after each treatment session.

“I became unable to study or read as I simply couldn't concentrate and my ability to absorb or retain new information has decreased to almost non-existent”

Immediate side effects

You may experience other side effects immediately after treatment. These can include:

drowsiness (you may sleep for a while)
confusion
headache
feeling sick
aching muscles
loss of appetite.

Very rarely, people may experience prolonged seizures. Some people also:

injure their teeth or jaw, or other muscles, although should be minimised by the muscle relaxant
become very confused between treatments, or more rarely become very restless or agitated.

There are also some risks associated with general anaesthetic. You can speak to your doctor or healthcare team if you have any questions about this.

“Immediately after treatments I was drowsy but not in pain and there were occasions of feeling nauseous.”

Longer-term side effects

Longer-term effects can include:

apathy (loss of interest in things)
loss of creativity, drive and energy
difficulty concentrating
loss of emotional responses
difficulty learning new information.

𝒩hat alternatives are there to ECT?

NICE guidelines say you should only be offered ECT if you have tried other treatments and found them unsuccessful, unhelpful or unacceptable, or you are so unwell that you are unable to benefit from them.

These other treatments might include medication, talking therapies, or arts and creative therapies.

If these treatments haven’t helped, it doesn’t mean you have to try ECT. Our guide to seeking help for a mental health problem has some suggestions for other treatments you could try.

Other physical treatments

Transcranial magnetic stimulation (TMS)

TMS is another physical treatment which can sometimes be used as an alternative to ECT or antidepressants. It stimulates the brain using magnetic fields.

NICE guidance says that there are no major safety concerns with TMS. Research has shown that it can be helpful in treating depression, but the benefits may vary for different people. TMS is now available on the NHS in some hospitals.

The advantages of TMS are that it does not require a general anaesthetic, and does not normally cause a seizure, so is much less likely than ECT to cause memory loss.

Neurosurgery

If nothing else has helped, including ECT, and you are still severely depressed, you may be offered neurosurgery for mental disorder (NMD), deep brain stimulation (DBS), or vagus nerve stimulation (VNS).

Useful contacts

Mind's services

Helplines – all our helplines provide information and support by phone and email. Our Blue Light Infoline is just for emergency service staff, volunteers and their families.

- Mind’s Infoline – 0300 123 3393, info@mind
- Mind’s Legal Line – 0300 466 6463, legal@mind
- Blue Light Infoline – 0300 303 5999, bluelightinfo@mind

Local Minds – there are over 140 local Minds across England and Wales which provide services such as talking treatments, peer support, and advocacy. Find your local Mind here, and contact them directly to see how they can help.
Elefriends is a supportive online community for anyone experiencing a mental health problem. See our Elefriends page for details.

Who else could help?

Electroconvulsive Therapy Accredication Service (ECTAS)

ectas.org.uk

Sets standards for ECT services.

National Institute for Health and Care Excellence

nice.org.uk

Publishes guidelines on treatment.

POhWER

pohwer.net 0300 456 2370

Provides advocacy services.

Rethink Mental Illness

rethink.org 0300 5000 927

For everyone affected by severe mental illness.

Royal College of Psychiatrists

rcpsych.ac.uk

Provides information on conditions and treatments.

To be revised in 2022

References are available on request.

Also the leaflet on the link below.

https://www.rcpsych.ac.uk/docs/default-source/mental-health/treatments-and-wellbeing/ect-files/electroconvulsive-therapy-(ect)-easy-read---dec-2022.pdf?sfvrsn=47e0317b_2

Please supply patient ECT consent form.

Appendix 4 can be found on the link below:-

ISL392 11 EasyRead Your rights to say yes or no to ECT UPDATE (cqc.org.uk)

Please supply any ECT reports/investigations

None.

How many ECT in 2023?

What proportion of patients were men/women?

15 men and 18 women.

How old were they?

Between 32 and 85 years.

What proportion of patients were classified people of the global majority or racialised communities (“POC/BAME”)?

None.

How many people covered by the equality act received ECT?

Whilst the Trust may hold this information, it would require detailed review of each individual patient’s record to locate, retrieve and extract all this the information. Therefore, this part of the Trust response is refused under S12(1) of the Freedom of Information Act.

How many people were offered talking therapy prior to ECT?

Whilst the Trust may hold this information, it would currently require detailed review of each individual patient’s record to locate, retrieve and extract all this the information. Therefore, this part of the Trust response is refused under S12(1) of the Freedom of Information Act.

The referral paperwork is being updated to take into account new ECTAS standards.

How many were receiving ECT for the first time?

How many patients consented to ECT?

How many ECT complaints were investigated outside the NHS and CCG?

None.

How many patients died during or 1 month after ECT and what was the cause (whether or not ECT was considered the cause)?

None.

How many patients died within 6 months after ECT and what was the cause (whether or not ECT was considered the cause)?

Two – none were ECT related.

How many patients died by suicide within 6 months of receiving ECT (whether or not ECT was considered the cause)?

None.

How many patients have suffered complications during and after ECT and what were those complications?

Three, of which:

One complained of chest pain and was referred to A&E.
One was sent to A&E following an anaesthetic assessment resulting in a delay in starting treatment until this was assessed and resolved.
One complained of numbness and weakness in their hand resulting in treatment being suspended whilst this was assessed and resolved.

Have there been any formal complaints from patients/relatives about ECT?

No.

If so, what was their concerns?

Not applicable.

How many patients report memory loss/loss of cognitive function?

What tests are used to assess memory loss/loss of cognitive function?

Comprehensive Psychopathological Rating Scale (CPRS)

Cognitive Impairment Test (6CIT)

Montreal Cognitive Assessment (MoCA)

Clinical Global Impression scale (CGI)

Used to assess severity of illness (CGI-S) and change (CGI-I)
CGI–S completed by referrer before treatment starts
CGI–I completed before each treatment session within the department’s Patient Health Questionnaire (PHQ-9)

Have MRI or CT scans been used before and after ECT?

One.

If so what was the conclusion?

One was requested and there were no issues reported.

How does the Trust plan to prevent ECT in the future?

Freedom of Information is about the provision of fact (recorded information) not opinion.

The Trust can advise that:

ECT is a scientifically evaluated and effective treatment for severe depression and other conditions. It is approved by NICE, the Royal College of Psychiatrists and is available in most Mental Health Trusts throughout the UK. It is internationally available in most countries and is recognised as a standard intervention in severe and treatment resistant depression.

ECT continues to be scientifically researched with research papers published in all major international psychiatric journals as well as in the specialist international journal for ECT.

ECT forms part of a range of treatments for the more severe types of depression and Mersey Care NHS Foundation Trust is committed to developing its service for severe and resistant depression as part of its commitment to Perfect Care. The option of patients receiving ECT forms a key part of this service. Following a successful 2-year pilot, Mersey care now also offer TMS (Transcranial Magnetic Stimulation) as a treatment option. Many patients with treatment resistant depression who would have previously been referred for ECT have now been offered and treated with rTMS as an alternative.

Although most patients with depression will not require ECT it remains an important part of standard psychiatric practice.

The ECT service at Mersey Care is accredited with the Royal College of Psychiatrists Elective Convulsive Therapy Accreditation Service (ECTAS), which provides independent external evaluation of ECT services, and has been so for more than ten years, since the ECTAS service has existed.

Appendix 5

Please provide restraints information under the FOI act to the following questions: -

Please supply any Restraints/investigations

Whilst the Trust holds this information, it is not held centrally and would require detailed review of each individual patient’s record (for all 4,313 restraints) to locate, retrieve and extract all this the information. Therefore, this part of the Trust response is refused under S12(1) of the Freedom of Information Act.

Wards are required to undertake a de-briefing for staff and service users following incidents of physical intervention. Debriefs are a helpful mechanism to support teams at times where there have been injuries or significant concerns in relation to the acuity of the incident and they also support learning in order to reduce and prevent future incidents.

We analyse all incident data weekly, which is fed back to clinical areas. This enables us to identify areas that require additional support and keeps our teams constantly engaged in the process of improvement. In addition to this, all incidents of PI are collated and monitored monthly by our divisional Reducing Restrictive Practice Monitoring Groups.

All seclusion episodes are reviewed and audited monthly by a ward manager not attached to that area. All seclusion episodes are also monitored for appropriateness and proportionality via the Reducing Restrictive Practice Monitoring Group.

How many RESTRAINTS in 2023?

4313

What proportion of patients were men/women?

Gender	Episodes
Female	1912
Male	2108
No Gender indicated	293

How old were they?

Age Bands	Episodes
19 and under	239
20-29	990
30-39	1391
40-49	604
50-59	480
60-69	120
70-79	132
80-89	63
90-99	1
No age indicated	293

NB Restraints on Older Peoples wards are low level holds to assist in personal care

What proportion of patients were classifiedpeople of the global majority or racialised communities ("POC / BAME")?

WHITE - BRITISH 80.32%

NOT STATED - 9.09%

OF GLOBAL MAJORITY - 10.59%

How many people covered by the equality act were restrained?

Whilst the Trust holds this information, it would require detailed review of each individual patient’s record to locate, retrieve and extract all this the information. Therefore, this part of the Trust response is refused under S12(1) of the Freedom of Information Act.

How many RESTRAINTS were investigated outside the NHS and CCG?

Whilst the Trust may hold this information, it is not held centrally and would require detailed review of each individual patient’s record to locate, retrieve and extract all this the information. Therefore, this part of the Trust response is refused under S12(1) of the Freedom of Information Act.

How many patients died during or 1 month after RESTRAINTS and what was the cause (whether or not RESTRAINTS was considered the cause)?

How many patients died within 6 months after RESTRAINTS and what was the cause (whether or not RESTRAINTS was considered the cause)?

Number of patients died within 6 months of restraint	2	Possible suicide	1
		Unexpected natural cause death	1

How many patients died by suicide within 6 months of receiving RESTRAINTS (whether or not RESTRAINTS was considered the cause)?

How many patients have suffered complications during and after RESTRAINTS and what were those complications?

Wards are required to seek a medical review following all incidents of physical intervention and seclusion by medical staff as per policy SD18. Whilst the Trust holds this information, it is not held centrally and would require detailed review of each individual patient’s record to locate, retrieve and extract all this the information. Therefore, this part of the Trust response is refused under S12(1) of the Freedom of Information Act.

Have there been any formal complaints from patients/relatives about RESTRAINTS?

Sent to Complaints

If so, what was their concerns?

Not applicable.

Are counts of forced injections available?

The Trust does not currently monitor the number of injections given without consent so are unable to provide this information.

How does the Trust plan to reduce restraints in the future?

Freedom of Information is about the provision of fact (recorded information) not opinion.

The Trust can advise that:

As part of our drive towards striving for Perfect Care, Mersey Care NHS Foundation Trust launched the ‘No Force First’ initiative, with the aim of eliminating restrictive interventions in our inpatient services, unless necessary.

The Trust believes people in our care who present with behaviours of concern should be supported through methods other than physical and medication-led restraint. We remain committed both to ‘No Force First’ and the ‘Safewards’ initiative in our specialist learning disability division, a new model of working that focuses on reducing restrictive practices and improving patient outcomes.

Mersey Care NHS Foundation Trust is leading research. We work very closely with service users on pre-agreed care plans and on co-produced positive behavioural support, in line with the national best practice and government policy documents and practice guidance to break the cycle of restriction and use positive early interventions.
Mersey Care NHS Foundation Trust treats the safety of its staff, patients and visitors very seriously and when incidents happen there are rigorous procedures in place, together with a review of the events so we may learn from them. It is necessary to point out that multiple levels of scrutiny are in place and staff are highly trained to deal with violent or aggressive situations.

Mersey Care NHS Foundation Trust clinicians and service users continue to share national award platforms which have recognised the joint working in reducing restrictive practice together.

Appendix 6

Please provide SECLUSION information under the FOI act to the following questions: -

Please supply any SECLUSION reports/investigations

Whilst the Trust holds this information, it is not held centrally and would require detailed review of each individual patient’s record (for all 819 seclusions) to locate, retrieve and extract all this the information. Therefore, this part of the Trust response is refused under S12(1) of the Freedom of Information Act.

How many SECLUSIONS in 2023?

There were 819 episodes of seclusion during 2023 which relates to 300 distinct patients.

What proportion of patients were men/women?

19% female and 81% male.

These percentages are based on the 300 distinct patients.

How old were they?

Age Bands	Episodes
18-20	11
21-30	94
31-40	106
41-50	52
51-60	33
61+	9

This data is based on the patient’s age at the start of the seclusion episode and therefore a patient could be reported in multiple age bands if multiple seclusions occurred.

What proportion of patients were classified people of the global majority or racialised communities ("POC / BAME")?

17.33% BAME / 80.3% White / 2.33% not stated.

These percentages are based on the 300 distinct patients.

How many people covered by the Equality Act were secluded?

How many SECLUSIONS were investigated outside the NHS and CCG?

None.

How many patients died during or 1 month after SECLUSION and what was the cause (whether or not SECLUSION was considered the cause)?

None.

How many patients died within 6 months after SECLUSION and what was the cause (whether or not SECLUSION was considered the cause)?

None.

How many patients died by suicide within 6 months of receiving SECLUSION (whether or not SECLUSION was considered the cause)?

One.

How many patients have suffered complications during and after SECLUSION and what were those complications?

Have there been any formal complaints from patients/relatives about SECLUSION?

There have been two complaints from patients regarding seclusion.

If so, what was their concerns?

A relative of one patient raised concerns regarding the length of time in seclusion, and one was from a patient who felt they were being unlawfully secluded.

How does the Trust plan to prevent SECLUSION in the future?

Freedom of Information is about the provision of fact (recorded information) not opinion.

The Trust can advise that:

The Trust has a preventative strategy through No Force First approach that is established and embedded in practice. There is a clear approach and interventions that are designed to support a reduction strategy for all restrictive practices including seclusion.

Reducing restrictive practices is a key priority and a zero approach to segregation has been embedded. Consequently, robust governance and oversight processes are embedded to ensure that seclusion is used as a last resort and that patients are not in seclusion for longer than is necessary

The Trust invests in staff training which focusses on preventative strategies and de-escalation. The training has been certified by Bild and is approved as meeting the standards set by the Restraint Reduction Network. Staff are equipped with clinical skills that harness positive relationships, human rights approaches and a compassionate culture

Better clinical Environments. The Trust is investing in clinical environments, use of de-escalation and comfort room as well as quiet rooms to offer alternative spaces for patients on wards. There is greater focus on trauma informed care and interventions

The HOPE(s) model has been developed within the Trust, has been applied, and shared both locally and nationally. The model aims to end long term segregation (LTS) and the harm associated with this. By reducing LTS the Trust will also focus on seclusion

Seclusion is always a last resort.

Appendix 7

Please provide MEDICATION ERRORS information under the FOI act to the following questions: -

Please supply any MEDICATION ERRORS reports/investigations

Whilst the Trust holds this information, it would require detailed review of each individual medication incident (3,064 such incidents) on the Trust’s incident reporting systems (Datix, Ulysses and Radar) to locate, retrieve and extract all this the information. It would also require review of each individual incident report to ensure they are individually checked to ensure any person confidential information is redacted. Therefore, this part of the Trust response is refused under S12(1) of the Freedom of Information Act.

How many MEDICATION ERRORS in 2023?

3,064

What proportion of patients were men/women?

Whilst the Trust holds this information, it would require detailed review of each individual incident reported to locate, retrieve and extract all this the information. If the patient’s gender is not recorded, each individual patient’s record would then need to be reviewed. Therefore, this part of the Trust response is refused under S12(1) of the Freedom of Information Act.

How old were they?

Whilst the Trust holds this information, it would require detailed review of each individual incident reported to locate, retrieve and extract all this the information. If the patient’s age is not recorded, each individual patient’s record would then need to be reviewed. Therefore, this part of the Trust response is refused under S12(1) of the Freedom of Information Act.

What proportion of patients were classified people of the global majority or racialised communities ("POC / BAME")?

How many people covered by the equality act endured medication errors?

How many MEDICATION ERRORS were investigated outside the NHS and CCG?

The Trust does not hold this information as it is outside its remit.

How many patients died during or 1 month after MEDICATION ERRORS and what was the cause (whether or not MEDICATION ERRORS was considered the cause)?

Cause of death is not routinely recorded on every patient care record. Whilst the Trust may hold this information, it would require detailed review of each individual patient’s record to locate, retrieve and extract all this the information. Therefore, this part of the Trust response is refused under S12(1) of the Freedom of Information Act.

How many patients died within 6 months after MEDICATION ERRORS and what was the cause (whether or not MEDICATION ERRORS was considered the cause)?

As per response to Q7 above.

How many patients died by suicide within 6 months of receiving MEDICATION ERRORS (whether or not MEDICATION ERRORS was considered the cause)?

As per response to Q7 above.

How many patients have suffered complications during and after MEDICATION ERRORS and what were those complications?

Have there been any formal complaints from patients/relatives about MEDICATION ERRORS?

Three

If so, what was their concerns?

A patients relative raised concerns that the patient was not provided with the correct dose of medication. One patient raised concerns regarding error of medication dose. One patient felt that the medication was prescribed incorrectly.

How does the Trust plan to prevent MEDICATION ERRORS in the future?

Freedom of Information is about the provision of fact (recorded information) not opinion.

The Trust can advise that:

The Trust takes medication errors very seriously and after an incident has happened there are rigorous procedures in place, together with a review of the events so we may learn from them. Extra training is given if required.

All medicines incidents are reviewed for emerging trends and themes through the Trust medicines management governance processes and ensures lessons are shared and learnt to prevent future incidents. The Trust has set ‘zero harm from medicines’ as a key perfect care goal in it’s Clinical Strategy to ensure that medicines safety remains front and centre, supports monitoring and quality improvement plans.

The Trust invests in staff training which focusses on preventative strategies and de-escalation.

Thanks

Regards

The FOI Team

Mersey Care NHS Foundation Trust

FOI@merseycare.nhs.uk