Introduction to special issue on social media for forensic mental evaluations.

This special issue of Behavioral Sciences & the Law presents six articles that focus on various issues related to social media in forensic mental health evaluations. These eclectic articles provide updated information about social media's use and navigating difficult ethical concerns. Ranging from violence risk assessment to disability evaluations, the up-to-date information in this special issue allows the forensic evaluator to be more prepared when they inevitably encounter information from social media. As social media continues to grow, both in terms of overall use and the number of available platforms, forensic clinicians will need to remain cognizant of the ways these data can be appropriately utilized as collateral data.

Readmission after discharge from a medium secure service between 1999 and 2017: A retrospective cohort study.

BACKGROUND: Previous research into outcomes after treatment in medium secure psychiatric hospitals has mostly relied on pre-millennium data. AIMS: To examine patient and inpatient service-related factors associated with readmission within 2 years following discharge to the community or open conditions from conditions of medium security. METHODS: A retrospective cohort study of 137 patients discharged either to the community or to open conditions from one 64-bed South Wales Regional Medium Secure Hospital Unit between July 1999 and November 2017 was completed using data from healthcare records to document demographics, diagnosis and nature of index offences together with researcher-completed ratings of inpatient progress using the Dangerousness Understanding Recovery and Urgency Manual (DUNDRUM) Programme Completion and DUNDRUM Recovery scales. Binary logistic regression analyses were used to identify independent associations between inpatient progress according to these measures and readmission. RESULTS: Forty-three patients (31%) were readmitted within 2 years of discharge and 23 (17%) in breach of legal conditions on discharge. Most readmitted patients (n = 29, 67%) returned directly to medium secure care. There were significant binary level associations between readmission and severity of the index offences (lower), number of adverse childhood experiences (higher), history of drug misuse (more likely) and number of previous psychiatric admissions (higher). Binary logistic regression confirmed that these relationships were not independent. No inpatient service-related variables, according to DUNDRUM scale scores, showed an independent association with readmission within 2 years post-discharge. CONCLUSIONS: The proportion of medium security hospital patients who were readmitted within 2 years of discharge aligns with estimates found in earlier national research using the same follow-up period. Since levels of inpatient progress bore little if any relationship to longer term outcomes, our findings highlight the need for investigating factors in the discharge environment that are linked to readmission. It is possible that readmission may indicate effective monitoring and responsive care to the changing needs of patients, but a better understanding of this is essential.

Characteristics associated with criminal responsibility assessment outcomes among women in Central Canada.

The number of women involved with forensic mental health systems internationally is rising, however, limited research has explored the characteristics of those assessed for criminal responsibility. We investigated the demographic, psychiatric, and criminological characteristics of women recommended as eligible or ineligible for the defence of Not Criminally Responsible (NCR) on account of mental disorder following a criminal responsibility assessment in Central Canada. Data were collected through retrospective chart reviews of court-ordered criminal responsibility assessments for 109 women referred for evaluations between 2003 and 2019. Accused were an average age of 34.55 years, predominately identified as Indigenous (37.7%) or Caucasian (20.8%), and had often been charged with assault (47.7%). Women identified in the reports as NCR-eligible were significantly more likely to be employed, experience delusions during the index offence, and have expert reports linking their mental health symptoms to NCR legal criteria. They were also significantly less likely to have a personality disorder, substance-related diagnosis, or have used substances during the index offence. Delusions during the index offence significantly predicted assessment recommendations when controlling for age at assessment order, current substance-related diagnosis, and whether the expert report linked mental health symptoms to NCR legal criteria. Findings indicate the key factors considered by forensic mental health professionals when conducting criminal responsibility assessments with women. Meaningful differences exist between women identified as NCR-eligible and ineligible, with findings illustrating who may be more likely to receive services within the Canadian forensic mental health system.

Testing a recovery-oriented nursing communication framework to encourage collaboration and discussion about aggression prevention: A mixed methods study.

Recovery-oriented practice is essential in healthcare, yet research exploring methods for integrating recovery-oriented principles in forensic mental health settings is limited. This study involved the co-development, with mental health care nurses and a lived experience expert, and testing of a recovery-oriented script for forensic mental health nurses to use when communicating with consumers at high-risk of imminent aggression. The aim was to examine whether nurses perceived the script as more empathic when the script included specific references to empathy, compared to an equivalent script that did not include empathic statements, and to explore nurses' perspectives on whether the script could help prevent aggression. Nurses (n = 54) working in a secure forensic mental health hospital were randomly allocated to read a script containing statements representing nine recovery-oriented principles that also included empathic statements, or an equivalent script that did not include empathic statements. After reading the script, the participants completed a questionnaire involving a recovery-oriented practice scale developed by the authors, measuring the extent to which the scripts reflected recovery-oriented principles, and open-ended questions about the script's potential to prevent aggression. Results revealed no significant difference in nurse perceptions of empathy between the two scripts. Content analysis indicated that nurses perceived the scripts could help prevent aggression.

Enhancing Pre-Treatment Motivation Improves Forensic Mental Health Outcomes.

Despite evidence that psychological treatments benefit from pre-treatment intervention, there remains no published research on the value of including a pre-treatment intervention in forensic mental health settings. The present study aimed to address this gap by examining the effects of adding a brief motivational preparatory program (MPP) to standard forensic psychiatric care. The MPP was based on hope theory and motivational interviewing within a cognitive-behavioral therapy approach. MPP participants and a waitlist control group completed a battery of self-report measures of hope and motivation to change, which were compared with respect to risk, demographic, offence history, and outcome variables. There was a significant increase in client motivation for change after completing the MPP. Additionally, those who completed the MPP evidenced modest reductions in aggressive behavior, but significantly increased engagement in subsequent forensic treatment and programming.

Don't Beat Around the Bush! The Relationship Between Forensic Vigilance and Communication Style.

The field of forensic mental healthcare is unique in several ways. Forensic vigilance is a specialty needed by forensic mental health professionals, consisting of professional forensic psychiatric knowledge, knowledge of individual patients, environmental observations, and clinical judgment. Though communication seems to play an important role in forensic vigilance, it is still unknown which communication styles are related to forensic vigilance, if any. In the current study, we examined if certain communication styles are related to forensic vigilance by means of an online survey among forensic mental health professionals. In total 138 Dutch forensic psychiatric professionals participated in the survey. The expressive and precise communication styles positively predict forensic vigilance, while the emotional and manipulative communication styles show a negative relationship with forensic vigilance. Findings of the present study further the understanding of the construct of forensic vigilance. The findings presented here may give rise to attention for specific manners of communication in supervision and training programs. The current study represents the first effort to study the relationship between communication styles and forensic vigilance.

The Internet is a scary place: How does evidence source and examinee race or ethnicity influence determinations of threat?

Violent rhetoric online is becoming increasingly relevant to the practice of forensic mental health assessment as examinee's virtual lives may transform into real-world acts of violence. With the rise of a diverse subculture of violent online communities, the aim of the present study was to inform how concerns with online sources of collateral data and racial/ethnic biases may influence determinations of violence potential. Using an experimental design, jury-eligible participants (N = 278) and forensic mental health experts (N = 78) were presented with mock Twitter (now referred to as X) posts that varied by data source (i.e., how information was accessed) and the examinee's race/ethnicity. Results showed no differences in participants' ratings of data credibility, how much weight they would place on the posts in a threat assessment, or how likely the examinee was to act violently against his intended target. Implications regarding the interpretation of social media evidence, relevant limitations, and future research are discussed.

Forensic Case Formulation: Exploring the Knowledge, Opinions, and Training Experiences of Staff Working Within the Offender Personality Disorder Pathway.

Forensic case formulation (FCF) is a key activity within the Offender Personality Disorder Pathway (OPDP), performed by OPDP specialist offender managers (OMs) and psychologists. Although FCF training is provided to OMs, there are a number of questions about the adequacy and effectiveness of this training. Furthermore, it is unclear whether psychologists receive sufficient support to keep their FCF skills relevant and effective over time. This study aimed to investigate the FCF training experiences of OPDP staff, to assess staff satisfaction with this training, to identify ways of improving this training, and to explore the value of FCF from a staff perspective. To meet these aims, OPDP staff were asked to complete an online Qualtrics survey disseminated nationally. Results reveal a lack of standardized FCF training across the OPDP, contributing to poor staff satisfaction and confidence. These results highlight a need for FCF training improvement within the OPDP.

The Nurse-Police Assistance Crisis Team (N-PACT): A new role for nursing.

AIM: This study aimed to gain insights into forensic nurses' perspectives and approaches to behavioural crisis situations, comparing them to disciplines traditionally involved in first-line behavioural crisis response. DESIGN: This study used a descriptive, qualitative exploratory design and was informed by Systems Theory. METHODS: The study was carried in the United States, between 2022 and 2023. Data were gathered through four focus groups: police officers (n = 12), co-response (mental health) clinicians (n = 13), sexual assault nurse examiners (n = 6) and correctional nurses (n = 4). Thematic analysis was performed. REPORTING METHOD: The Standards for Reporting Qualitative Research (SRQR) guidelines were used. RESULTS: Findings revealed temporal themes in crisis response: (1) Searching for Historical Information; (2) Safety and Acting at the Present Scene; and (3) Future Strategies and Interventions. Common priorities (e.g. safety and de-escalation) were identified across groups. Notably, nurses demonstrated a comprehensive approach, addressing physical and mental health assessments, substance involvement, and physical injury evaluation. CONCLUSION: This study proposes the creation of a novel nursing role within first-line multidisciplinary teams (MDTs) for crisis response-the Nurse-Police Assistance Crisis Team (N-PACT). Nurses bring expertise and comprehensive assessment skills to enhance crisis responses, particularly in cases involving mental health emergencies, medical crises, and drug-related incidents. IMPLICATIONS: Forensic nurses, with their diverse competencies and comprehensive training, are highly valuable assets within MDTs. Their expertise extends to proficiently conducting mental and physical assessments, ensuring safety and adeptly navigating situations that intersect with the legal system. IMPACT: The N-PACT concept can improve outcomes and streamline the allocation of resources, particularly considering the number of police calls involving behavioural crises. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.

Potential Sources of Moral Injury for Healthcare Workers in Forensic and Psychiatric Settings: A Systematic Review and Meta-ethnography.

The current research examines potentially morally injurious events (PMIEs) faced by healthcare professionals working in forensic and psychiatric environments. A systematic literature review was conducted to identify peer-reviewed articles reporting on sources of moral injury or similar concepts (e.g., moral distress) for healthcare workers in such settings. Thirty articles were included and analyzed using a meta-ethnographic approach. Synthesis yielded three third-order factors, each reflecting a moral dichotomy: (a) "between profession and system," (b) "between relations with patients and relations with others," and (c) "between principles and practices." Findings illustrated the hierarchical relationships between dichotomies, with discordance between values of the healthcare profession and features of the healthcare system providing the conditions for PMIEs to occur. The review advances conceptual understandings of PMIEs in forensic and psychiatric settings, illustrating the multilayered dimensions within which morally injurious events are experienced. Theoretical and practical implications are offered that may support the early detection and prevention of moral injury in healthcare professionals.

Procedural justice and forensic mental health: An introduction and future directions.

This article advocates for integrating procedural justice principles into forensic mental health services to enhance patient engagement and autonomy. Procedural justice, broadly defined as fair decision-making processes, is introduced and key principles including voice, neutrality, respect and trustworthiness are described. Evidence suggestive of positive outcomes following procedural justice experiences, such as improved satisfaction, collaboration and reduced perceptions of coercion is outlined. Practical applications are suggested, including staff training and reflective practices using procedural justice principles. The article then calls for further research to explore patients' and staff members' experiences of procedural justice in forensic settings, develop measurement tools, undertake intervention studies and establish causal links between procedural justice and outcomes important for forensic patients.

Nurses' and patient' descriptions about forms of power in pro re nata medication participation in forensic psychiatric care: A qualitative secondary analysis.

Despite there being an emphasis on patient participation in their own care, it has been a challenge in pro re nata (PRN, as the circumstance arises) medication in forensic psychiatric care. The power imbalance in treatment relationships can be a barrier to patient participation and should therefore be further explored. This qualitative descriptive study aimed to explore the aspect of power in the descriptions of patients and nurses interviewed in a Finnish forensic psychiatric hospital about patient participation in PRN. A qualitative secondary analysis was conducted through the semi-structured interviews of the patients (n = 34) and nurses (n = 19). The data were analysed with deductive content analysis. The Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines were used to ensure comprehensive reporting. The findings revealed that patients and health professionals may have conflicting goals in PRN and that they both use power to try to achieve them. Power in PRN was described in different forms, including authority, force, manipulation and persuasion. Based on our results, the power that health professionals have in PRN medication is particularly based on their legitimate authority and the hierarchical structures of the hospital environment. Patients also hold power in the dynamics of PRN medication care, but their position as a power holder can vary individually and situationally. Recognizing different forms of power and supporting patients with a decreased capacity for decision-making is essential for promoting high-quality and patient-centred forensic psychiatric nursing.

A Nominal Group Technique to finalise Safewards Secure model and interventions for forensic mental health services.

WHAT IS KNOWN ON THE SUBJECT?: Safewards was developed for acute mental health units, and while could be effective in forensic mental health services, there are some gaps in the model for such services, where factors including offending behaviour and longer term care can have an influence. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: The importance of acknowledging and addressing responses related to offending behaviour in forensic mental health settings, while also understanding the vulnerability of the consumer group and responsibilities to the maintenance of professional boundaries. Enhancing collaboration with consumers/families/carers/supporters is important in a forensic mental health setting, and an important element of Safewards Secure. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: This study completes the development of Safewards Secure, designed to foster collaboration, address issues pertinent to forensic mental health settings to enhance implementation and acceptance of the model and reduce conflict and containment. ABSTRACT: INTRODUCTION: Safewards is a model developed for acute mental health settings designed to reduce conflict and containment; however, it requires adaptation to forensic mental health settings. AIM: To develop the Safewards Secure model, a model to assist forensic mental health services to reduce conflict and containment. METHOD: A literature review was conducted to elicit possible modifiers and adjustments to the interventions. A Nominal Group Technique was then used to engage forensic mental health experts who had experience implementing Safewards (n = 12) to seek feedback about the suggestions and reach consensus on the Safewards Secure model and interventions. Data were thematically analysed. RESULTS: Experts reached consensus on all suggestions, however, did recommend minor additions and modifications. Two themes were also interpreted: Safewards Secure is just as much for staff as it is for consumers, and the proposed additions encourage more meaningful staff to consumer collaboration. DISCUSSION: This study identified key challenges experienced by nurses working in forensic mental health settings, however, these challenges were not seen as insurmountable. The Safewards Secure model offers prompts and suggestions to encourage reflection, collaboration and a humanistic approach to care in forensic mental health settings. IMPLICATIONS FOR PRACTICE: Addressing reactions to offending behaviour and encouraging more collaboration might assist in ensuring a more person-centred approach to forensic mental health nursing care.

Implementation and evaluation of participatory advisory boards in mental health research: a research protocol of the 'PART-Beirat' project.

BACKGROUND: The use of participatory research approaches in the field of dementia and forensic mental health research has been on the rise. Advisory board structures, involving people with lived experience (PWLE), have frequently been used for guiding and leading research. Yet, there has been limited guidance on the establishment, retention and use of advisory boards in the field of dementia and forensic mental health research. OBJECTIVE: This project outlined in this research protocol will investigate the benefits and challenges of establishing three patient advisory boards, involving PWLE, practitioners and researchers with the purpose to guide research. Data will be used to develop guidelines for best practice in involving PWLE in dementia and forensic mental health research through advisory boards. METHODS: The research project will be divided into three phases: Phase I will involve two topic-specific systematic reviews on the use of participatory research with PWLE, followed by an initial study exploring PWLE's, practitioners' and researchers' expectations on research involvement. Phase II will consist of the establishment of three advisory boards, one focusing on dementia, one on forensic mental health and one overarching coordinating advisory board, which will involve PWLE from both fields. Phase III, will consist of interviews and focus groups with advisory board members, exploring any challenges and benefits of involving PWLE and practitioners in advisory boards for guiding research. To capture the impact of involving PWLE in different research phases and tasks, interviews and focus groups will be conducted at four different points of time (0, 6, 12, 18 months). Reflexive thematic analysis will be used for the analysis of data. DISCUSSION: The project aims to explore the involvement of PWLE and practitioners in guiding research and aims to develop guidelines for best practice in establishing and using patient advisory boards in dementia and forensic mental health research and involving PWLE and practitioners in research.

There is an increasing involvement of people with mental health issues in research, especially in the form of advisory boards. So far People With Lived Experience [PWLE] of mental health issues acquired either from first person experience or through family members, and mental health practitioners' involvement in research has been found to benefit research and society. This is because it increases reach and quality of research, whilst raising the voice of people commonly excluded from decision making (e.g. research, care provision). This research protocol describes the design of a three-year research project. The project aims to establish and use patient advisory boards, involving PWLE, practitioners and researchers, to guide research. The project will consist of three phases: (1) a review of previous studies on the use of participatory research with PWLE of dementia and forensic mental health care, followed by an initial study exploring PWLE's, practitioners' and researchers' expectations in research involvement, (2) the establishment of three advisory boards, one focusing on dementia, one on forensic mental health and one overarching coordinating advisory board, and (3) an exploration of challenges, barriers and benefits of involving PWLE of dementia/forensic mental health care and practitioners in advisory boards for research through interviews and focus groups. Interviews with PWLE and practitioners involved in the advisory boards will be conducted at four different points of time (0, 6, 12, 18 month). At the end, we aim to develop guidelines for establishing advisory board structures, involving PWLE and practitioners in research.

Modifying the clinical reasoning cycle to enhance forensic mental health nursing utility.

Forensic mental health nursing is a specialty area of practice requiring specific knowledge and skills to work collaboratively with consumers. The Clinical Reasoning Cycle has been recognised as a potential framework to support nursing practice; however, it has been identified that adaptations are required to enhance utility in a forensic mental health services. The aim of this study was to explore and finalise a version of the cycle for forensic mental health nursing practice. Focus groups and interviews were used to explore adaptations with staff from a state-wide forensic service and forensic mental health nursing academics. Data were thematically analysed. Four main themes were interpreted: (1) allegiance to the Nursing Process, (2) moving the cycle from page to practice, (3) working as a team, or not, and (4) implementation will be a marathon and not a sprint. While nursing academics were more in favour of updating the Nursing Process to ensure contemporary practice is captured, staff from the service were supportive of the adapted cycle but emphasised the need to ensure collaboration with the consumer and their supporters. The adapted cycle was seen to articulate the contribution of forensic mental health nursing care, and support for a nursing-specific cycle was embraced by other disciplines, despite some hesitation from nurses. Prior to implementation there is a need to ensure the merits of the cycle are clearly articulated, along with a range of resources and specific contextual information to ensure the cycle can be successfully applied to enhance nursing practice and consumer care.

Forensic Mental Health Evaluators' Unprocessed Emotions as an Often-Overlooked Form of Bias.

There has been robust interest in the influence of cognitive and implicit biases that can hamper a forensic mental health evaluator's ability to provide objective opinion evidence. By contrast, literature exploring the biasing effects of the examiner's unacknowledged and unprocessed emotions has been scanty. Borrowing from concepts originating from psychodynamic treatment literature, this article explores how a forensic mental health evaluator's emotional and transferential reactions can affect the assessment process and formulation of findings. We make the case that forensic mental health evaluators are not impervious to their own mental health concerns, including vicarious trauma. We ultimately argue for a cultural shift in forensic practice that acknowledges the unavoidable existence and influence of a forensic evaluator's human emotions, personal reactions, and conflicts, so that strategies can be developed for compassionate but careful management in training programs, supervision, and beyond. We suggest that self-reflection, sometimes with the aid of consultation and psychotherapeutic support, is not only important for clinical trainees but also could serve forensic practitioners throughout their careers, especially during challenging junctures in their personal and professional lives.

Homicide in the context of psychosis: analysis of prior service utilisation and age at onset of illness and violence.

BACKGROUND: Public stigma and fear are heightened in cases of extreme violence perpetrated by persons with serious mental illness (SMI). Prevention efforts require understanding of illness patterns and treatment needs prior to these events unfolding. AIMS: To examine mental health service utilisation by persons who committed homicide and entered into forensic care, to investigate the adequacy of mental healthcare preceding these offences. METHOD: Forensic patients across two mental health hospitals in Ontario with an admitting offence of homicide between 2011 and 2021 were identified (n = 112). Sociodemographic, clinical and offence-related variables were coded from the health record and reports prepared for the forensic tribunal. RESULTS: Most patients (75.7%) had mental health contacts preceding the homicide, with 28.4% having a psychiatric in-patient admission in the year prior. For those with service contacts in the year preceding, 50.9% had had only sporadic contact and 70.7% were non-adherent with prescribed medications. Victims were commonly known to the individual (35.7%) and were often family members in care-providing roles (55.4%). Examination of age at onset of illness and offending patterns suggested that most persons admitted to forensic care for homicide act in the context of illness and exhibit a low frequency of pre-homicide offending. CONCLUSIONS: Many individuals admitted to forensic care for homicide have had inadequate mental healthcare leading up to this point. Effective responses to reduce and manage risk should encompass services that proactively address illness-related (e.g. earlier access and better maintenance in care) and criminogenic (e.g. substance use treatment, employment and psychosocial supports) domains.

A Comprehensive Framework to Advance Equity, Diversity, and Inclusion in a Forensic Service.

Minority and Indigenous populations have disproportionate representation within forensic mental health services. Social determinants of health and systemic discrimination have contributed to the difficulties these populations have in accessing care, as well as significant differences in care trajectories. In addition, staffing and structural equity, diversity, and inclusion (EDI) challenges permeate forensic systems as in other health care settings. There is little literature to guide forensic mental health services in how best to provide equitable, diverse, and inclusive practices for patients, families, and staff. The forensic service at a major urban center in the Canadian province of Ontario has adapted an EDI framework to describe the processes employed to organize and integrate EDI principles and initiatives within a culture of learning and continuous improvement. This Forensic EDI Framework is composed of six domains: Organizational Commitment, Staff/Workforce Competencies, Service Access and Delivery, Promoting Responsiveness, Community Outreach, and Data Collection. Initiatives within each of these domains form the foundation of a sustainable platform for forensic service EDI practices that will promote lasting change.

Collateral Consequences for Third-Party Interviewees in Forensic Contexts.

Collateral interviews can be an integral source of third-party information used in a range of forensic mental health assessments. Although family members and spouses often have the most knowledge about the evaluee, research suggests that they may also experience distress related to the legal proceedings. This article discusses the nature and purpose of collateral interviewing with close collateral contacts, comparing collateral interviews with direct interviews with evaluees. The secondary consequences of having a justice-involved family member are considered, including the possibility of vicarious trauma. Finally, the responsibilities of evaluators are considered, especially in the context of trauma-informed principles applied to collateral interviewing. Recommendations regarding consent, the use of empathy, and feedback to collateral are provided.

Men placed on waiting lists for psychiatric admission from Irish Prisons over five years: Clinical outcomes during a forensic "bed crisis".

BACKGROUND: Ireland has low provision rates of general and forensic beds compared with other western countries. In recent years there have been difficulties and delays in accessing forensic beds for prisoners with severe mental illness. AIMS: We aimed to determine clinical outcomes for male prisoners assessed as requiring psychiatric admission over an extended period, with time frames for admission and other outcomes. We aimed to determine whether admissions to forensic and non-forensic locations were risk-appropriate. METHODS: Participants included all male prisoners placed on psychiatric admission waiting lists in Ireland over five years 2015-2019. We described demographic, clinical and offending variables. We measured clinical outcomes including forensic admission, other admission and recovery with voluntary treatment in prison. We also measured times to clinical outcomes. Security requirements and clinical urgency were assessed using the DUNDRUM Toolkit scales 1 and 2. RESULTS: 541 male prisoners were placed on admission waiting lists and spent an aggregate of over 114 years on admission waiting lists during 2015-2019. Almost one quarter improved with voluntary treatment allowing removal from waiting lists, while over 75% did not. Admission was achieved for a majority of cases, albeit after lengthy delays for some. The most frequent outcome was diversion from remand to non-forensic inpatient settings. Non-forensic admissions arranged by the Prison Inreach and Court Liaison Service (PICLS) at Ireland's main remand prison at Cloverhill contributed 54% (179/332) of all admissions achieved and 76% (179/235) of all non-forensic admissions from prison waiting list. Median delay to admission was 59 days for forensic admissions and 69 days for admissions to non-forensic hospitals from sentenced settings, compared with 16.5 days for admissions to non-forensic hospitals from remand. CONCLUSIONS: Long delays for forensic admission during a five-year period of limited access to such beds were partly mitigated by transfers to non-forensic hospitals, mainly diversion of minor offenders from remand settings.