RCEM Conference 2025: Reflections from Day 3

By Joey Godfrey | Shared with permission on St Emlyn’s Blog

Day 3 of the RCEM 2025 Conference was perhaps the most varied—and intense—of them all. From mental health and legal frameworks to high-intensity users, autism-friendly emergency care, end-of-life pathways, transfusion updates, and paediatrics, it was a day of practical, emotive, and often challenging content. As ever, I’ve tried to distil the detail into something useful for everyday practice.

Managing Complexity in the ED

Dr Mark Buchanan opened the day by reflecting on how we can do better when it comes to mental health emergencies—scenarios that often bring uncertainty, risk, and frustration for clinicians and patients alike. He introduced the AEIOU framework as a practical way to assess patients who have presented with self-harm or psychological distress. Rather than just another checklist, it felt like a call to pause, think more deeply, and plan more safely:

A – Agitation: Consider the patient’s peak level of agitation, not just their current presentation.
E – Environment: Is the space calm, safe, ligature-free, and comfortable for assessment?
I – Intent: Does the patient express any ongoing desire to harm themselves or others?
O – Objects: Check for concealed or dangerous items, including everyday tools that could become weapons.
U – You (or Unknown): Reflect on your own role, your safety, and the complexity of co-existing mental and physical health needs.

For instance, asking not just “Is the patient calm now?” but “What was their peak level of agitation?” opens a richer understanding of risk. Looking around to assess the environment for safety, removing potentially harmful objects (even something as simple as a phone charger), and reflecting on your own role as a responder (“U” might just stand for “you”) reframes these moments as shared human encounters, not just clinical assessments.

He reminded us of the value in side-by-side assessments with mental health teams—something championed by the Royal College of Psychiatrists, yet still patchy across the country [1]. And crucially, he encouraged us to keep our medical index of suspicion high: if someone presents with what appears to be a new psychiatric illness, don’t miss the organic masqueraders.

Dr Emma Barrow picked up on that thread, sharing a complex case of a young woman whose presentation—initially bizarre and aggressive—could have been dismissed as purely behavioural. In fact, it involved dissociation, safeguarding concerns, and later, likely catatonia requiring high-dose benzodiazepines. Her message was stark but essential: “There’s a grey zone between psychiatric and medical causes, and it’s wider than we think.”

Police, Patients and Mental Health

Chief Inspector Stephen Naylor brought a thoughtful and honest police perspective. He acknowledged that his colleagues are often first to be called when someone is distressed, absconding, or potentially at risk. But he questioned whether they are the right people to respond. “We’re not trained mental health professionals,” he said. “We’re doing our best, but it’s not the best system.”

His insights into Section 136, the legal framework around capacity, and the decision-making tensions that arise between ED and the police highlighted the gaps between legislation and lived practice. He encouraged us to shift the conversation: not about pushing responsibility onto another service, but about co-owning risk while keeping the person at the centre of our decision-making.

High Intensity Use and Whole-System Thinking

From theory to transformation, Dr Emma Jenkins showed how a focused, compassionate approach to high-intensity ED users can yield extraordinary results. Wolverhampton’s model, which actively identifies rather than passively receives referrals, centres on building trust and continuity.

Monthly MDTs, real-time data sharing, and tailored care plans have led to a 58% drop in ED attendances and a complete elimination of Section 136 detentions for this group [6]. She reminded us that it’s not just a health issue—it’s about housing, trauma, isolation, addiction, and systems that weren’t designed with these people in mind.

Supporting Autistic People in the ED

Dr Charlotte Heaps painted a vivid picture of the sensory overload that many autistic people experience in the ED: harsh lights, overlapping noises, unpredictable staff interactions. For patients with communication differences, poor interoception, or trauma around healthcare, even basic assessments can be distressing.

Rather than offering a checklist, she urged us to embrace small, personalised changes: using visual cues, pacing assessments one task at a time, offering sensory tools. One takeaway was to never assume capacity based on speech or facial expression alone. Many autistic people may appear calm, or speak little, but are fully capable of understanding and making decisions. Health passports can be game-changing here [7].

Dying in the ED

What does a “good death” look like in the chaos of an emergency department? Dr Jen Hancox approached this sensitive subject with clarity and compassion. Drawing from the West Midlands Palliative Care guidelines [8] and RCEM’s toolkit [9], she challenged us to be braver about naming dying when we see it—and to act on that recognition.

She offered frameworks like SPIKES for difficult conversations and “Wish, Worry, Wonder” as a way to open space for patients and families to express their hopes and fears. Her emphasis on holistic care—mouthcare, open windows, family presence—was a grounding reminder that dying is more than a medical event. It’s personal, relational, and can be made better by small acts of thoughtfulness.

Medical Examiners and the Coroner’s Process

Dr Kaye England and Dr Boland demystified what’s changing around Medical Examiner processes. From September 2024, every death not referred to a coroner will be reviewed by a Medical Examiner. It’s not just bureaucracy—it’s about better safeguards, better data, and better conversations with bereaved families.

They also covered what makes a death reportable to the coroner, and how to prepare for inquests if called. Dress smartly. Be honest. Speak to the family. And if in doubt—ask.

Tissue Donation: Missed Opportunities

We don’t often think of the ED as a place for donation—but maybe we should. Dr James Dearman and Dr Charlie Harrison spoke about the impact of tissue donation and the surprisingly wide eligibility criteria. Most patients can donate, and many families are open to it, yet referrals remain low.

They encouraged us to pause and ask: “Would this person, or their family, want the chance to donate?” Corneas, valves, tendons—gifts that change lives. Timing matters, but we have longer than we think: up to 48 hours post-mortem.

Wheezy Kids, Pollution, and Practice Change

Dr Isobel Fullwood brought practical paediatrics to life. She challenged myths around viral wheeze, stressed the dangers of relying on empty inhalers (most kids and families don’t know how to check), and urged us to stop overusing nebulisers.

Instead, she advocated for smarter discharge planning, better inhaler technique education, and use of asthma plans [11]. Her call to link paediatrics with environmental health—particularly air pollution—felt timely and important.

Noted impact of Air pollution in cities likely causative in part to increasing respiratory admissions in kids, Apps are available to track local air quality. however, they.currently use outdated UK standards, ideally would use lower thresholds as per WHO clean air standards . See @mumsforlungs.bsky.social, @mumsforlungs insta for more on this https://www.mumsforlungs.org/

Transfusion: Risk, Protocol, and Precision

Dr Simon Stanworth’s update on transfusion reflected both evidence and ethics. With new national guidance [12,13], the emphasis is now on restrictive transfusion: less is more, unless proven otherwise. He also covered the British Society of Haematology’s major haemorrhage protocol [14] and the anticipated findings from the SWIFT trial on whole blood.

His key message? Delay kills. Every minute between protocol activation and first red cells increases mortality by 5%.

Diabetes, Devices and Dilemmas

Dr Petre Hanson delivered an excellent overview of current diabetes therapies and technologies. From GLP1 agonists to hybrid closed-loop pumps, he explained both the clinical benefits and the front-door challenges.

ED clinicians need to know when to disconnect pumps, how to recognise euglycaemic DKA, and what red flags warrant caution at discharge—especially in frail, older adults on sulphonylureas. DVLA rules on hypos remain under-recognised and are essential for safe advice [15].

Testing for BBVs in the ED

Finally, Dr Steve Taylor closed the day with a data-rich presentation on the national opt-out testing programme for bloodborne viruses. Since 2022, over 7 million tests have been run, identifying thousands of new cases of HIV, hepatitis B, and C [16].

He reminded us that most patients are not opposed to testing—they just need it to be normalised. With good systems for follow-up, EDs can become a powerful frontline for public health screening.

Final Thoughts

If Day 1 asked “Who are we?” and Day 2 asked “How do we do better?”, Day 3 demanded we confront our blind spots—mental health, neurodiversity, end-of-life care, and the missed opportunities in between. Thanks to everyone who made space for hard conversations—and to all who continue them in your departments every day.

joey Godfrey

Simon Carley