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Death certification plays a central role in health service planning therefore identification of specific causes of death is critical. The requirements of biochemical toxicology as set out in the Coroners Acts in Ireland, Northern Ireland and England and Wales will be parsed to facilitate the construction of a modern best practice template for coroners' toxicology. The Royal College of Pathologists (RCPath) provides published standard guidelines for pathologists reporting to coroners. Their adequacy will be critically evaluated to facilitate reform with the intention of maximising the accuracy of death certification. The roles of psychological factors, tobacco smoking, non steroidal anti-inflammatory drugs, and cannabis in cardiac death will be detailed. The potential for adverse drug reactions to prescription medication to cause death by misadventure will be explored. The role for the expert witness in the inquisitorial coroners system to improve the accuracy of the causes of death and thus the verdict will be explored. My experience has shown that misinterpretation of presence of cannabis in autopsy blood and urine samples is common and this underlines the need for true expert guidance for the coroner. The current practice in biochemical toxicology of screening blood, urine and vitreous humor will be critically evaluated and the necessity for a wide ranging screen of potential toxins as a contributor to the cause of death examined. The appropriate analytes on the screening menu will be determined by local cultural factors. Gas and liquid chromatography with mass spectrometry are the methods of choice. The interpretation of isopropanol, ethanol and ketones in post-mortem blood will be considered as will t~e role of alcohol in death. The apparent population exposure to poisons as reported by Poisons Information Services will be used to explore the dichotomy between the usually benign outcome of common poisons and the often lethal consequences of poisoning by prescription and illicit drugs. The aim of this research is to use the template of the current legal requirements and routine laboratory procedures to suggest reforms which will improve the analytical protocol and reporting of biochemical toxicology in the coronial system resulting in greater accuracy in delineating the causes of death The narrative of this thesis travels through the areas of the coroners acts especially in the Republic of Ireland and the United Kingdom where forensic biochemistry plays a role in the specification of the causes of deaths. There is a deconstruction of the place of doctors in the coronial system and in the new arrangements following the passage of the Coroners and Justice Act 2009 in England and Wales and the potential for change in the Coroners Bill in the Republic of Ireland which fell with the dissolution of the Dail in20ll. There is an examination of the autopsy guidelines issued by the RCPath and suggestions for change which have been published. There is an analysis of the place of cannabinoids in coroners ' cases and publications setting out the position are included. A series of recommendations are made regarding improvement in practice for the reporting of biochemical toxicology in the coronial system. Two cases where there appears to be potential misinterpretation of the toxicological evidence, which may result in the review of the causes of death, are detailed as relevant clinical examples. Some laboratory pitfalls in relation to alcohol analysis have been demonstrated and the consequences of a protocol free service have been detailed with a prescription for improvement and practical solutions to improve outcomes. The under-estimation of the impact of tobacco toxicity is also addressed as is the potential for error due to lack of appreciation of drug-drug interactions. The role of biochemistry in the post-mortem diagnosis of alcoholic and diabetic ketoacidosis is discussed. Multidisciplinary reviews of biochemical toxicology for the coroners' court are suggested as the best safeguard of accurate interpretation to assist coronial enquiry. Conclusions suggesting standard operating procedures for post-mortem scenarios are detailed where possible.

Background: Psychopathy is a controversial psychological construct with a contentious history. Ambiguity regarding its pathology persists, coincident with long-standing critique of the construct. Contemporary research indicates ontological confusion, limitations with assessment practices, and the presence of a negative bias towards individuals identified as psychopathic; the implications of this raise serious ethical concerns. Despite this, the psychopathy construct is used within forensic settings to understand the psychology of forensic service users; in particular, clinical psychologists hold status as a professional group able to understand, assess for, and confer the presence of, psychopathy. In addition to the aforementioned limitations, there is also a lack of research into the accounts of clinical psychologists working in forensic settings. Aims: To examine how clinical psychologists discursively construct psychopathy, including an investigation of the discourses and subjectivities produced and utilised in their talk, and the implications for action resultant from these. Method: Eight one-to-one semi-structured interviews were conducted with clinical psychologists currently working in forensic mental health contexts (low, medium and high secure). Foucauldian Discourse Analysis was used to analyse the data. Results: (1) Persons with psychopathy were constructed as problematised individuals. Constructions arose from four overarching discursive sites: dangerous, challenging, manipulative, and psychologically deficient. ‘At risk’ and ‘trauma’ discourses were utilised to explain the aetiology of psychopathy. ‘Intuition’ talk was employed by participants as a marker of the presence of psychopathy. (2) The psychopathy construct was identified as contested and problematic. To manage this, a variety of subject positions were taken up; three overarching subjectivities were identified: pragmatist, subversive, and expert/specialist. (3) Accounts pointed to a psychological imperative for psychopathy. Central to this was the promotion of three core psychology technologies: formulation, supervision, and reflective practice. These were constructed as solutions to the ‘problem’ of psychopathy in different ways. Clinical and research implications are discussed in light of the analysis.

Occupational burnout is highly prevalent in mental health services and has a deleterious effect upon the psychological wellbeing of staff. Few studies have explored burnout in inpatient settings; those that have do not address the possible systemic impact. This study aimed to explore burnout and emotional reactions to behaviour that challenges in a secure forensic mental health service for young people; a specialised environment in which severe and frequent incidences of aggression and violence occur. Following a systematic review of burnout literature pertaining to inpatient mental health services, an empirical study was conducted using a convergent parallel mixed method design. Forty three staff members were recruited to the quantitative strand and ten were recruited to the qualitative strand. Emotional Reactions to Challenging Behaviour Scale (ERCBS) and Maslach Burnout Inventory (MBI) instruments were used. A significant moderate positive correlation was found between emotional exhaustion and negative emotional reactions to behaviour that challenges. This relationship was mediated by general self-efficacy, which buffered the effect of emotional exhaustion on negative responses to behaviour that challenges; responses found to be detrimental to the relational environment. ‘Young People Blame Themselves’ was explored as a relational barrier and maintaining factor in occupational burnout. In ‘You Want Someone You Recognise’ and ‘We Lack That Consistency’ a high ratio of agency staff and a lack of operational consistency were identified as occupational stressors. Emotional exhaustion is associated with negative emotional reaction to challenging behaviour. Interventions should be targeted towards developing staff self-efficacy, through the use of reflective practice and ecological changes that enhance team-working and feelings of safety on the ward. When on the ward, staff should be mindful of young people’s predisposition towards attribution bias. Future studies need to give greater consideration to systemic outcomes associated with burnout.

This research project offers initial assessment in forensic psychiatry a new assessment guideline, the Forensic Assessment Format, (Carey 2006) which is a development from Jane Ussher’s material-discursive-intrapsychic model of critical realism, (Ussher 2000a). It presents a review of the technical and theoretical literature looking at the development of assessment methods in forensic psychiatry and discusses current practice and how a critical realist perspective could inform the assessment process. It is a qualitative study using both an empirical and an analytic auto-ethnographic approaches, (Anderson 2006). The research project presents data from 19 semi-structured interviews and a focus group analysed using grounded theory, (Glaser and Strauss 1967) to aid both deductive and abductive approaches, (Timmermans and Tavory 2012). Service users were involved from the beginning of the project to inform the themes that developed into the interview questions. The outcomes of the study offer support for the potential of this critical method of initial assessment to be collaborative, holistic and inclusive and that it could act as a boundary object, (Star and Griesemer 1989), between different social worlds providing a bridge for information to flow. This encourages cooperation in completing the assessment and then formulating and meeting the identified needs. It explores and provides an insight into the initial assessment process in forensic psychiatry from the perspective of the service user, referrer and assessor. Further suggestions are offered in associated areas such as how plural realities can be understood and how the assessment process in forensic psychiatry could be further improved.