Care UK
Private Sector
Action Planned
Care UK will develop a formal policy detailing the action required by nursing staff when they are unable to administer medication to a prisoner, for example due to a threat of violence. (AI summary)
View full response
Dear Sir, RE: The inquest touching the death of Edward Devlin Deceased Response to Regulation 28 Report to Prevent Future Deaths I am writing in reply to you letter dated 22nd July 2014 containing the Regulation 28 Report to Prevent Future Deaths ("PFD Report") following the conclusion of the inquest touching the death of Edward Devlin Deceased which was heard before you, sitting with a jury, at the Coroner's Court, Crook commencing on Monday 16th June and concluding on 24th June 2014. You have requested a response by 16th September 2014 and I am able to respond now. When this issue was raised at the inquest an investigation was commenced prior to receipt of your letter. In hearing evidence at Mr Devlin's inquest you have identified matters of concern as follows:
1. It was stated by a nurse that he had, whilst dispensing medication to Mr Devlin and other patients on F wing, slid strips of medication including dihydrocodeine under locked cell doors instead of handing it to the patient
2. He claimed this was common practice amongst nursing staff on F wing This was in relation to potentially dangerous and/or tradeable drugs like dihydrocodeine.
3. If this were the case, no one would know whether a patient is taking the medication intended for him.
4. Further. Other healthcare professionals, assuming that medication was being taken by the patient, could base a future diagnosis upon this which would be potentially flawed.
5. Assessing any other patient would become fraught with uncertainty as healthcare professionals could never know for certain what medication had been taken by him.
6. The concomitant concern with 3, 4 and 5 above would be that the system whereby the dispensing of drugs is recorded by signatures of nurse and patient is either ignored or subject to forgery.
7. Further, no one would know whether somebody else was appropriating that patient's medication.
8. Depending on the type of medication, this may be traded within the establishment raising security concerns.
9. The drugs could be stockpiled with a view to creating a potentially lethal overdose Firstly at Box 4 paragraph 16 in recalling the evidence you have said that it was the practice of the Nurse in the case of Mr Devlin when he was on F wing to slide his medication, including dihydrocodeine, under his cell door. That he described how he would take it out of its packaging, fold the strips over, and slide it under the door. He said that this happened in the case of other patients too. He said that no thought would be given as to whether the medication would end up in the possession of the intended patient. He said that this was common practice among nursing staff (general and mental health). It is not our recollection that the Nurse referred to having placed dihydrocodeine under the cell but that it was In possession medication. At box 4, paragraph 17 you have confirmed that when other discipline staff and healthcare staff were question as to whether the practice had ever happened, they expressly denied it. This evidence was heard during the course of the inquest. You will also recall that disciplined staff were asked what they would do if they saw this practice. They all confirmed if they had seen that practice then they would have reported it. At the inquest you heard evidence regarding In possession and Not In Possession medication. In order to assist you and dealing with your matters of concern, I consider it would be helpful if I could expand on the management and administration of medication in prison. With In possession medication (IP), following the generation of a valid prescription and the supply being issued by pharmacy, medication is issued to the patient from the hatch located on the wing and signed for by the patient. The volume issued may vary from one week's supply to eight weeks and is dependent on the medication. The patient is then expected to take the medication as directed with no healthcare supervision. With Not In Possession (NIP) medication the patient is required to attend the medication administration hatch located on the relevant wing where one dose of the prescribed medication would be administrated and taken under direct supervision of the nurse. Once administrated, the prescription/administration drug kardex is initialled by the trained nurse administering the drug; there is no requirement for a signature from the prisoner. Following the transfer of the responsibility of healthcare delivery to the NHS in 2004 it was identified that nursing staff were required to administer NIP medication by sliding it under
the cell door. This was limited to night time medication rounds as the requirement to open a cell door when in patrol state requires a senior prison officer to be present and the working arrangements at the time did not always allow this. At the time this was highlighted as a clinical risk and not appropriate. Procedures were therefore put in place to ensure this practice ceased. As in a community setting the patient has a responsibility to order and collect any IP medication. In the event of the patient not collecting medication it is expected that an assessment be carried out by healthcare staff as to the continued need for the medication. This may include seeking out the patient and enquiring of his rationale for not collecting which in turn may result in the acceptance of his rationale or an attempt to educate the patient as to its importance. In the event of the continued refusal the prescriber and/or relevant professional would be informed. Under no circumstances would there be an expectation for IP medication to be delivered by nursing staff by sliding it under the door of a cell and therefore limit the required level of interaction needed to establish if it is appropriate to continue the medication. I have investigated the claim that was made by the Nurse and interviewed healthcare staff. Other than the claim made by the Nurse there are no recorded incidents of IP medication being issued "under the door". There are a number of practical difficulties nursing staff would face if this was a method used as follows:
• The medication would have to be unpacked and individual strips 'inserted along with the packaging.
• A signature would have to be obtained either before or after the medication was inserted under the door. In the majority of situations the medication is wanted by the patient and the patient would make efforts to obtain his supply by attending the collection point. In most situations when a decision not to collect the medication is made it is one of patient choice, with the medication being returned to pharmacy and no further intervention. In the event that there is a clinical concern that the patient has not collected the medication, nursing staff have a procedure to follow. Which is an assessment be carried out by healthcare staff as to the continued need for the medication. This may include seeking out the patient and enquiring of his rationale for not collecting which in turn may result in the acceptance of his rationale or an attempt to educate the patient as to its importance. In the event of the continued refusal the prescriber and/or relevant professional would be informed. That procedure to make a special effort to attend the cell and then pass all the IP medication under the door when the patient may have made no effort to collect the medication himself and the assessment of the medication indicates it is not essential does not appear to create any advantage or benefit for nursing staff.
A number of Healthcare and Prison service staff have been approached and asked directly if they had witnessed or carried out the process of administering NIP medication under a cell door. A staff meeting was held on 1st July 2014 and staff were informed of the claim made by the Nurse. Healthcare staff were asked if they had ever witnessed or performed such actions. While it was acknowledged by the trained nurses who attended the meeting that the issue of putting night time NIP had been raised in the past, no one indicated that IP medication was ever administrated this way. As part of investigation in the event of nursing staff not being able to administer NIP medication to a prisoner by opening the cell door, for example; the threat of violence from the individual or industrial action, I have identified that a formal policy should be developed and approved by Care UK clinical governance detailing the action required by nursing staff. There is no evidence to suggest that putting IP medication under the cell doors is common practice in HMP Durham. If you require any further information, please do not hesitate to contact me.
Head of Healthcare HMP Durham
1. It was stated by a nurse that he had, whilst dispensing medication to Mr Devlin and other patients on F wing, slid strips of medication including dihydrocodeine under locked cell doors instead of handing it to the patient
2. He claimed this was common practice amongst nursing staff on F wing This was in relation to potentially dangerous and/or tradeable drugs like dihydrocodeine.
3. If this were the case, no one would know whether a patient is taking the medication intended for him.
4. Further. Other healthcare professionals, assuming that medication was being taken by the patient, could base a future diagnosis upon this which would be potentially flawed.
5. Assessing any other patient would become fraught with uncertainty as healthcare professionals could never know for certain what medication had been taken by him.
6. The concomitant concern with 3, 4 and 5 above would be that the system whereby the dispensing of drugs is recorded by signatures of nurse and patient is either ignored or subject to forgery.
7. Further, no one would know whether somebody else was appropriating that patient's medication.
8. Depending on the type of medication, this may be traded within the establishment raising security concerns.
9. The drugs could be stockpiled with a view to creating a potentially lethal overdose Firstly at Box 4 paragraph 16 in recalling the evidence you have said that it was the practice of the Nurse in the case of Mr Devlin when he was on F wing to slide his medication, including dihydrocodeine, under his cell door. That he described how he would take it out of its packaging, fold the strips over, and slide it under the door. He said that this happened in the case of other patients too. He said that no thought would be given as to whether the medication would end up in the possession of the intended patient. He said that this was common practice among nursing staff (general and mental health). It is not our recollection that the Nurse referred to having placed dihydrocodeine under the cell but that it was In possession medication. At box 4, paragraph 17 you have confirmed that when other discipline staff and healthcare staff were question as to whether the practice had ever happened, they expressly denied it. This evidence was heard during the course of the inquest. You will also recall that disciplined staff were asked what they would do if they saw this practice. They all confirmed if they had seen that practice then they would have reported it. At the inquest you heard evidence regarding In possession and Not In Possession medication. In order to assist you and dealing with your matters of concern, I consider it would be helpful if I could expand on the management and administration of medication in prison. With In possession medication (IP), following the generation of a valid prescription and the supply being issued by pharmacy, medication is issued to the patient from the hatch located on the wing and signed for by the patient. The volume issued may vary from one week's supply to eight weeks and is dependent on the medication. The patient is then expected to take the medication as directed with no healthcare supervision. With Not In Possession (NIP) medication the patient is required to attend the medication administration hatch located on the relevant wing where one dose of the prescribed medication would be administrated and taken under direct supervision of the nurse. Once administrated, the prescription/administration drug kardex is initialled by the trained nurse administering the drug; there is no requirement for a signature from the prisoner. Following the transfer of the responsibility of healthcare delivery to the NHS in 2004 it was identified that nursing staff were required to administer NIP medication by sliding it under
the cell door. This was limited to night time medication rounds as the requirement to open a cell door when in patrol state requires a senior prison officer to be present and the working arrangements at the time did not always allow this. At the time this was highlighted as a clinical risk and not appropriate. Procedures were therefore put in place to ensure this practice ceased. As in a community setting the patient has a responsibility to order and collect any IP medication. In the event of the patient not collecting medication it is expected that an assessment be carried out by healthcare staff as to the continued need for the medication. This may include seeking out the patient and enquiring of his rationale for not collecting which in turn may result in the acceptance of his rationale or an attempt to educate the patient as to its importance. In the event of the continued refusal the prescriber and/or relevant professional would be informed. Under no circumstances would there be an expectation for IP medication to be delivered by nursing staff by sliding it under the door of a cell and therefore limit the required level of interaction needed to establish if it is appropriate to continue the medication. I have investigated the claim that was made by the Nurse and interviewed healthcare staff. Other than the claim made by the Nurse there are no recorded incidents of IP medication being issued "under the door". There are a number of practical difficulties nursing staff would face if this was a method used as follows:
• The medication would have to be unpacked and individual strips 'inserted along with the packaging.
• A signature would have to be obtained either before or after the medication was inserted under the door. In the majority of situations the medication is wanted by the patient and the patient would make efforts to obtain his supply by attending the collection point. In most situations when a decision not to collect the medication is made it is one of patient choice, with the medication being returned to pharmacy and no further intervention. In the event that there is a clinical concern that the patient has not collected the medication, nursing staff have a procedure to follow. Which is an assessment be carried out by healthcare staff as to the continued need for the medication. This may include seeking out the patient and enquiring of his rationale for not collecting which in turn may result in the acceptance of his rationale or an attempt to educate the patient as to its importance. In the event of the continued refusal the prescriber and/or relevant professional would be informed. That procedure to make a special effort to attend the cell and then pass all the IP medication under the door when the patient may have made no effort to collect the medication himself and the assessment of the medication indicates it is not essential does not appear to create any advantage or benefit for nursing staff.
A number of Healthcare and Prison service staff have been approached and asked directly if they had witnessed or carried out the process of administering NIP medication under a cell door. A staff meeting was held on 1st July 2014 and staff were informed of the claim made by the Nurse. Healthcare staff were asked if they had ever witnessed or performed such actions. While it was acknowledged by the trained nurses who attended the meeting that the issue of putting night time NIP had been raised in the past, no one indicated that IP medication was ever administrated this way. As part of investigation in the event of nursing staff not being able to administer NIP medication to a prisoner by opening the cell door, for example; the threat of violence from the individual or industrial action, I have identified that a formal policy should be developed and approved by Care UK clinical governance detailing the action required by nursing staff. There is no evidence to suggest that putting IP medication under the cell doors is common practice in HMP Durham. If you require any further information, please do not hesitate to contact me.
Head of Healthcare HMP Durham