PRISON IN POSSESSION POLICY - SPS · 2020. 3. 1. · Prison in Possession Policy IN-315 Version 1 Oct 2013 3 1.0 EXECUTIVE SUMMARY: It is the aim of this policy to enable medication

Prison in Possession Policy

IN-315 Version 1 Oct 2013 1

PRISON IN POSSESSION POLICY

CLINICAL AREA: Prison Establishments POLICY SPONSOR: Chief Pharmacist IMPLEMENTED: September 2013 REVIEWED: September 2013 DUE FOR REVIEW: September 2017 Date Approved:

APPROVED BY: Medicines Management Group Sep 2013 Directors Management Group 24/09/13

DISSEMINATED TO: All Prison Healthcare Staff and Pharmacy

ADDED TO INTRANET BY: Mark Dobbs Date added: 07/10/13

Directorate: Corporate Office

Ref No IN-315



CONTENTS 1.0 EXECUTIVE SUMMARY: ...................................................................... 3 2.0 INTRODUCTION: ................................................................................... 3 3.0 PURPOSE AND SCOPE: ...................................................................... 4 4.0 DEFINITIONS: ....................................................................................... 4

5.0 DUTIES: ................................................................................................. 5 6.0 RISK ASSESSMENT AND REVIEW: ..................................................... 6 7.0 SECURITY PROCESS ........................................................................ 10 8.0 PRESCRIBING .................................................................................... 11 9.0 DISPENSING ....................................................................................... 12

10.0 ISSUING WEEKLY/MONTHLY IP MEDICATION ............................. 13 11.0 RE-ORDERING OF MEDICATION ................................................... 13 Appendix A: Red Medications ....................................................................... 15

Appendix B: Not In-Possession Medication .................................................. 17 Appendix C - Equality Impact Assessment (Stage One) – Screening ............ 18



1.0 EXECUTIVE SUMMARY:

It is the aim of this policy to enable medication to be supplied on an in-possession (IP) basis, as described in the joint paper „A Pharmacy Service for Prisoners‟ utilising a robust framework of risk management to support the decision making process used to determine IP status.

2.0 INTRODUCTION: 2.1 A Pharmacy Service for Prisons, Department of Health 2003

established the premis that prisoners should have access to equivalent health care to that which is available in the community. Specifically, in relation to medicines, it stated “As a matter of principle, in keeping with the community, prisoners should be given responsibility for their medicines, unless there are clearly identified factors why this should not be the case for that patient.” PSI 45/2010 states that “All drugs liable to misuse within the prison setting

must be administered under supervised conditions.” 2.2 In line with the general public, patients in prisons should be treated as

responsible people. A large number of them are perfectly capable of taking responsibility for storing and using their medication and have been used to doing so when in the community. There are of course some tensions that can arise, and these are discussed later in the policy.

2.3 Continuing self-care is important as the majority of prisoners serve

relatively short sentences and there is regular movement within and between establishments. Medication in-possession can provide continuity of care in medicine-taking, it avoids missing doses and reduces waste and improves efficiency.

2.4 There are often clinical reasons why patients should be given access to

in-possession medication. Some medications have side effects that require patients to take their medication in the evening and some medications require specific timings between doses to ensure effectiveness. It is also important to include medication management and responsibility as part of a patient‟s recovery plan.

2.5 Understandably, as medicines can be abused, there is a real concern

that potentially increasing the amount of medication in prison circulation might lead to an increase in inappropriate use. There is also a risk of patients being bullied to supply their medication to others. This can be minimised by a robust risk assessment and risk management process that is agreed and jointly managed between health and prison services.

2.6 Each prisoner should be deemed as eligible to hold medication in

possession (IP) unless otherwise indicated. However, such decisions



need to be based on a framework of clinical evaluation and risk assessment and should be part of an agreed care plan.

3.0 PURPOSE AND SCOPE: 3.1 The objective of this policy is to establish a framework of risk

management to use to promote the safe and secure supply of in possession medicines to prisoners at all HMPs in Devon and Dorset.

3.2 The Policy is in line with the requirements of CQC Essential standards

of Quality and Safety Outcome 9 Management of Medicines and RCGP Safer Prescribing in Prisons November 2011. This policy applies to all medicines prescribed and supplied to all patients within Devon and Dorset Prisons. It is relevant to all nursing, pharmacy and medical staff.

3.3 This document has been developed in line with the Trust‟s Policy for

Procedural Documents, which is compliant with NHS Litigation Authority standards on procedural documents. Standards in relation to the following areas are covered within the Trust-wide Policy for Procedural Documents, which this document complies with:

Consultation and communication with stakeholders

Committees responsible for approval of procedural documents

Procedural documents required style and format

Development process for Trust-wide procedural documents including prioritisation of work, identification of stakeholders, responsibility for document development

Consultation, approval and ratification process

Review and revision arrangements

Document control including archiving arrangements

4.0 DEFINITIONS: 4.1 ACCT – Assessment, Care in Custody, and Teamwork. A care

planning system to identify prisoners at risk of suicide or risk of self-harm.

4.2 IRs – Intelligence Report. A reporting mechanism to allow for the

information gathering, recording and dissemination of security risks within a prison.

4.3 IP – in-possession 4.4 NIP – Not in possession



5.0 DUTIES: 5.1 Team Leader

Ensures that: The environment where medicines are stored and delivered to the

patient is kept appropriately clean and is well-organised. The appropriate training has been completed for any member of

the nursing staff using the policy. 5.2 Registered Nursing Staff

Ensure that:

A risk assessment is undertaken for all prisoners within 28 days of arrival in prison (to enable gathering of relevant information), or following any changes to the circumstances of the prisoner which may affect his risk, or at the time of the risk assessment review date. Patients in their care are educated concerning their medicines and

associated monitoring requirements and monitored appropriately throughout.

They bring to the attention of the Multidisciplinary Team (MT) or appropriate clinical forum any problems or risks encountered with the patients in their care with respect to medication or to discuss any action staff have taken.

Concordance is assessed as part of the risk assessment process prior to the patient self administering.

They inform Pharmacy of changes to prescriptions as soon as possible.

All medication given to, or refused by, patients is recorded on their administration record

All poor compliance is investigated, recorded and reported to prescriber and pharmacy staff.

Spot checks are regularly undertaken. 5.3 Prescribers

Select the possession status of each drug they prescribe and determine whether the item should be NIP or be allowed on daily, weekly or monthly in possession.

Ensure that the medication regime is as simple as possible. Ensure any changes in medication are notified to the patient and

nursing staff as soon as possible so that the pharmacy may be informed.

Ensure all prescriptions reflect the NIP/IP status of the patient and/or individual medications and follow the In Possession Policy.

5.4 Pharmacy

Ensures that: They work effectively to ensure that there is a quality service

provided to support nursing staff and patients within their care. The patient‟s understanding of their medication is supported by

written information leaflets.



Any compliance and concordance issues are addressed with the patient and MT.

A medication review is provided to assist in the simplification of the regimes.

Any inaccuracies between IP status of patient/medication and prescription are queried and followed up as necessary.

The medicines are dispensed with full directions on the label and a Patient Information Leaflet (PIL) is provided with the first supply of any new medicine.

5.5 Prison Staff

Share information to assist healthcare staff in assessing an individual‟s risk relating to IP status

liaise regularly with healthcare to discuss any security issues involving the supply of in-possession medication

assist healthcare with routine spot checks

6.0 RISK ASSESSMENT AND REVIEW:

6.1 Each patient will be assessed for their ability to manage their own

medication:

Within the first 28 days in prison, taking into account any notes/observations from the previous prison, police custody officers, prison security, health or other sources.

At any significant event occurring in the course of the sentence which might affect the way the patient‟s medication is managed e.g. change in mental health, bereavement, illegal substance misuse, change in expectation of sentence.

On being prescribed new medication that may prompt a new risk assessment.

The risk assessment should be a dynamic process. 6.2 A risk assessment may be carried out by any clinical registered

member of Healthcare, authorised paramedic employed by healthcare, pharmacist or pharmacy technician or medical staff who has completed Medication Possession Policy risk assessment training. Where an individual has insufficient expertise to interpret information they should seek the advice of a clinician with the relevant expertise.

6.3 On reception, if the prisoner is unknown to staff and the establishment

and has not been transferred from another prison so that the risk cannot be properly assessed, it is appropriate to decide that the prisoner cannot have their medication „in possession‟ (IP) at that time.

6.4 Prisoners prescribed medication for long-term conditions, where they

have a good understanding of their condition and it is in their interest to



be in control of their treatment, may be assessed as suitable for IP during the initial period of evaluation.

6.5 The process of risk assessment and review must be explained to each

prisoner prescribed medication so that they can understand why and how their medication possession status is determined, and how this may change.

6.6 Within 28 days a risk assessment is carried out according to the

procedure detailed in this policy. Where there is active input from the mental health team or substance misuse service the assessor must liaise with that team the outcome of the risk assessment will be discussed with the healthcare team and the result of this recorded in the patient record. Information must also be gained from security. A risk assessment plan should be completed and agreed and documented on the assessment and within SystmOne and where appropriate within their prison record.

6.7 An appropriate review date is set and recorded. On SystmOne use

should be made of the recall date 6.8 If the risk assessment has determined that the prisoner is to receive IP

medication, the IP compact must be read out to and discussed with the prisoner to ensure that they understand their obligations and those of the staff.

6.9 The prisoner must sign the compact, a copy must be given to him and

the original scanned onto the medical record or held in their notes. If they refuse, they will not be deemed eligible for in possession medicine. If the patient has literacy issues, the compact will be read out to the patient and explained. This will be documented within the patient record.

6.10 When, or before, the review date is reached, the risk assessment is

reviewed for any changes to the circumstances of the prisoner that may affect his risk.

6.11 If the risk assessment review produces a change in medication

possession status for the prisoner this must be communicated to the prisoner and recorded in their notes and on any paper prescriptions.

6.12 If the prisoner‟s circumstances change at any time then this should

prompt a review of the risk assessment. 6.13 If a member of healthcare, prison staff or the prisoner has concerns

about a prisoner‟s/their ability to comply with self-medication, or the safety of the prisoner or other prisoners, and then this should prompt a risk assessment/review.



6.14 Medication review, medicines use review and cell searches are important parts of ensuring that medication is being used effectively and to inform the risk assessment review and must be carried out at appropriate intervals. Any clinician who has concerns may decide to remove all the IP medication and place patient NIP until further assessments have taken place. A discussion with a prescriber must take place in such cases to ensure patients are not put at risk and ensure safe continuation of treatment

Considerations for deciding what medication review interval is appropriate are:

Type of medicine

Number of medicines

Complexity of medicines regime

Concerns raised by clinicians 6.15 The patient-specific risks include:

Patient related risk factors

VERY HIGH RISK

Previous self harm

On an ACCT

Severe mental illness

Unstable mental illness

History of trading medication

Severe confusion state

Recent/ongoing drug abuse

HIGH RISK

Poor ability to understand instruction

Historical factors related to poor compliance

Recent life event causing concern to staff e.g. bereavement

Target for bullying

Poor literary skills

Not proficient in English

Mildly confused

MODERATE RISK

High number of prescribed medicines

Learning disability

6.16 Other risk factors include:

Patients on reception or remand are most vulnerable at this time.

Patient‟s cell mate – risk of overdosing on medication not belonging to him



Medication-specific risks to be considered:

Current trend for trading potential within establishment

Addictive potential

Toxicity relating to overdose

Toxicity relating to therapeutic use

6.17 Opinion should be sought on the suitability of the patient to manage their own medication from:

Nursing/healthcare staff

Mental health team

Security department

Substance Misuse Team

Residential unit staff At any time any member of the healthcare staff or the prison service can request that IP is discontinued if in their opinion the patient is having difficulty in managing their medication, is abusing the agreement, is misusing the medication, is found to have medication missing or unaccounted for without a justifiable reason, is suspected of supplying their medication or is suspected of being bullied. The reason for the change must be recorded in patient record and where appropriate within prison records. If the patient is found to be misusing their medication, it may be appropriate to inform the prison security department all patients prescribed in-possession medication will have their concordance of the regime reviewed at least every 2 months or during any clinic attendance. The review outcome will be documented in the patient record.

6.18 All medication will be given in possession unless:

It is a schedule 2 or 3 controlled drug, for example methadone, buprenorphine, morphine.

It is a benzodiazepine

It is an opiate prescribed as part of the opiate prescribing protocol, in which case the opiate is supervised.

Compliance needs to be closely monitored.

There is a high risk associated with the patient having any stock of their medication, both risk to themselves and others (for example cell sharer).

Bullying of the patient for their medication is an issue.

There is strong evidence the patient is trading their medication.

The patient is on an ACCT.

The medication is in the Dorset /Devon Prison Healthcare list of medicines that are not allowed in possession (Appendix B).



In the above instances the medication will be supervised. For patients prescribed insulin refer to insulin IP policy 7.0 SECURITY PROCESS

7.1 Healthcare and the prison services will liaise regularly to discuss any

security issues involving the supply of in-possession medication. 7.2 If any of the red “security issues” indicators within the risk assessment

are flagged up, the healthcare department will liaise with the security

department and further risk assess the indicator.

7.3 If the patient has a history of being bullied the healthcare department

and the prison services will complete a wider risk assessment of the

patients living area, associates and prison activities.

7.4 Individual patients have the right to terminate the in-possession

agreement with healthcare at any time .This can be highlighted through

any department within the prison.

7.5 Any agreement or decision from the risk assessment process will be

documented on patient record and where appropriate discussed with security

7.6 All patients‟ prescribed in-possession medication will be subject to a

spot check of their compliance with the regime. Patient‟s prescribed

Red medication will have a routine spot check carried at least once a

month.

7.7 The spot check will involve a member of the healthcare department

and a member of the prison service checking the patient‟s supply of

medication against their prescriptions. This will include:

Asking the patient to produce all the medication they have

within their property.

This will then be checked against the medication supply that

would be expected for their prescription.

A review of their process for storage of medication will be

undertaken.

7.8 A record of the spot check will be recorded on SystmOne/patient notes



7.9 If a patient is found to be in breach of the agreement, or to be taking

the medication outside of the clinical care plan, the in-possession

medication prescription will be terminated immediately and the need for

medication to be reviewed together with the possession status.

7.10 If a patient is found to be in breach of prison security by misusing their

medication they will be subject to prison disciplinary action. If this is of

a serious nature it will be reported to the police. The healthcare

department will assist in this process at the request of the prison or

police services.

7.11 If a member of healthcare suspects a prisoner is bullying a patient for

their medication they have a responsibility to inform security.

8.0 PRESCRIBING 8.1 Prescribers need to be aware of the national and local guidance on

prescribing in prisons before any medication is given in possession. 8.2 Dorset Healthcare University Foundation Trust‟s Prison Healthcare

Department has drawn up two lists of medications to assist the safe implementation of in possession across the prisons

a list of medications (Red Medication) that require precaution before being administered in-possession. (Appendix A)

8.3 The list comprises medications that are deemed inappropriate for in-

possession without a full assessment of clinical need and multidisciplinary discussion. There should also be a joint risk assessment by healthcare and security. These prescriptions will be subject to a spot check at least once a month. Documentation of the risk assessment and clinical need for in possession medication should be clearly documented.

A list of medication given in ONE WEEK instalments (1wk IP) (appendix3)

a list of those medicines Not for IP under any circumstances has been developed.(appendixB)

All lists are approved and reviewed by the Prisons Medicines Management Group.

8.4 When considering the IP status of a medicine for a patient the following

medication-specific risks must be considered:

Current trend for trading potential within establishment

Addictive potential



Toxicity relating to overdose

Toxicity relating to therapeutic use 8.5 Medication and related devices should be prescribed as in-possession

unless the assessment suggests that to do so would pose a significant risk to the patient or, through trading or bullying, other prisoners.

8.6 All prescriptions should have the appropriate IP status selected when

being issued on SystmOne (Not In-possession, daily IP, weekly IP, or Full IP).

8.7.1 Where medication charts are used, the IP status must be clearly written

on the chart and daily weekly or monthly IP clearly stated. Where the IP type is not stated, the prescriber will be contacted. Where this is not possible the pharmacist may, following liaison with other members of health care, issue the prescription as weekly IP and make a record to that effect in the patient‟s notes.

8.8 Prescribers should consider prescribing on an annual basis for

patients receiving long-term medication, especially if being dispensed monthly. Further supplies will be requested by the patient using the appropriate form for the establishment.

8.9 The choices for supply of medication are as follows:

28 day IP (or patient pack size if different, eg 30 days)

7 days IP, as part of an ongoing repeated prescription for which a longer supply is not desirable (working towards 28 day IP).

A discrete number of days for unrepeated medication, eg antibiotics, short course of analgesia, hypnotics

Daily IP (to be used in exceptional circumstances e.g. hypnotic)

Not IP i.e. supervised. 9.0 DISPENSING

9.1 Where possible, medication will be dispensed in manufacturer‟s original packs. Where this is not possible, plain white boxes or standard dispensing bottles will be used. Patients assessed as requiring compliance aids will be provided with 7 day disposable compliance aids.

9.2 Patient information leaflets will be supplied on the first dispensing or

following a patient request. 9.3 If the prescription and the IP assessment do not match (ie drug that

should be given daily prescribed in as monthly IP), the pharmacist should contact the prescriber for confirmation. The pharmacist may, if



unable to contact the prescriber, following discussions with healthcare staff, issue one week in possession.

9.4 The pharmacist may alter the IP quantity downwards (i.e. monthly to

weekly, weekly to daily) if required in response to any prevailing circumstances and refer the patient for reassessment.

10.0 ISSUING WEEKLY/MONTHLY IP MEDICATION 10.1.1 On issue of the IP medication, the issuer will record on SystmOne or

the drug administration card and indicate the quantity issue.

10.2 If after 7 days the patient has not collected their medication, the

prescription will be endorsed “did not attend” (DNA), and the DNA procedure followed.

10.3 Any medication that the patient misplaces for any reason will not be

replaced other than in exceptional circumstances; a Ulysses incident form must be completed and a record of the incident placed on System One/patient record. The patient‟s IP status should be re-assessed.

10.4 Any medication that is unused must be returned to healthcare staff. 10.5 If the prescription is changed in any way the patient must first return

their supply before being issued with the new medication. 11.0 RE-ORDERING OF MEDICATION 11.1 Patients receiving weekly / monthly IP medication will be responsible

for re-ordering their medication using the appropriate form for the establishment. This should be handed to a nurse or pharmacy technician 7 days prior to the item being required for full IP items, or at the time of the last supply for weekly items.

11.2 The request should then be sent to the doctor to rewrite the

prescription if appropriate. 11.3 Prescribers should make appointments for patients they feel should be

seen for review prior to the prescription being rewritten. 11.4 Access to treatment of minor ailments

For patients assessed as being at risk and not allowed IP medicines nurses must check the risk assessment and establish whether the patient is on an open ACCT before deciding is the issue of a supply of medicines through a PGD is appropriate.





Appendix A: Red Medications The medications listed below should always be given Not in possession unless, following a full risk assessment and multidisciplinary discussion, in possession medication is deemed clinically most appropriate and safe for the patient and wider population. These prescriptions should include a joint risk assessment by healthcare and security. These prescriptions will be subject to a spot check at least once a month. Documentation of the risk assessment and clinical need for in possession medication should be clearly documented.

DRUG RISK ASSESSMENT ISSUES

IN-POSSESSION RESTRICTIONS

Codeine and all related pain killers

Substance misuse history.

Overdose history. Bullying history.

Prescription places them at risk of bullying.

Cell occupancy needs to be taken into account.

Tramadol Substance misuse history.

Overdose history. Bullying history.


Cell occupancy needs to be taken into account.

Trazadone Bullying history. Dealing history.

Overdose history.


Cell occupancy needs to be taken into account. Prescriptions places

others at accidental OD risk.

Mirtazapine Bullying history. Dealing history.


Cell occupancy needs to be taken into account...

Venlafaxine

Bullying history. Dealing history.

Overdose history.

Prescriptions places others at accidental OD

risk.

Antipsychotic medication


Should be open to the mental health team.


Gabapentin Substance misuse history.

Bullying history.

Prescription places them at risk of bullying. Cell

occupancy needs to be taken into account.

Pregabalin Substance misuse history.

Bullying history.


occupancy needs to be



taken into account.

Zopiclone Zolpidem Zaleplon

3 day maximum

Substance misuse history.



occupancy needs to be taken into account.

Morphine 10mg in 5ml Bullying history. Dealing history. Overdose

history.


risk. Lethal in overdose.

Tricyclic Antidepressants

Bullying history. Dealing history. Overdose

history.


risk. Lethal in overdose.



Appendix B: Not In-Possession Medication

These medications should not be prescribed as in-possession medication.

Schedule 2 or 3 controlled drug, for example methadone, buprenorphine, morphine.

Benzodiazepines



Appendix C - Equality Impact Assessment (Stage One) – Screening

1. Policy/Service Directorate New or existing? Date of Assessment

Medicines Management in Possession Policy for Prisons

Adult Mental Health Directorate

Existing

2. Briefly describe the purpose of the Policy/Service:

Patients being cared for in the Crisis and Home Treatment Team are receiving intensive care as an alternative to hospital admission. It is expected that these patients will be prescribed and administered medication as part of their overall package of care.

3. Legislation Check

Equality Area

Key Equalities Legislation Is the policy/service relevant to this equality area? Yes/No

Assessment of Potential Impact:

High/ Medium/ Low/ Not Known

Required Actions

Positive (+) Negative (-)

Gender Sex Discrimination Act 1975 Equal Pay Act 1970 Equalities Act 2006 Gender Recognition Act 2004

Race Race Relations Act 1976 Race Relations (Amendment) Act 2000

Disability Disability Discrimination Act 1995 & 2005



Age Age Regulations 2006

Lesbian, Gay, Bisexual, Transgender

Equalities Act 2006

Religion Equalities Act 2006

Other Human Rights Act 1998

4. Is this Policy/Service likely to have a positive impact on one or more minority/under represented or community groups? If so, who may be affected and why? Or is it clear at this stage that it will be equality „‟neutral‟‟? i.e. will have no particular effect on any group.

5. Is this Policy/Service likely to have an adverse impact on one or more minority/under represented or community groups? If so, who may be affected and why? Or is it clear at this stage that it will be equality „‟neutral‟‟?

6. Is the Impact of the Policy/Service (whether positive or negative) significant enough to warrant a more detailed assessment?

7. If not, explain how the Policy/Service will be monitored and reviewed to assess the impact over time. Briefly give reasons and bullet point any steps you are taking to address particular issues, including any consultation with staff or external groups.

8. Full EIA Required (Y/N):

9. Screening Completed By:

Policy Approval Group:

Review Date:



Equality Impact Assessment (Stage Two) – Full Assessment

1. Policy/Service Directorate Assessed by New or existing? Date of Assessment

Medicines Management in the Crisis and Home Treatment Service

Adult Mental Health Directorate

Existing

2. Briefly describe the purpose of the Policy/Service: Patients being cared for in the Crisis and Home Treatment Team are receiving intensive care as an alternative to hospital admission. It is expected that these patients will be prescribed and administered medication as part of their overall package of care.

3. Briefly Explain areas of concern/attention raised by Screening exercise (please attach the screening document)

4. Summarise the activity undertaken to understand the full impact of the policy/service. (This should include reference to any monitoring data, consultation activity, sources of advice, examples of good practice etc).

5. Can any adverse impact be justified? (If the policy/service results in people being treated less favourably purely on the grounds of their race/gender/disability/age/sexual orientation/belief, this is direct discrimination, and cannot be justified. However, if the policy/service inadvertently disadvantages a particular group, it can be justified if this is a due to a reason not related to the equality strands).



6. Outline the Changes to the Policy/Service and/or the Actions to be taken (This should include what are you going to do to reduce any adverse impact and a timetable for actions).

7. What are the monitoring arrangements? (This should outline the systems that you will put in place to monitor any adverse impact in the future, and how you will use the results to develop the policy/service)

8. EIA Completed By : Lead Clinical Pharmacist Date Completed: 12 October 2010

Policy Approval Group:

Review Date:

October 2013