Decision Report 201404111

Summary

Mr C complained that he was not given his prescribed medications on his first days in prison, and that all his medications were stopped soon after entering prison. Mr C also complained that the board did not investigate when he complained about this.

The board said Mr C's medications were stopped in accordance with his signed medications agreement after he was found concealing suboxone (a medication used to manage addictions) and after he refused to open his mouth to let staff check that he had taken his medication. The board said that, as Mr C had raised these issues with healthcare staff rather than complaining to complaints handling staff, they had treated this as a 'concern' rather than a 'complaint'. They also said that, in any case, they had responded to Mr C's verbal complaints reasonably, by discussing the complaints with him directly on each occasion.

After taking independent advice from a psychiatrist, we upheld Mr C's complaints. We found there was no evidence the health centre had given Mr C his prescribed medication on his first days in prison, aside from one drug, for which there were two conflicting prescriptions (and he had been given one of these). We also found Mr C had been given incorrect medication on several other occasions. However, we found that it was reasonable for the health centre to decide to stop Mr C's medications when they did. Two medications were stopped or reduced soon after Mr C arrived in prison, and the adviser said this was appropriate, as these medications were addictive and not intended for long term use. Mr C's suboxone was stopped after he was found concealing this, and we found this was reasonable, as suboxone is used for addictions management, and there is a risk of overdose or harm if it is taken other than as directed. However, we were critical that the health centre were not able to show that Mr C had been warned about the consequences of concealing medications, as he had been asked to sign the wrong medications agreement (for 'in possession' medications, rather than 'supervised' medications). Mr C's remaining medications were stopped when he refused to comply with instructions to open his mouth. We found this was reasonable, as these medications were not essential for Mr C's condition and there is a risk of harm when medications are taken other than as directed.

We found that the board did not investigate Mr C's complaints appropriately. Although we found it was reasonable for the board to treat these issues as a 'concern' when Mr C initially raised them, when Mr C continued to raise these issues, and was not satisfied with the board's response, they should have been fully investigated.

Recommendations

We recommended that the board:

• remind nursing staff of the need to take care when administering medications (particularly where there are multiple prescriptions);
• review the processes for issuing prescriptions for incoming patients to the prison to ensure that existing prescriptions (from the community and/or time in custody) are continued or amended without delay, and the patient’s agreement is obtained to the applicable medication process ('supervised' or 'in possession');
• apologise to Mr C for the failings our investigation found; and
• take steps to ensure that complaints raised verbally with healthcare staff at the prison are appropriately handled and reported in accordance with the 'Can I help you?' guidance.