Operational partnerships - Security, administration and disposal of drugs and medicines in custody SOP (Q01h)

1. Summary of changes

1.1 This Standard Operating Procedure (SOP) has been reviewed in June 2026 and the following amendments made:

• Section 6 – clarification included around the method to store and document detainee medication

2. What this procedure is about

2.1. This SOP is to ensure that a safe regime for the administration of medication to those in custody is maintained.

Compliance with this SOP and any governing policy is mandatory.

3. Ordering, storage and auditing of all medication including controlled drugs

3.1 Allocated FHP audit SPOCs complete a monthly medicine supplies order which is collected by the FHP admin assistant who places an order with the supplier from the FMS office situated in North Kent Custody. The order is delivered to North Kent reception in a sealed box and is promptly collected by the admin assistant. 

3.1.1 All drugs are checked and audited with batch numbers and expiry dates and placed in a locked cabinet in the FMS North Kent custody storage locked cupboard. At this point the admin assistant will over label any TTO’s (tablets to take out) with corresponding patient information labels.

3.1.2 Controlled drugs are checked into a locked tin and stored in a locked medicine cabinet in North Kent custody and audited with batch numbers and expiry dates. This medicine cabinet remains under constant CCTV. The keys to the controlled drugs tin are kept in key safe in Forensic Medical managers office and only FMS managers and the FMS admin assistant have access to the locked tin.

3.2 Controlled drugs requiring distribution to custody suites must be signed out of the controlled drugs audit book and transported to the new suite by FMS staff in a pool car fitted with a drugs safe. 

3.2.1 On arrival at the custody suite all drugs including controlled drugs must be signed in on the relevant custody’s audit form. TTO’s will be checked and signed by the FHP receiving the medication ensuring accuracy of the over label. These drugs are then stored in a locked medicine cabinet. In the case of controlled drugs, this medicine cabinet remains under constant CCTV. The keys to the medicine cabinets are stored in a key safe in the medical room. These are only accessed by Forensic Medical service staff.

3.3 All non-controlled drugs will be subject to weekly checks by an appointed FHP in each custody suite. These audits will be recorded, in a medicines management journal securely located within the medicine cabinet within each custody suite.

3.3.1 Controlled drugs are subject to daily checks by an appointed FHP in each custody suite. These audits will be recorded in a controlled drugs audit book which is securely located within the medicine cabinet within each custody suite.  

Prior to administering a controlled drug, a further medication count will be undertaken by the FHP administering the medication.

3.3.2 A monthly audit will be undertaken by a named FHP within each custody suite. This audit includes both controlled and non-controlled drugs. These audits will be recorded, and audit documents scanned to a centralised repository.  

3.3.3 Any discrepancies found during daily auditing will be immediately reported via a clinical incident form for the attention of the Risk Management SPOC and FMS managers. Following receipt of these forms the FHP manager will determine if further investigation is required, in which case this will be reported to PSD. 

In the event that the loss or theft of a controlled drug is identified it is the FHP manager’s responsibility to ensure that this is reported to both the Home Office Controlled Drugs Licencing Authority and the Police within 14 days. A report can be made to the Home Office Controlled Drugs Licencing Authority using the following link:Controlled drugs and precursor chemicals: thefts or losses - GOV.UK (www.gov.uk)

3.4 Once full, all controlled drugs registers must be returned to the FMS admin assistant to be stored in a locked cupboard within the Forensic Medical Office for a minimum of seven years after the date of the last entry.

3.5 Where there is a planned custody closure, any controlled drugs stored at the closed suite will be transferred to an alternative suite following the above transportation guidelines and audited via the controlled drugs registers. Upon notification of the suite reopening controlled drugs will be restocked.

4. Administration

4.1 Medication administered by an FHP will be supplied from the medicine cabinet, emergency grab bag or a detainee’s own medication that is suitably labelled and marked as the detainees. Detainees own medication that is in a blister pack can be administered to a detainee if all the relevant checks are completed, either by checking a prescription, summary care record (SCR) or confirmation from GP surgery.

4.2 The FHP will either administer the medication personally or place it into a signed and clearly labelled polybag (one for each medicine), for the C/sgt to dispense and when administered Athena and the MARs (Medicine Administration Record) form will need to be completed to record the drug has been given.

4.3 A strip of Paracetamol and a Salbutamol Inhaler (single person use) is to be stored in the locked Nicotine Replacement Therapy (NRT) red box held within custody. A Salbutamol inhaler or Paracetamol can be issued by the C/sgt when required only if authorised by the FHP.

4.4 Prior to the administration of dihydrocodeine and diazepam for alcohol and drug withdrawal a CIWA-AR or COWS assessment must be carried out for guidance on the requirement of medication. This will be documented on the detainee assessment stored on SystmOne.

4.5 It is every FHP’s responsibility to ensure MARs are scanned onto Athena and the paper copy is disposed of appropriately.

4.6 Before any medication or drugs are approved or administered by an FHP they must be satisfied as to the detainee’s medical history. This is particularly important if the detainee has been produced from prison or has been brought into custody from a hospital.

4.6.1 If a detainee declines to take their prescribed medication or any medication provided by the Patient Group Directive (PGD) then this must be fully documented within the medical notes with any rationale given.

4.6.2 On occasions it has been found that detainees secrete medications (both prescribed and illicit) about their person and may have taken medication and or alcohol prior to being arrested. Therefore, the FHP must carry out a full clinical examination as soon as safe to do so following a risk assessment. The FHP may then consider if it is appropriate to administer or withhold medication within the custody setting.

4.6.3 If the FHP has any concerns and believes that a detainee has taken any type of medication prior to arrival at custody, or whilst in a suite, then they should strongly consider withholding any further administration of medication that could potentially harm the detainee, for example causing an overdose. If the FHP deems it inappropriate to administer any medication, a review must be carried out within a suitable time frame, to allow the affects of any intoxication to wear off ( a guide of six hours could be considered as acceptable, however this is subject to the individuals initial assessment). Some routine medications may still be required, such as insulin/anti-hypertensives etc. the FHP can contact the FME if they are unsure and require further guidance. Medication should not routinely be withheld unless the FHP has concerns following a comprehensive assessment.

4.6.4 Lifesaving medication is exempt from this criterion and if required will be administered without any delay.

4.6.5 Caution must be given with tablets contained within a dispensed bottled rather than blister packs as these are harder to identify and will require addition scrutiny and consideration when administering by the healthcare professional.

4.7 Medication will only be administered to the detainee by an FHP or a C/sgt.

4.7.1 Any detainee requiring medication will be issued it by the FHP. In the absence of an FHP the C/sgt can dispense previously checked and bagged medication issued by the FHP. This must be done at the charge desk unless it is physically impractical to do so. Only C/sgt’s are permitted to issue bagged up medication. The detainee’s full details, identity, dosage and type of medication will be checked before the detainee is provided with the medication. The detainee will be observed taking the medication to prevent hoarding.

4.8 Any Dossett medication box that has been produced by a pharmacy or GP, can be issued to a detainee if suitable, following completion of all relevant checks.

4.8.1 If a Dossett box has been made up by the detainee themselves or a family member then these are not to be issued. It will be impossible to check expiry dates on the medications, some of which maybe unidentifiable. Every effort should be made to get the detainees prescribed boxed and labelled medication from the home address. If blister sheets of medication are only able to be obtained, then all the relevant checks (using Summary Care Records and/or phoning the GP) should be completed to ensure they are safe to be administered to the detainee.

4.9 When a detainee is to be provided with a TTO, the FHP who initiates the first dose is responsible for checking and signing the patient information over label. Upon release the medication box must be checked by custody sergeant responsible for releasing the detainee to ensure that both the issued by and checked by box have been initialled by an FHP.

5. Administration of medication prescribed prior to arrival in custody

5.1 Where a person comes into custody and has with them previously prescribed medication, including controlled drugs, the C/sgt should consult the FHP. The rules for self-administration under PACE Code C 9.10 Pace Code C (Revised) will apply.

5.2 Where a controlled drug is a schedule 2 or 3, an FHP who has been in the role for longer than six months can administer the medication without the need to contact the FME, if all the relevant checks have been completed to ensure the drug is correctly prescribed to the detainee.

5.2.1 FHP’s with less than six months experience must contact an FME for the authorisation of these medications and must clearly document on the medical notes which FME they have spoken to and the time and date.

5.2.2 Schedule 2 or 3 medications (with the exception of Diazepam and Dihydrocodeine) must not be bagged up for the next FHP or C/sgt to administer. An FHP can only administer scheduled 2 or 3 medications (with the exception of Diazepam and Dihydrocodeine).

5.3 Under no circumstances should any detained person be allowed to take any medication prior to arrival in custody without consent of the FHP. If it appears a detainee requires urgent medical attention or medication before the advice of an FHP is available, they will be taken to hospital (by ambulance if appropriate).

5.4 Methadone can be administered to any persons in custody that are known to be pregnant, and the FHP can verify a claim by the detainee that they are the subject of a supervised programme and the methadone has been collected by police from a pharmacy/treatment centre. The FME must be consulted before issuing Methadone to a pregnant detainee.

5.4.1 Non pregnant detainees that are on a methadone programme can have methadone administered in certain circumstances to avoid interrupting their methadone programme. In this situation the FHP must fully assess the detainee and make contact with the Drug Treatment Agency responsible for the detainee’s care, confirming the current treatment programme being delivered. If the FHP is fully satisfied that the detainee is suitable to continue their Methadone programme within the custody setting then they will contact the relevant pharmacy and with the authority of the detainee request the Methadone is collected on their behalf and brought to the custody suite for administration by the FHP. 

5.4.2 If the pharmacy concerned is in agreement for the methadone to be collected then the custody sergeant will request a CAD be raised for LPT officers to collect the methadone as soon as reasonably possible. If the pharmacy will not supply the methadone, the Drug Treatment Agencies must be informed by the FHP.

5.4.3 It is the responsibility of police officers to collect any medication on behalf of a detainee, however in exceptional circumstances whereby a police officer is not readily available and a long delay is anticipated that would be detrimental to the detainee’s welfare whilst detained then a FHP can collect the methadone, however, this can only be collected using a Kent Police vehicle fitted with a drug safe.

5.4.4 Any FHP with less than six months experience must liaise with an FHP manager or appropriate FHP before any decision can be agreed.All other persons claiming that they are the subject of a supervised Methadone/drug treatment programme may be treated by the FHP, with other substitute medications if deemed appropriate during their detention period.

5.4.5 If a detainee is prescribed an alternative drug treatment therapy other than Methadone, consideration can be made to collect from the relevant pharmacy by police officers if the FHP deems appropriate and administered within the custody suite under supervision of the FHP.

5.4.6 Any detainee subject to a drug treatment programme should be asked if we are able to disclose to the relevant Drug Treatment Agency any drug treatment therapy received within the custody suite.

5.5 Prior to administering any medication that is obtained by a police officer or FHP from a pharmacy the FHP must check the batch number and expiry date.  Where there is uncertainty around the validity of either the batch number or expiry date the FHP must make efforts to verify the information by phoning the issuing pharmacy and documenting this verification.

6. Storage of detainee's personal medication

6.1 When a detainee arrives in custody with personal medication, the custody sergeant is responsible for ensuring the medication is securely recorded, stored, and managed.

6.2 The medication must be booked into property on Athena, with the name of the medication clearly recorded. The medication must then be placed into a clear bag and sealed with a seal with a unique reference number and stored in the designated secure locker associated with the detainee’s cell. The sealed bag must be clearly labelled with the detainee’s surname and custody number. The seal number must also be recorded on Athena.

6.3 Where an FHP is required to access the medication in order to administer it, the sealed bag must be opened and the medication administered as clinically indicated. Any remaining medication must then be replaced within the bag and a new seal used to close the bag. For continuity and audit purposes, the original seal must be retained within the bag and the new seal number must be recorded on the Athena property log by the FHP administering the medication. This process must be followed on each occasion the medication is accessed during the detainee’s period in custody.

6.4 Once the medication property bag has been opened and the first dose administered by an FHP, prescribed medication (excluding controlled drugs) may, where clinically appropriate, be bagged for the next scheduled dose. Where this occurs, the medication must be labelled and managed in accordance with the standard medication bagging and administration process set out in section 4.7 of this SOP. Controlled drugs must not be pre‑bagged and must continue to be managed in line with controlled drug requirements.

7. Medical cannabis

7.1 Medical cannabis can be prescribed in a number of forms including:

• liquid form: For oral administration (i.e. Epidyolex)
• spray: For oromucolsal administration (i.e. Sativex)
• tablet (capsule): For oral administration (i.e. Nabilone)

7.1.1 Other forms may be available and may be prescribed, but it is unlikely that medication in the form of ground cannabis leaf for example would be appropriate for administration in custody. The above forms will contain an accurate, stated dose (in terms of concentration of active ingredient in mg) whereas this is unlikely to be the case for ground leaf/flower.

7.2 Where a detainee presents with an NHS prescription for medical cannabis, prior to allowing the administration of either version, the prescription must be checked by the FHP to ensure it is current and lawfully prescribed. This includes checking Summary Care Records. The name of the prescriber should be checked and documented.

7.3 UK legislation states that the initiation of prescribing of medical cannabis must be done by a doctor who is on the GMC specialist register. Thereafter follow up prescribing may be done by anyone who is a legitimate prescriber. Where a detainee presents with a private prescription for medical cannabis, the FHP must consult with the on call FME prior to allowing the administration. The FME may consider arranging a prescription for an alternative drug to be given whilst in custody*. Every effort should be made by the FHP to contact the private prescriber to confirm the necessity of the prescription to support clinical decision making around the administration of medical cannabis.

*Note the on call FME will not be able to provide a prescription for cannabis, but in the case of pain relief they may authorise a PGD drug.

7.4 Once the FHP has satisfied themselves of the legitimacy of the prescription, this should be treated as any other lawfully prescribed drug. That is to say that as with every other prescribed medication, the detainee must be assessed to ascertain whether it is clinically appropriate to issue the medication, irrespective of whether there is a valid prescription for it. Some of the clinical circumstance where it would clearly not be appropriate to administer it include, the dose is not due, detainee is intoxicated, detainee has a head injury, or is otherwise unwell, but this list is not exhaustive. If the FHP is unsure as to whether it is appropriate to administer the prescription, they should consult the on call FME for clinical advice.

7.5 Where legal cannabis has been issued to a detainee, they must then be reassessed before interview, to confirm that they remain fit for interview having taken medically prescribed cannabis.

8. Asthma

8.1 The C/sgt after completing the risk assessment is to inform the FHP that the detainee is an asthmatic. If there is no FHP on duty between the hours of 05:00 and 07:30, then the FHP is to be notified at the next available opportunity.

8.2 Inhalers may be stored in the detainee’s locker for easy access. It is recommended that the inhaler is not retained in the cell by the detainee however this is at the discretion of the C/sgt following their risk assessment. Reassurance to the detainee must be given advising them that urgent access to their inhaler will be provided if required.

8.3 Inhalers must be examined to ensure, as far as is possible, they have not been tampered with or used to conceal other substances. The appointed FHP will ensure that custody supplied inhalers remain in date and are replaced as necessary. Where a detainee has their inhaler in their property or an inhaler is issued for urgent use from the NRT box, the circumstances will be reported to the FHP and further instructions sought. The custody record will be endorsed with the details of all actions taken.

8.4 If an inhaler is urgently required by a detainee the C/sgt can access one from the NRT box and issue two puffs of the inhaler under supervision. If no improvement after initial two puffs follow asthma guidelines. The circumstances will be reported to the FHP, if no FHP on duty between the hours of 05:00 and 07:30 the FHP is to be notified at the earliest opportunity. If the detainee is requesting frequent use of an inhaler and symptoms are not improving then an ambulance should be called immediately by the 999 number and the detainee MUST be monitored closely in the cell, whilst awaiting the arrival of the ambulance.

9. Heart conditions

9.1 The C/sgt after completing the risk assessment is to inform the FHP that the detainee has a diagnosed heart condition. If there is no FHP on duty between the hours of 05:00 and 07:30, then the FHP is to be notified at the earliest opportunity.

9.2 Any detainee who has in their possession a Glyceryl Trinitrate Spray (GTN) will not be permitted to retain this in the cell. However, if it is believed the individual requires this medication urgently and guidance cannot be sought from an FHP (for reasons that there is no FHP on duty between 05:00 and 07:30 hours or is not present in the custody suite), then the C/sgt can allow immediate use without delay and appraise the appropriate healthcare professional as soon as possible.

• the administration of this drug in most individuals can cause adverse reactions
• the dose to be given is one spray under the tongue
• an ambulance should always be called immediately by the 999 number and the detainee must be monitored closely in the cell, whilst awaiting the arrival of the ambulance
• repeat the dose after five minutes if symptoms are not relieved and the ambulance crew is yet to arrive
• Aspirin is available in the red tin should custody sergeants be advised by the ambulance call taker to administer this prior to the ambulance crews arrival and in the absence of an FHP.

If further guidance is required, this can be sought from the Emergency Medical Advisor using the 999-phone number.

9.3 The custody record will be endorsed with the details of all actions taken. In all cases where an individual has in their possession a GTN spray, the care regime should be a minimum of 30-minute visits unless advised otherwise by an FHP. Detainees with heart conditions that require GTN spray can have their symptoms exacerbated by the anxiety etc, of being in custody and reassurance should be given to these detainees that their GTN spray can be readily available on request and these individuals should be reminded to call custody staff at the earliest opportunity if they are starting to experience chest pain or feeling unwell.

10. Paracetamol

10.1 A strip of Paracetamol is to be held in the NRT box within custody and is to only be administered by the C/sgt following instruction from the FHP.

10.2 Should a detainee request analgesia for mild to moderate pain, Paracetamol can be administered by the C/sgt without an FHP carrying out a face-to-face medical assessment. The FHP will carry out a telephone or video consultation, to gain a medical history and information surrounding the requirement of the analgesia. This is in the circumstance that an FHP’s workload at their current custody suite is such that there would be a significant delay in their attendance and therefore the analgesia could not be administered in a timely fashion.

10.2.1 The following questions must be asked by the FHP.

• • what is the reason for analgesia?
  • are you allergic to anything?
  • have you had any drugs or alcohol in the last 24 hrs and if so, how long ago?
  • have you taken any other paracetamol-based medication in the last six hours?
  • do you have any history of kidney or liver issues?
  • recent history of an overdose
  • previous medical history
  • current prescribed medication
  • female detainee - could they be pregnant?
  • any analgesia request for headache must be asked the additional questions below
    • have you had any nausea, vomiting, photophobia, dizziness or a rash, any neck stiffness?
    • have you had a recent head injury within the last week?
    • previous history of headaches/pain
    • current duration of this headache/pain?

10.2.2 Following the telephone consultation, the FHP must give full handover to the C/sgt and prescribe the Paracetamol on Athena, if it’s decided that Paracetamol is suitable to be prescribed over the telephone and a face-to-face consultation is not necessary. The C/sgt can then obtain the prescribed dose from the red NRT medication box in the custody suite. Following confirmation of the detainee’s name and date of birth, any allergies will need to be confirmed before providing the detainee with the medication with water at the custody desk (unless necessary to issue in the cell). The detainee will be observed taking the medication by the C/sgt to prevent hoarding. The FHP should also ensure they have completed a PGD 2050 and sent this via work email to the C/sgt to sign and place in the detainees locker. The C/sgt should action that the Paracetamol has been given on Athena.

10.2.3 The FHP will complete a medical assessment and the custody record and SystmOne will be endorsed with the details of all actions taken.

11. Custody records

11.1 Where a C/sgt or FHP administers drugs to a detainee the custody record will be endorsed accordingly. Refusal of the detainee to take medication approved by the FHP or FME must be recorded in the custody record and the FHP informed immediately or notified at the next available opportunity

12. Disposal

12.1 The FHP should be contacted by the C/sgt for advice if required relating to disposal of all medicines prescribed to a detainee. Where detainees are being transferred to a prison, any prescribed drugs (which can include controlled drugs) will be placed securely in a sealed bag with each detainee’s property and handed directly to the prison escort. All details pertaining to the use of the medications will be clearly detailed on the Prison Escort Form (PER).

12.2 Detainees may leave the custody suite with medications under the following circumstances, subject to a risk assessment by the releasing C/sgt:

• the detainee arrived into custody with these medications and they are suitably prescribed to that detainee.
• the medications have been collected from their home address whilst detained in police custody and these are suitably prescribed to the detainee.
• the medications were prescribed by the hospital whilst in detention.
• the detainee has been given a full course of Patient Group Directive antibiotics, prescribed by the FHP.

12.3 Detainees who have been prescribed medication from the Patient Group Directive by an FHP will not be permitted to take these medications with them when they are released with three exceptions. Where a detainee has been issued with a Salbutamol inhaler, a full course of antibiotics or a custody issued GTN spray, they will be permitted to take these with them adhering to the processes detailed in 4.9 above.

12.4 Medication that is suitable for disposal should be placed in the custody suite drug disposal locked cupboard and the drug disposal book updated by the individual disposing of the medication.

12.4.1 Medication that is suitable for disposal should be placed in the custody suite drug disposal locked cupboard and the drug disposal book updated by the individual disposing of the medication. 

12.4.2 Prior to placing the medication into the theatre bin, the discarded medication record books are to be reviewed by the custody sergeant who will countersign the book ensuring the medication name and amount corresponds. Only once the custody sergeant has countersigned should the medication be sealed into the theatre bin in the presence of the custody sergeant.

12.4.3 Sealed theatre bins should then be taken directly to the property officer who will arrange for the appropriate disposal of the medication.

12.5 All discarded medication record books are to be retained for a minimum of seven years from the date of the last entry.

12.6 General and clinical waste bins located in medical rooms within custody suites are changed daily by cleaning contractors. Clinical waste bins will also be changed following an intimate sample procedure

12.6.1 Sharps bins located in medical rooms are checked daily by FHPs to ensure that they have not reached capacity. When full, sharps bins are sealed by FHPs and collected by contractors.

13. Controlled drugs licencing arrangements

13.1 An annual check will be undertaken by the responsible officer named on the controlled drugs licence to ensure that the organisation supplying controlled drugs to all Kent Custody Suites has a valid wholesalers licence which includes category 3.1.1 authorisation for the supply of narcotic or psychotropic products. This can be done via the following link:Human and veterinary medicines: register of licensed wholesale distribution sites - GOV.UK (www.gov.uk)

13.2 The responsible officer named on the controlled drugs licence must ensure that an annual return is submitted to the Home Officer controlled drugs licensing authority for each cluster prior to  31 January every year using the following link:Controlled drugs: annual returns form - GOV.UK (www.gov.uk)

13.3 The responsible officer will ensure that annual renewal documents are submitted 12 weeks prior to the expiry date of the existing controlled drugs licence. In addition the responsible officer and all those names on the controlled drugs licence will ensure that they maintain valid DBS certificates.

14. Monitoring and review

14.1 This procedure will be monitored by the policy owner who also has oversight of the practical delivery of custody. It will be reviewed every year.

14.2 Each month each custody suite is subject of an inspection intended to identify compliance with this policy and areas for continuous improvement. This inspection will also include a medication audit.

15. Security

15.1. Kent Police have measures in place to protect the security of your data in accordance with our Information Management Policy (Policy W1000 – Information Management).

16. Retention and disposal of records

14.1. Kent Police will hold data in accordance with our Records Review, Retention and Disposal Policy (Policy W1012 – Records Review, Retention and Disposal).