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

Q01h Security, Administration and Disposal of Drugs

 

1. Summary of Changes

1.1 This Standard Operating Procedure (SOP) has been reviewed in August 2024 - no amendments to content have been made. 

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 prison. The order is delivered to North Kent (FHQ 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 logged into a Controlled Drugs Register and placed in a locked cabinet in the FMS North Kent Custody Storage locked cupboard.

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.

3.1.3. The combination to all key safes containing keys to medicine cabinets, including controlled drug medicine cabinets must be changed every 6 months.

3.2 Controlled drugs requiring distribution to custody suites must be signed out of the Controlled Drugs Register 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 - or Controlled Drugs Register in the case of controlled drugs. 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 controlled drugs stored either in the medicine cabinets or emergency grab bags, will be subject to daily checks by FHPs on duty in each custody suite. Non controlled medication will be subject to weekly checks. These audits will be recorded in a bound Controlled Drugs Register in the case of controlled drugs, and an audit document folder for non controlled drugs, all audit documents will be scanned to a centralised repository.

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

3.3.2 Any discrepancies found during daily or weekly drug 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.

3.3.3 In the event that the loss or theft of a controlled drug is identified it is the FHP Managers 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 2 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 DP 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 FHP’s will generally work to a 6 hour guideline, whereby medication will not be administered to a detainee within the first 6 hours of detention, due to the risks associated with potential overdose from any medication that may have been administered prior to arrival in custody. However, this does not preclude a clinical assessment from being conducted within the first 6 hours of detention. This clinical assessment may on occasion dictate a clinical need for the 6 hour guideline to be overruled, and medication administered within the first 6 hours of detention. This decision is down to the FHPs discretion, based on medical need, and the FHP must document a clear rationale for administering medication prior to the 6 hour guideline on SystmOne.

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 DP 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 G.P) should be completed to ensure they are safe to be administered to the DP.

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 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 6 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 6 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 & 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 & 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 Detained person 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 will NOT be administered to any persons in Custody, unless that person is 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 ANY Methadone.

5.4.1 In certain circumstances it may be deemed unsuitable to interrupt a methadone programme for non-pregnant Detainees. In this situation the FHP must fully assess the Detainee and make contact with the Drug Treatment Agency responsible for the Detainees 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.

5.4.3 It is the responsibility for 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 Detainees 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 6 months experience MUST liaise with an FHP Manager or appropriate FHP before any decision can be agreed5.4.1 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.

6. Asthma

6.1 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.

6.2 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.

6.3 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.

6.4 If an Inhaler is Urgently required by a Detainee the C/Sgt can access one from the NRT box and issue 2 puffs of the inhaler under supervision. If no improvement after initial 2 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.

7. Heart Conditions

7.1 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.

7.2 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.

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

7.3 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.

8. Paracetamol

8.1 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.

8.2 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.

8.2.1 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 6 hrs?
  • 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?

8.2.2 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 DP’s locker. The C/Sgt should action that the Paracetamol has been given on Athena.

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

9. Custody Records

9.1 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

10. Disposal

10.1 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).

10.2 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 anti-biotics, Prescribed by the FHP.

10.3 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.

10.4 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.

10.5 It is the FHP’s weekly responsibility to check the drug disposal cupboard and to place all medication in a sealed evidence bag. The evidence bag containing the drugs for disposal and the discarded medication record books are then to be reviewed by the Custody Sgt who will countersign the book ensuring the medication name and amount corresponds with the bag and record sheet. This evidence bag is then taken directly to the Property Officer who will sign to confirm receipt and arrange for appropriate disposal of the medication.

10.6 All discarded medication record books are to be retained for a minimum of 7 years from the date of the last entry.

11. Controlled Drugs Licencing Arrangements

11.1 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)

11.2 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 the 31st January every year using the following link:
Controlled drugs: annual returns form - GOV.UK (www.gov.uk)

11.3 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.

12. Monitoring and Review

12.1 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 with the next review taking place in August 2025.

12.2 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.

13. Security

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

14. 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).