Decision Report 201303434

Summary

Mr C complained that after he was sent to prison there was a delay in the prison health centre prescribing medication that he had been taking in the community. In particular, Mr C was concerned that he had not received a blood thinning drug for deep vein thrombosis (a blood clot in a vein) and diazepam for anxiety. In responding to his complaint, the board acknowledged and apologised that there had been a delay and partially upheld his complaint. However, they did not agree that he should have been prescribed diazepam. The health centre prescribed him a different drug that also treats anxiety and which he had been taking in the community.

After taking independent advice from our GP adviser, we found it reasonable for the health centre not to have prescribed diazepam, as it is not used to treat anxiety long term, and we noted that he was prescribed an appropriate medication that he had already been receiving. However, we noted a delay of six days before he was given this and that this may have caused him some side effects. We also found that there was an unreasonable delay of five days before Mr C received his blood thinning medication. Our adviser said that this is a potentially life-saving drug that can wear off after 24 hours. We found that both the locum (temporary) doctor who reviewed Mr C shortly after his admission to prison and the on-call doctor who saw him several days later had failed to access Mr C's emergency care summary (ECS - an electronic system for checking information about a person's health in an out-of-hours care environment), and we upheld his complaints.

During our investigation, the board carried out a further review and accepted that there were failings in the doctors promptly accessing the ECS to confirm Mr C's medication on admission. Because of this, the board drafted written guidance on the process to be followed when obtaining and maintaining an accurate list of a patient's medication on admission to prison, through their transfer and at the time of discharge.

Recommendations

We recommended that the board:

• confirm to us when the draft medicines reconciliation guidance has been implemented; and
• confirm the steps they have taken to ensure all relevant clinicians working for the health centre have knowledge of and access to the emergency care summary.