Decision Report 201405660

Summary

Mr C complained that a nurse at his prison health centre gave his medication to a prison officer to administer.

We looked at Mr C's medical records and the board's file on Mr C's complaint, and we took independent advice from one of our nursing advisers. We found that the board took Mr C's complaint seriously, and the nurse was managed in line with the board's medication safety policy. We concluded this was appropriate action to take. However, this was a serious incident which the board should have acknowledged in their response to Mr C's complaint, and for which they should have offered him an apology. We upheld Mr C's complaint.

Recommendations

We recommended that the board:

• apologise to Mr C for the error made in the administration of his medication;
• explain to us what steps have been put in place to prevent such an incident from occurring again; and
• provide us with a copy of a drug recording sheet.