Celebrating and promoting the best in UK prisons, probation and youth justice
AWARD WINNER 2011-12: Cathryn is Head Pharmacist at Swansea. Against considerable resistance she has turned the pharmacy from one described by HMCIP as “barely legal” in 2005 to a beacon of excellence. She has improved staff training, developed standard operating procedures on all aspects of medication handling, introduced nurse-prescribing of drug detox medication on reception, set up specialist prescribing and overdose prevention services for drug users, increased “in possession” medication rates from 20% to 80%, and improved health outcomes for prisoners. (This Award is supported by G4S Care and Justice Services).
[Cathryn Richards gives her account of the work for which she won her Award]
At HMP Swansea, I introduced a seamless transition of care by the writing of Patient Group Directions and Standard Operating Procedures. This enabled nurses to administer emergency medication to prisoners on entry into prison and during their stay.
HMP Swansea is a local category B prison that holds remand, convicted and sentenced adult male prisoners over the age of 18 years. It primarily serves the courts within the unitary authority boundaries of South West Wales. HMP Swansea’s operational capacity is 437, with its certified normal accommodation being 248. Its focus is to develop its function as a short term resettlement prison for those serving a prison sentence of two years or less.
The first night in custody in a remand prison is very important, in that all prisoners must be held lawfully, and their well being must be the primary concern of staff throughout the reception and first night process. The guiding principle in management of reception and first night is the duty of care to prisoners.
Given the high turnover of prisoners at HMP Swansea, it is vital that identifying and managing acute medical need is carried out at the beginning of custody. Self reported levels of drug misuse in HMP Swansea stand at 63 percent and alcohol dependency at 43 percent. Prisoners enter Reception at any time, and usually there is no doctor present. The use of Patient Group Directions (PGDs) is essential in the treatment of the vast majority of prisoners who are undergoing detoxification, and /or have acute life threatening medical needs.
PGDs are legal documents permitting the administration of Prescription Only Medicines (POMs) to patients, without individual prescriptions, and being seen by a doctor. This means that a PGD, written by myself , the pharmacist, signed by myself, lead prison doctor and governing governor, enables a nurse to administer POMs to patients, using the nurse’s own clinical assessment of patient need. The medicines which the nurse administers from the PGDs are mainly detoxification medicines which will be used over the following days to detoxify the patient.
The patient is supported by these medicines and nursing input within an hour of him entering prison. At this prison there is twenty four hours nursing care, so the patient will be monitored closely on his patient journey.
The use of PGDs was introduced, into HMP Swansea, in June 2006. Over the past six years, I have developed new and reviewed existing PGDs on a continuous basis to meet the changing clinical needs of the prison population, and to date, a total of 23 PGDs have been written. The five original PGDs written, (diazepam for alcohol withdrawal, diazepam for benzodiazepine withdrawal, metoclopramide, quinine sulphate and lofexidine), have been modified over the years but are still the most commonly used on a daily basis. The other 18 PGDs cover a greater range of drugs used in alcohol dependency, substance misuse detoxification and acute clinical needs. The PGDs used in HMP Swansea, are written for up to three days treatment (five days including Bank Holidays). They were written for up to three days treatment in the event of a medical emergency with doctors not being available in the prison. A list of the PGDs and their clinical indications are listed in the Appendix.
The nursing staff were trained by myself on the legal aspects of the use of PGDs and the pharmacological properties of the medicines being given out on the PGDs. Initially certain staff showed a slight trepidation in their use but they also felt empowered by their use. Prisoners entering the prison knew about their use in the community and word soon spread on their use.
After urine testing the prisoners in reception, medication would be given to them within an hour of their entering prison.
The clinical leads at HMP Swansea produced detoxification clinical audit tools to be used in combination with the PGDs so that doses of medication could be tailored to the patient’s needs. Detoxifying patients are monitored through the night and day and, if extra medication is required, then they are given via the PGD. In a recent HMCIP Inspection the use of PGDs, at HMP Swansea was cited as good clinical practice.
Below are some snap shot examples of their uses giving a greater understanding of their employment.
Patient A was experiencing difficulties in breathing, his saturated oxygen levels were 75 – normal levels should be between 95-100. An ambulance was called at 18.00 hours on telephone advice from the out of hours doctor. The ambulance had not arrived by 21.00 so a 999 telephone call was placed. The ambulance arrived at 02.10. During this time the nurse used oxygen, Glyceryl Trinitrate CFC free 400mcg/ actuation spray and salbutamol 5mg nebules via PGDs.
Patient B was detoxifying badly from alcohol dependency and illicit substances and had an epileptic seizure which lasted for 30 minutes. The ambulance had difficulty in reaching the prison, the nurse on duty administered diazepam rectal tubes, from a PGD, in order to prevent the patient from having severe brain damage or possibly dying, until the ambulance arrived and admitted him to hospital.
In prison, some prisoners self harm or fight, and the nursing staff have been trained to suture and use lidocaine 1% ampoules from a PGD to provide the patient with local anaesthesia when suturing him. This causes the patient less stress rather than waiting in the Casualty Department of the local hospital.
If a prisoner has a life- threatening allergic reaction, the use of an adrenaline pen is used. This is administered by nurses; and a PGD has been written which covers them legally in its usage. In the case of hangings, oxygen is readily available on the prison wings, and the nurse on duty will use this. A PGD has been produced for naloxone injection, which is used in opioid overdose. Naloxone injections are available in the treatment rooms of both prison wings. In an emergency this can be used to save a patient’s life until the ambulance arrives.
Last year, the administration of thiamine (vitamin B1) 100mg tablets and vitamin B Co Strong tablets was introduced in Reception via PGDs to all alcohol dependent patients entering the prison. This was in order to reduce the incidence of Korsakoff’s syndrome in chronic alcohol abuse and/ or severe malnourished patients.. Korsakoff’s syndrome (also called Korsakoff’s dementia or Korsakoff’s psychosis) is a neurological disorder caused by a lack of thiamine (vitamin B1). If left untreated dementia can ensue.
The majority of cases using PGDs are run of the mill cases but prevention is better than cure. The morale of prisoners entering this prison is raised due to clinical treatment starting within an hour of entry, and also provides better healthcare.
In conclusion, I have no doubt that the use of PGDs has contributed to a significant reduction in first night death in custody of prisoners at HMP Swansea. They have stabilised patients in acute clinical conditions, verging on death, until the ambulance arrives, which can take up to several hours. The nursing staff have been empowered by their use and I have gained a lot of knowledge in writing them. Due to their extended roles, two of the nurses and myself have trained as non-medical Independent Prescribers. The use of PGDs help medical staff to give a service to the best of their ability to prisoners at HMP Swansea.
[The following article appeared in issue 4 of the Butler Trust’s magazine, Inspire]
In 2005 the HMCIP described the pharmacy as ‘barely legal’. On her arrival, Cathryn began its radical transformation to a beacon of excellence, changing operating procedures, improving staff training and increasing ‘in possession’ medication rates from 20 per cent to 80 per cent. She re-educated staff on how a community model of pharmacy should operate – no mean feat, as there was a culture of resistance to change.
On her first day she was asked to write patient group directions (PGDs) for nursing staff so they could give prescription only medication in the absence of the doctor. She has also written nearly 80 Standard Operating Procedures (SOPs) on all aspects of medication handling, which are used for training as well as reference. She took the initiative much further, giving the nursing staff training and confidence to begin immediately tailoring treatment to their needs.
‘You start treating them the minute they come in,’ she says. ‘Some of them are in quite a poor state, so we really improve their health. They see the doctor, they are reviewed by nursing staff, and we administer medication from the pharmacy on their first full morning in prison.’
Cathryn’s expertise in substance misuse has been invaluable. The Swansea area has one of the highest proportions of heroin and drug-related deaths in the UK – a group highly represented in the prison population. She has restructured the service to give substance misuse treatment high priority and the administration of medication within a few hours of entering prison has helped many prisoners with detoxification issues on their first night.
Careful auditing of medication and counselling on health issues revealed the extent of prisoners’ drug and alcohol use, and she set up weekly substance misuse clinics in the prison. By promoting team work with CARATs and external agencies, and involving families, she has been able to offer prisoners every chance to break their cycle of substance misuse.
‘Giving up an opioid addiction is extremely difficult, but if successful, the benefits for the patient and the wider public are immense, as 55 per cent of prisoners report committing offences connected to their drug taking,’ she says. ‘This benefit filters down to the NHS, in that less HIV and hepatitis C drugs are needed. So the prisoners are treated without judgemental attitudes, to achieve the best possible outcomes.’ As they plan for release Cathryn ensures community services are engaged and is working to make sure prisoners’ families are ready to support ‘through the gate’ care. Pioneering a naltrexone prescribing programme has helped to support prisoners in remaining abstinent and she is pursuing further ideas to develop a support network in the community, to increase motivation after release.
Cathryn was instrumental in making sure prisoners are trained in the use of naloxone on release – a treatment that counters the effect of overdose and has been proven to save lives. According to her colleagues, this is among many examples of her quietly and professionally getting on with changing the culture of the establishment in her ‘truly remarkable’ way.
For more information: contact HMP Swansea