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Covert Administration of Medicines

Covert Administration of Medicines

Recent Court of Protection Ruling on Covert Medication – 6th July 2016

A recent Court of Protection ruling on the administration of covert medication has implications for all care settings. In this training update, John Greene (Lead Trainer, Prescription Training) looks at this Court of Protection ruling, and what care services need to do to ensure that they operate within the law.

Details of the case (click to view judgement)

‘AG’ (92 years old) was admitted to A&E after a fall in November 2014. The hospital had concerns that she was not coping at home and suggested she go into respite care. She refused. A best interest’s decision was made to place her in a care home. It was also agreed at the time, to covertly administer thyroxine to AG.

Mental Capacity Act: Background

It would be helpful to revisit some background around the Mental Capacity Act 2005, which states that when depriving someone of their liberties, a mental capacity assessment is needed, then something called a best interests decision should follow.

The mental capacity assessment can be made by someone trained in the Mental Capacity Act. However, the best interest’s decision cannot be made by just one person. It also needs to involve any health and social care members involved in that person’s care plus the “relevant person’s representative” (or RPR for short)

An RPR is someone who represents the views of the person who will have their liberties deprived. They act as their advocate. Ideally it’s a family member, but if no family members are forth coming, the RPR can be someone independent (so they can’t be a paid carer or health professional involved in that person’s care).

With a best interest’s decision, you should state for what period of time it applies and then set the review date. The maximum time it can apply for, before it needs to be reviewed, is 12 months. However, there should also be some triggers that would prompt a review before the maximum time period is met. By triggers, we mean changes in that person’s circumstances.

In AG’s case, the best interest’s assessor was from the council, referred to as ‘KL’. As no family members were forth coming, an independent RPR (referred to as ‘SH’) was appointed. The initial best interest’s decision was set to be reviewed after 12 months (the maximum period you can have).

So in November 2015, a review was to be carried out. In AG’s case, the review was actually carried out by a Judge at a Court of Protection. In this review, the judge noted that two more medicines had been given covertly: promethazine (from Nov 2014 to Feb 2015) and then diazepam (in Feb 2015).

The judge picked up two problems:

1) There were no triggers for review set for the whole of the 12-month best interest’s decision. Considering that 12 months is the maximum period that you can have a best interest’s decision, this was poor practice.

2) The decision to give promethazine and diazepam covertly should have been a clear trigger for review of the whole best interest’s decision. Hence, the initial best interest’s assessor (KL) and the RPR (SH) should have agreed to these additional medicines being given covertly.

The judge said that whilst every case should be judged individually, you should not give medication covertly for 12 months (the maximum period you can) without setting clear triggers for review. In AG’s case, he said 6 months would have been a more suitable time period.

The judge stated that if the best interest’s decision is for longer than 6 months, then he’d suggest possibly monthly reviews of that decision thereafter. Those reviews should involve the RPR and the care professionals.

He stated that any change in medication (that is given covertly) should trigger a review.

Comment

This court ruling is helpful in that it contains some practical specifics around time frames for reviewing best interest decisions, who should be involved in the reviews. It also contains useful information stating what changes of circumstance would trigger a review of the best interests decision.

Quoting the court report directly, it says:

“In relation to change of circumstance: That to a large degree is fact specific. Alternate medication, similar in prescription, may not do so; a change in prescription in strength/dosage nature and effect will almost certainly do so. In this particular case the change in medication in February 2015 (diazepam being a stronger form of medication) should have triggered a review, it being a change to the care plan and revision to the covert medication known at the time the authorisation was given.”

So if you are giving a medication covertly, the following would trigger a review:

• an increase in the dose (e.g. an increase in strength or number of doses over a set time period)
• a change from one drug to another (where the effect is different or the new drug is considered to be ‘stronger’). You can always ask the supplying pharmacist if they consider a new drug ‘stronger’ than the previous one.

If you want more information or want to discuss how this might affect you, call us (01273 917210), email us or click here to find out about our open workshops running this month.

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John Greene BSc (HONS), MRPharmS, MIfL
Consultant Pharmacist – Prescription Training