ILLICIT DRUGS POLICY
Version / 1Name of responsible (ratifying) committee / Security and Fire Steering Group Meeting
Date ratified / 10 May 2017
Document Manager (job title) / Head of Legal Services
Date issued / 24 July 2017
Review date / 23 July 2019
Electronic location / Management Policies
Related Procedural Documents / Controlled Drugs Policy
Key Words (to aid with searching)
Version Tracking
Version / Date Ratified / Brief Summary of Changes / Author1 / 10.05.2017 / New Policy / J Haines
CONTENTS
QUICK REFERENCE GUIDE
1.INTRODUCTION
2.PURPOSE
3.SCOPE
4.DEFINITIONS
5.DUTIES AND RESPONSIBILITIES
6.PROCESS
7.TRAINING REQUIREMENTS
8.REFERENCES AND ASSOCIATED DOCUMENTATION
9.EQUALITY IMPACT STATEMENT
10.MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS
EQUALITY IMPACT SCREENING TOOL
APPENDIX 1: Substance Surrender Form
QUICK REFERENCE GUIDE
The use, possession or supply of controlled drugs and psychoactive substances (so called “legal highs”) on Portsmouth Hospitals NHS premises is strictly prohibited.
For the purposes of this policy these substances are collectively referred to as illicit drugs or illicit substances.
Any patient or visitor who is either seen with, or suspected to be in possession of, illicit drugs may be liable to be reported to the police .
This policy should be read in conjunction with the Controlled Drugs Policy and sets out what action staff should take if they know or have reasonable cause to suspect that a patient or visitor has in their possession illicit drugs including what they should do if they find or otherwise come into possession of an illicit drug on Trust premises.
1.INTRODUCTION
The Misuse of Drugs Act, 1971 (MDA) controls certain classes of dangerous drugs, which are listed and known as “Controlled Drugs”. Its main purpose is to prevent the misuse of these drugs by imposing a total ban on the possession, supply, manufacture or importation of Controlled Drugs, except as allowed by regulations.
The Psychoactive Substances Act 2016 restricts the production, sale and supply of a new class of psychoactive substances known as "legal highs." Unlike controlled drugs it is not an offence to possess a "legal high" for personal use. However it is extremely difficult for staff to be able to distinguish between a controlled drug and a psychoactive substance in the possession of a patient or visitor and therefore, for the purpose of this policy it is not intended to distinguish between the 2 types of substance, which together are referred to as illicit drugs.
Section 8 of the MDA provides that an occupier or manager of any premises commits an offence if they knowingly permit the supply or use of illegal drugs on those premises, Section 21 extends the duty to health bodies and directors and managers of those bodies.
2.PURPOSE
The purpose of this policy is to:
Protect the Trust as an employer and individual members of staff as employees of the Trust from legal liability under the Misuse of Drugs Act 1971 and the Psychoactive Substances Act 2016 and inform staff what steps they should take if they know or suspect a patient or visitor is in possession of an illicit drug as well as to inform them what steps to take if they find, are given or otherwise come into possession of a substance that they have reasonable cause to suspect is a controlled drug or psychoactive substance.
3.SCOPE
This policy applies to all staff working within Portsmouth Hospitals NHS Trust who come into contact with patients and visitors.
This policy should be read in conjunction with the Controlled Drugs Policy.
‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises that it may not be possible to adhere to all aspects of this document. In such circumstances, staff should take advice from their manager and all possible action must be taken to maintain ongoing patient and staff safety’
4.DEFINITIONS
4.1.Manager
For the purposes of this policy the term“Manager” is defined as the Trust Duty Manager, a Consultant or Head of Nursing.
4.2.Controlled Drug
For the purpose of this policy, the term “controlled drug” (CD) refers to those substances currently controlled under the misuse of drugs legislation, including the Misuse of Drugs Act (1971) and the Misuse of Drugs Regulations 2001, a current list of which can be found at
4.3.Psychoactive Substance
For the purpose of this policy the term “psychoactive substance” has the same meaning as it does in the Psychoactive Substances Act 2016 , namely any substance which
a)is capable of producing a psychoactive effect in a person who consumes it, and
b)is not an exempted substance (under the act).
These substances are commonly known as “legal highs”.
4.4.Illicit drug/Illicit substance
For the purpose of this policy an illicit drug/illicit substance that is reasonably believed to fall within the definitions set out in paragraphs 4.1 and 4.2 above.
5.DUTIES AND RESPONSIBILITIES
Accountable Officer (Controlled Drugs) – Director of Medicines Optimisation and Pharmacy.
Each healthcare organisation must appoint a fit, proper and suitably experienced person to be its Accountable Officer. This should be a senior executive officer of the organization (i.e. an Executive Director or someone who reports directly to an Executive Director). The Accountable Officer does not, or does only exceptionally, prescribe, supply, administer or dispose of controlled drugs. If staff have concerns about the practice of the Accountable Officer these should be raised with PHT’s Chief Executive.
The Accountable Officer has overall responsibility to ensure that the Trust operates appropriate arrangements for the securing and safe management of CDs within the Trust, as described in this Policy and in standard operating procedures used within the Pharmacy Departments.
The regulatory requirements for Accountable Officers are set out in full in the Controlled Drugs (Supervision and Management of Use) Regulations 2013.
Security
May be called to provide support in circumstances where a person is suspected of being in possession of an illicit substance.
Police
May be called when a person is found in possession of an illicit substance. May also be required to remove illicit substances from clinical areasin cases where they have had direct involvement.
Managers
Responsible for the safety of patients within their clinical area. May be asked to decide on how to proceed where a person is suspected of possessing an illicit substance.
Individual Staff Members
Responsible for raising concerns regarding suspected possession or use of illicit substances and taking appropriate action.
6.PROCESS
Patients
6.1. If a member of staff has reasonable grounds to suspect that a patient/ visitor has in
their possession or may have consumed or otherwise “used” an illicit drugthen the member of staff should report their concerns to the Ward Manager, who should consult with the patient’s Consultant, the Head of Nursing or the Trust’s Duty Manager.Reasonable suspicion might include the presence of drugs paraphernalia, sudden changes in mood, loss of appetite, drowsiness, hallucinations, incoherent speech, unusual stains, marks or smells, or dilated/ pin point pupils.The reasons for the suspicion and any advice given to the patient should be recorded in the clinical record.
6.2.The Ward Manager should, following discussion with the patient’s Consultant, the Head of Nursing or the Trust’s Duty Manager, agree who is best placed to discuss with the patient the concerns raised, the nominated person should be a senior member of staff.It is advised that any subsequent discussion with the patient should be carried out with at least 2 members of staff present. If it is considered safe to do so, the nominated person should remind the patient/visitor that the use, possession or supply of illicit drugs on Portsmouth Hospitals NHS Premises is strictly prohibited. Care must be taken when discussing the situation to ensure the patient is not accused of possession/use of an illicit drug but should be advised of the danger of using drugs brought in without the knowledge of staff as it may affect their treatment/ health. They should beadvised thatif they do possess an illicit drug they should surrender it to the member of staff who will deal with it in accordance with the appropriate procedure as set out in paragraph 6.11 below.
6.3. If the patient still refuses to hand over any substance or denies use and the nominated person remains suspicious that the patient has in their possession/has used an illicit drug then the Manager needs to consider whether to refer their concerns to the Police and should inform the patient that the Police may have to be called.
6.4Staff should not search a patient/ their property without consent. This is potentially a breach of the right to respect for private and family life as set out in the European Convention on Human Rights and as embodied in the Human Rights Act 1998. Conducting a personal search of a patient/ visitor could also constitute assault.
6.5Although the possession and/or use of illicit drugs on the premises of Portsmouth Hospitals NHS Trust is strictly prohibited, it should be borne in mind that the reporting of the suspected possession of small amounts of illicit substance for personal use may constitute a breach of the duty of confidentiality owed to patients. The decision whether or not to refer those suspicions to the Police needs to be carefully considered. If it is considered either that it is in the best interests of the patient because the use of drugs is affecting their health and welfare , or that it is in the public interest to refer the matter to the Police the reasons for doing so should be recorded in the patient’s medical records.
6.6 If the Manager makes the decision to contact the Police, in the first instance he should contact the Trust’s Resident Police Officer on ext 3601 or via switchboard and if he is not available the Police should be contacted via 101.
6.7ASafety Learning Event form should be completed.
Visitors
6.8.If a member of staff has reasonable grounds to suspect that a visitor is supplying an illicit drug to any person on trust property or using an illicit drug on Trust premises Security should be called in the first instance and the visitor asked to leave and then if necessary Security will call the Police and ask them to attend. The Police can be contacted either via the Trust’s Resident Police Officer who can be contacted on 07584 223619 or ext 3601or if he is not available the Police should be contacted on 101.
6.9A Safety learning Event form should be completed.
6.10If a visitor has been asked to leave the premises for possession or supply of illicit drugs, the Ward Manager should prohibit the visitor from visiting. This must be recorded in the relevant patient’s health record.
Dealing with illicit drugs if they come into the possession of a member of staff
6.11 If a member of staff gains possession of an illicit substance following a situation as described above they should :
- Inform nurse in charge of the ward/department
- Consider contacting security and asking that they attend
- Inform patient that as there is a suspicion that they are illicit substances they will be handed to pharmacy for destruction.
- Obtain consent to this process by completion of the PHPSF 03.010 Substance Surrender Form. (appendix 1). If the patient refuses to sign the form, the member of staff must record this fact on the form. The form should then be filed in the patient’s clinical notes with a copy made which should remain with the substance.
- Package the substance in a suitable container and seal in an envelope marked “suspected illegal/illicit substance”. Secure the item in the Ward Department Controlled Drug cupboard until arrangements for removal are made. (See 6.12.3.)
- Make an entry in the Ward/ Dept CD Record Book on a separate page (either within the designated patient’s own CD Record Book or at the back of the standard Ward/ Dept CD Record Book). Record the patient’s name, the date and time of the confiscation and a description of the substance, amount and two witnessing staff signatures.
- Do not report small amounts of illegal substances to the Police as, on balance, the duty of confidentiality outweighs the misdemeanour of possession.
- Do not under any circumstances return suspected illicit substances to a patient on discharge. A person doing so would be committing an offence of unlawful supply of a under the relevant law.
- The Manager should decide if the police should be informed, as this is a criminal offence that warrants overriding the patient’s confidentiality in the public interest. The manager should in the first instance attempt to contact the Trust’s Resident Police Officer on 07584 223619 in the first instance and if he is unavailable the Police via 101 or 999( with security presence on ward) depending on the urgency of the matter. An incident number should be obtained. The patient should not be informed about the action taken.
•If the police are called in and decide to take action, the officer should be asked to accept responsibility for the illicit substance and any subsequent action. A record should be made in the Ward/Dept. CD Record Book of what is handed to the police.
•Staff may be asked to make witness statements to the police in order to maintain the continuity of evidence.
6.12Removing Suspected Illegal Substances from the Clinical Area
Controlled drugs/illicit substances may only be removed from clinical areas by persons authorised to do so by legislation, such as Police Officers and Pharmacists. Police Officers would only be expected to remove substances in cases where they have had involvement. In all other cases, a PHT Pharmacist must be asked to collect the substances during the next routine opening hours. Other staff are not permitted to transfer illicit substances as they would then be unlawfully in possession.
A pharmacist, under two specific exemptions, can take possession of such CDs. The first exemption is when possession is taken for the purpose of destruction. The second is for the purpose of handing over to a Police Officer.
The Pharmacist (or Police Officer) will sign the substances out of the Ward/Dept CD Record Book.
On arrival in the pharmacy an entry will be made in the Receipt, Removal and Disposal of Controlled Drug Register and the substances will be stored securely in the CD cupboard for subsequent witnessed destruction.
The pharmacist should then inform the Accountable Officer or their nominated deputy of the presence of this substance. The Accountable Officer will then contact the appropriate authority for removal and/or witnessed destruction.
7.TRAINING REQUIREMENTS
All Ward and Clinical Department Managers will need to be aware of the contents of this policy and ensure that their staff are aware of and understand the procedures, roles and responsibilities given. Support and advice will be available from the Pharmacy Department to anyone requiring assistance.
8.REFERENCES AND ASSOCIATED DOCUMENTATION
- Misuse of Drugs Act, 1971
- Psychoactive Substance Act 2016
- Human Rights Act 1998
- PHT Controlled Drug Policy
9.EQUALITY IMPACT STATEMENT
Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services to the public and the way we treat our staff reflects their individual needs and does not discriminate against individuals or groups on any grounds.
This policy has been assessed accordingly.
Our valuesare the core of what Portsmouth Hospitals NHS Trust is and what we cherish. They are beliefs that manifest in the behaviours our employees display in the workplace.
Our Values were developed after listening to our staff. They bring the Trust closer to its vision to be the best hospital, providing the best care by the best people and ensure that our patients are at the centre of all we do.
We are committed to promoting a culture founded on these values which form the ‘heart’ of our Trust:
Respect and dignity
Quality of care
Working together
Efficiency
This policy should be read and implemented with the Trust Values in mind at all times.
10.MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS
Minimum requirement to be monitored / Lead / Tool / Frequency of Report of Compliance / Reporting arrangements / Lead(s) for acting on Recommendations100% of drugs incidents are dealt with in accordance with the policy / Head of Legal Services / Audit of Safety learning Event incidents relating to use/ possession of illicit drugs / Annually / Policy audit report to:
- Security and Fire Steering Group Meeting
This document will be monitored to ensure it is effective and to assurance compliance.
EQUALITY IMPACT SCREENING TOOL
To be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval for service and policy changes/amendments.
Stage 1 - ScreeningTitle of Procedural Document: Illicit Drugs Policy
Date of Assessment / Responsible Department / Legal Services
Name of person completing assessment / Jacqueline Haines / Job Title / Head of Legal Services
Does the policy/function affect one group less or more favourably than another on the basis of :
Yes/No / Comments
- Age
- Disability
- Ethnic Origin (including gypsies and travellers)
- Gender reassignment
- Pregnancy or Maternity
- Race
- Sex
- Religion and Belief
- Sexual Orientation
If the answer to all of the above questions is NO, the EIA is complete. If YES, a full impact assessment is required: go on to stage 2, page 2
More Information can be found be following the link below
Stage 2 – Full Impact Assessment
What is the impact / Level of Impact / Mitigating Actions
(what needs to be done to minimise / remove the impact) / Responsible Officer
Monitoring of Actions
The monitoring of actions to mitigate any impact will be undertaken at the appropriate level
Specialty Procedural Document: Specialty Governance Committee
Clinical Service Centre Procedural Document:Clinical Service Centre Governance Committee
Corporate Procedural Document:Relevant Corporate Committee
All actions will be further monitored as part of reporting schedule to the Equality and Diversity Committee
APPENDIX 1: Substance Surrender Form
Illicit Drugs Policy
Version: 1
Issue Date: 24 July 2017
Review Date: 23 July 2019 (unless requirements change)Page 1 of 13