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Anaesthesia and critical care for patients in the criminal justice system

2017; Elsevier BV; Volume: 17; Issue: 8 Linguagem: Inglês

10.1093/bjaed/mkx010

2058-5357

Tim Orr, Sughrat Siddiqui, Marilyn Whittle,

Ethics and Legal Issues in Pediatric Healthcare

There are around 90 000 adults in prisons and thousands more detained in police custody in the UK. They are disproportionately from populations with low socio-economic status1Singleton N Meltzer H Gatward R Psychiatric Morbidity Among Prisoners: Summary Report. Office for National Statistics, London1997Google Scholar and suffer from a high burden of chronic disease.2Mental Health of Adults in Contact with the Criminal Justice System; Draft for Consultation. National Institute for Clinical Excellence, London2016Google Scholar It has been estimated that up to 90% of the prison population suffer from a mental illness with substantially higher rates of deliberate self-harm and suicidal ideation than the general population.2Mental Health of Adults in Contact with the Criminal Justice System; Draft for Consultation. National Institute for Clinical Excellence, London2016Google Scholar The General Medical Council's (GMC) Good Medical Practice imposes professional obligations on doctors, stating ‘you must treat patients fairly and with respect whatever their life choices and beliefs’ and ‘you must not unfairly discriminate against patients by allowing your personal views to affect your professional relationships or treatment you provide’.3Good Medical Practice 2013. General Medical Council, London2013Google Scholar The Equality Act 2010 imposes legal obligations on public bodies to consider the rights of all individuals and eliminate discrimination.4Equality Act.Available from http://www.legislation.gov.uk/ukpga/2010/15/contentsDate: 2010Google Scholar The prison population is very likely to interact with acute medical services and will therefore be regularly encountered in anaesthetic practice. The management of this population can prove challenging for clinicians, police, and prison services. This article will outline some of the issues associated with the perioperative and critical care management of these patients. The provisions for health care in prisons and custody suites are variable but should be at least equivalent to the level of primary care available in the community. All prisons and police stations have access to health care professionals, but they may have variable experience of health care provision in custodial settings. They can deal with the majority of routine medical problems and refer for specialist treatment when necessary. Many prisons have on-site inpatient facilities and can provide some services equivalent to those available in hospital. The Police and Criminal Evidence Act 1984 details the responsibilities of custody officers for obtaining urgent assessment of a prisoner by a health care professional.5Police and Criminal Evidence Act 1984.Available from http://www.legislation.gov.uk/ukpga/1984/60/contentsGoogle Scholar If an immediate medical assessment is unavailable and there are concerns for the prisoner's well-being, they should be sent directly to hospital by ambulance. In a prison, the prison medical officer determines whether the health care needs of the individual can be met internally or whether transfer to hospital is required. Treatment is provided within the police station or prison if this is achievable without compromising the standard of care. The police and prison services have been criticized for deaths resulting from delays in transferring patients to hospital caused by delayed assessment by a medical officer and problems providing adequate escorts or vehicles for transfer and so may have a low threshold for calling an emergency ambulance. Prison and police services are encouraged to establish good working relationships with their local health trusts. They should assess the layout of the relevant departments and identify any risks in collaboration with the trust's security staff. If transferring a prisoner to a hospital out of their area they should contact the local prison to obtain information about the key security issues.6National Offender Management Service External Escorts—NSF External Prisoner Movement 7.1.Available from https://www.justice.gov.uk/downloads/offenders/psipso/psi-2015/psi-33-2015-external-prisoner-movement.pdfDate: December 2015Google Scholar There should be collaborative protocols to clarify key roles and responsibilities, streamline communication, and ameliorate risks to patients, staff, the public, and the trust. When admission is necessary and time allows, the medical officer should refer the patient to hospital and handover to the receiving clinician. Transfer and treatment in hospital is regarded as a high-risk period with security vulnerabilities and a heightened potential for escape. Communication between the police or prison service and hospital management, security staff, and the receiving ward or department will ensure the patient is transferred directly, safely, and accommodated in the most appropriate location with minimal disruption. Listing the patient at the beginning of an operating session or clinic can potentially minimize their hospital stay. All prisoners should have an assessment to identify the risks they pose and the procedures that should be followed for transfers. This is fluid and should take into account the impact of their current medical condition on their risk. In an emergency where there is not yet a risk assessment it must be completed within 24 hr of transfer and approved by the prison governor (Table 1).6National Offender Management Service External Escorts—NSF External Prisoner Movement 7.1.Available from https://www.justice.gov.uk/downloads/offenders/psipso/psi-2015/psi-33-2015-external-prisoner-movement.pdfDate: December 2015Google ScholarTable 1Categories of prisoner riskMale (England, Wales, and Northern Ireland) (+ female in Northern Ireland)Female (England and Wales only)Category AEscape would be highly dangerous to the public, the police, or the security of the State. The aim must be to make escape impossible.Category AEscape would be highly dangerous to the public or the police or the security of the State. The aim must be to make escape impossible.Category BThe very highest conditions of security are not necessary but escape must be made very difficult.RestrictedEscape would present a serious risk to the public and are required to be held in designated secure accommodationCategory CCannot be trusted in open conditions but do not have the resources and/or will to make a determined escape attempt.ClosedThe very highest conditions of security are not necessary but too high a risk for open conditionsCategory DCan reasonably be trusted in open conditions.OpenCan reasonably be trusted in open conditions.U (Northern Ireland only)Remand, awaiting trial or awaiting sentence except those classified as category AE listPrisoners who have attempted escape and have extra precautions such as regular cell movements, distinctive bright clothing, and the removal of some of their possessionsScotland High supervisionA prisoner for whom all activities and movements require authorization. Always supervised and monitored by an officer. Medium supervisionA prisoner for whom activities and movements are subject to limited supervision and restrictions. Low supervisionA prisoner for whom activities and movements are subject to minimum supervision and restrictions and who may be given the opportunity to participate in supervised or unsupervised activities in the community. Open table in a new tab Prisoners identified as posing a significant risk of escape or violence will require safeguards. Obligations on clinical staff to provide quality care can conflict with obligations on escort staff to maintain public safety and prisoner security. The patient's privacy and dignity must be balanced with the risks they pose. Hospital staff should never become involved in the security or custody of a prisoner. If a prisoner attempts to escape, the accompanying escort staff are responsible for taking control of the situation and securing them.6National Offender Management Service External Escorts—NSF External Prisoner Movement 7.1.Available from https://www.justice.gov.uk/downloads/offenders/psipso/psi-2015/psi-33-2015-external-prisoner-movement.pdfDate: December 2015Google Scholar Consideration should be given to the most appropriate location in which to manage the patient. An ensuite single room with secure windows will minimize disruption to other patients and staff and may reduce the need for the immediate presence of escort staff if they are able to observe from outside. There should be an emergency alarm, no unsecured objects that could be used as weapons and an unobstructed escape route for staff. Such an environment promotes privacy and patient cooperation and may reduce anxiety, agitation, and escalation with a consequent reduction in the need for physical or pharmacological restraint. Prisoners are accompanied by two or more escort staff depending on their perceived risk. This poses challenges in cramped environments such as anaesthetic rooms, radiology suites, and operating theatres. Trusts should develop protocols in collaboration with their local prison and police services to facilitate the pragmatic escort and supervision of prisoners in these environments. Prisoners under regional or general anaesthesia are usually not accompanied into theatre except in exceptional circumstances. Escorts must remain by the theatre exits and maintain an awareness of the prisoner's location and condition.6National Offender Management Service External Escorts—NSF External Prisoner Movement 7.1.Available from https://www.justice.gov.uk/downloads/offenders/psipso/psi-2015/psi-33-2015-external-prisoner-movement.pdfDate: December 2015Google Scholar Prisoners are routinely physically secured for transfer. Physical restraint is guided by the European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment7European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment. The CPT Standards. Council of Europe, Strasbourg2002Google Scholar and is ultimately governed by the Human Rights Act 1998 and Article 3 of the European Convention of Human Rights (Fig. 1). Where the absence of escort staff is neither practicable nor safe, consideration should be given to the use of privacy screens and escort chains.6National Offender Management Service External Escorts—NSF External Prisoner Movement 7.1.Available from https://www.justice.gov.uk/downloads/offenders/psipso/psi-2015/psi-33-2015-external-prisoner-movement.pdfDate: December 2015Google Scholar Accompanying police officers or security staff will decide on the degree of restraint appropriate. However, prisoners should never be attached to furniture, fixtures, or fittings, and restraints should be removed on a sedated or anaesthetized patient and reapplied when deemed clinically safe on emergence.8The Medical Role in Restraint and Control: Custodial Settings. British Medical Association, London2009Google Scholar Where physical restraint or escorts are compromising clinical care, clinicians should discuss their concerns with security staff. In non-emergency situations, following discussion with the prison governor or police, restraints will usually be removed although this may require the presence of additional escort staff to maintain security. If the security risk is too great or the Justice Secretary has mandated continuous physical restraint as a condition of transfer to hospital, removal may not be permitted. If disagreement persists, the trust can refuse to treat the patient except in an emergency.8The Medical Role in Restraint and Control: Custodial Settings. British Medical Association, London2009Google Scholar In an emergency or for procedures such as defibrillation, escort staff will always remove restraints when requested.6National Offender Management Service External Escorts—NSF External Prisoner Movement 7.1.Available from https://www.justice.gov.uk/downloads/offenders/psipso/psi-2015/psi-33-2015-external-prisoner-movement.pdfDate: December 2015Google Scholar Pharmacological restraint (or rapid tranquilization) uses medication to control disturbed behaviour which is not normally prescribed for the treatment of a defined physical or mental illness. It is appropriate for aggressive and violent patients who are a serious threat to themselves, others, or their surroundings when less restrictive de-escalation techniques have failed. A typical regimen for parenteral rapid tranquilization is intramuscular lorazepam or haloperidol combined with intramuscular promethazine. Lorazepam is preferred in a patient who is antipsychotic naive, has cardiovascular disease, or has not had prolonged QT interval excluded.9Violence and Aggression: Short-Term Management in Mental Health, Health and Community Settings. Clinical Guideline NG10. National Institute for Health and Care Excellence, London2015Google Scholar Physical restraint will be necessary until the medication takes effect and patient observation will be required. Rapid tranquilization may reduce the need to manage extreme behaviour on critical care in the absence of other indications for admission. The Association of Anaesthetists of Great Britain and Ireland recommends that anaesthetic trainees should only be involved in pharmacological restraint in exceptional circumstances and only as the result of a multidisciplinary decision following clear guidelines with the support of a consultant anaesthetist. All patients with capacity have the right to refuse treatment even if this is judged contrary to their best interests.10Mental Capacity Act 2005 Code of Practice. Department for Constitutional Affairs, The Stationary Office, London2007Google Scholar An imprisoned patient lacking capacity is entitled to the same safeguards of the Mental Capacity Act 2005 (MCA 2005) (Adults with Incapacity Act in Scotland) as others. The Deprivation of Liberty Safeguards (DOLS) amendment to the MCA 2005 applies to patients whose liberty is deprived to facilitate medical treatment in hospital in their best interests.11Keene A Dobson C Deprivation of liberty in the hospital setting Mental Capacity Law Guidance Note. Thirty Nine Essex Street.Available from http://www.39essex.com/docs/articles/deprivation_of_liberty_in_the_hospital_settingv3.pdfGoogle Scholar This may apply to patients who are imprisoned and already subject to lawful deprivation of liberty. This has not yet been tested in case law. DOLS legislation is complex, has been criticized, and is likely to be reviewed in the near future. In the interim, consideration should be given to seeking expert advice on whether a DOLS assessment should be sought based on the circumstances of the case. DOLS does not apply in Scotland or Northern Ireland. Under the provisions of the MCA 2005, paid staff are not suitable to advocate for the patient and so in the absence of appropriate family members or friends an independent mental capacity advocate should be appointed. If it is suspected a patient is being manipulative, for example with repeated hospital admissions and non-cooperation with treatment, a multidisciplinary meeting should determine an appropriate management plan. The police may request blood or other samples be obtained to assist in their investigations. The quality of evidence must be maintained and demonstrated with an audit trail that will stand up to legal scrutiny. Providing samples without appropriate forensic training could lead to the compromise of a conviction and the police should instruct a forensic clinician for this purpose. If the patient requires urgent treatment that may influence toxicology results (such as a blood transfusion), this should not be delayed while awaiting a forensically trained professional.12Boyle A Aw-Yong M Providing Pre-transfusion Samples for the Police. Clinical Effectiveness Committee. The College of Emergency Medicine, London2011Google Scholar The GMC confidentiality guidance forbids the disclosure of personal patient information to a third party such as a police officer without consent unless required by law or justifiable in the public interest. Such exemptions include the detection, prevention, or prosecution of a serious crime or where failure to disclose would expose others to a risk of serious harm or death. The potential harm to the patient's interests and the repute of the profession must be balanced against the risks from withholding information. Consent should still be sought even if it is not required and the patient should be informed unless that would undermine the purpose.13Confidentiality. General Medical Council, London2009Google Scholar In Scotland, there can be limited disclosure of information before a criminal trial without the patient's consent. The disclosure must be confined solely to the nature of injuries and their likely causes.13Confidentiality. General Medical Council, London2009Google Scholar Discharge information should be shared with the escorting officers if the patient consents. Otherwise, it should be provided in a sealed envelope for the attention of the medical team responsible for their ongoing care. Where the justification for disclosure of information without consent is unclear, expert advice should be sought from the trust's Caldicott Guardian, legal department, or a medical indemnity provider. Efforts must be taken to maintain the patient's privacy and confidentiality. Requests for information about the attendance of a prisoner, dates and times of appointments, or medical details should be redirected to the prison or police station or with their agreement, information may be divulged once the inquirer's identity is confirmed by password. Access to bedside communication and entertainment devices may need to be restricted. Visiting and gifts are usually based on the prison's or police station's regime and supervised by escort staff. Unscheduled visitors are usually not permitted.6National Offender Management Service External Escorts—NSF External Prisoner Movement 7.1.Available from https://www.justice.gov.uk/downloads/offenders/psipso/psi-2015/psi-33-2015-external-prisoner-movement.pdfDate: December 2015Google Scholar Admission should be as brief as possible and discharge should be well planned, taking into consideration the facilities available at the discharge destination. Administration of medication in prisons and police stations is supervised, but there remains the potential for misuse. The provision of liquids or syrups is preferable to reduce the ability to secrete or share medication. Discharge medication is normally given to the escorting staff rather than the patient. Details of follow-up are withheld from some prisoners. Where feasible, the provision of follow-up at the prison or police station may be convenient. If a prisoner dies in state custody, Article 2 of the European Convention on Human Rights places a responsibility on the state to conduct a thorough, prompt, and transparent investigation. Deaths in police custody in England and Wales are investigated by the Independent Police Complaints Commission14Deaths in Custody. London, Crown Prosecution Service.Available from http://www.cps.gov.uk/legal/d_to_g/deaths_in_custody/Google Scholar and in Northern Ireland by the Police Ombudsman. Deaths in prison are investigated by the police in England and Wales14Deaths in Custody. London, Crown Prosecution Service.Available from http://www.cps.gov.uk/legal/d_to_g/deaths_in_custody/Google Scholar and the Prisoner Ombudsman for Northern Ireland.15Deaths in Custody. Belfast, The Prisoner Ombudsman for Northern Ireland.Available from http://www.niprisonerombudsman.gov.uk/index.php/death-in-custody/Google Scholar All deaths must be reported to the coroner who will also conduct an investigation, although this is usually delayed until after the other investigation is concluded. Investigations into deaths in custody in Scotland are undertaken as a fatal accident enquiry directed by the Lord Advocate/Procurator Fiscal.16Our Role in Investigating Deaths. Edinburgh Crown Office and Procurator Fiscal Service.Available from http://www.copfs.gov.uk/investigating-deaths/our-role-in-investigating-deathsGoogle Scholar The Police Investigations and Review Commissioner may also investigate deaths involving the police. The police have a legal responsibility to secure the scene and any physical evidence. Where a death in custody involves a hospital, this could lead to the closure of a resuscitation suite, operating theatre, or critical care unit with consequences for the provision of services and ongoing safety and welfare of other patients. Where this would prejudice the care of other patients, senior officers will often agree to move the deceased patient. All equipment should be left in situ including tracheal tubes, indwelling cannulae, and electrocardiogram stickers. Last offices should not be performed until after the arrival of the investigating officers. Staff may need to provide statements. Drugs may be concealed on or within the person. The Misuse of Drugs Act 1971 makes unlawful the production, possession, and supply of drugs subject to control except under permitted conditions. Section 8 of the Act also makes it unlawful to allow the supply or attempt to supply a controlled drug and to allow the smoking of cannabis or heroin on premises which you occupy or manage.17Misuse of Drugs Act.Available from http://www.legislation.gov.uk/ukpga/1971/38/contentsDate: 1971Google Scholar This exposes trusts to prosecution if they knowingly allow the dealing or abuse of illicit drugs on the premises. Patient property cannot be searched or confiscated without consent. A patient suspected to be in possession of illegal drugs should be asked to surrender them. If they decline, senior staff should consider whether to report this to the police in the wider public interest. This usually applies if the quantity is inconsistent with personal use and indicates an intention to supply. Possession of small quantities of illegal drugs are not routinely reported to the police as the breach of confidentiality is not in the wider public interest. If disclosing information, the patient should be informed and the disclosure justified. If the patient lacks capacity, for example if they are sedated on intensive care, staff cannot search their property. However, controlled or illicit drugs already identified should be secured for the safety of others. If the drugs are stored on or in the person, they can be removed with consent from a patient with capacity or in the best interests of a patient who lacks capacity. Trusts should have local policies on the handling of illicit drugs retrieved from patients. Locally, the drug is sealed in an envelope, labelled with an objective description of the nature of its contents, signed and dated by two members of staff, entered in the controlled drugs register, and stored in the controlled drugs cupboard. It should be destroyed by the pharmacy at the earliest opportunity or surrendered to the police if relevant to a crime they are investigating. The drug should never be returned to the patient or their representative, as this could lead to conviction for unlawful supply of a controlled drug.17Misuse of Drugs Act.Available from http://www.legislation.gov.uk/ukpga/1971/38/contentsDate: 1971Google Scholar Perinatal care in prisons is generally equivalent to that available in the community. Female prisoners are frequently transferred to hospital for antenatal clinics and scans. The pregnancy risk and patient's preferences are considered when planning the location of delivery. Pregnant women are not routinely restrained in transit or hospital except in exceptional circumstances.8The Medical Role in Restraint and Control: Custodial Settings. British Medical Association, London2009Google Scholar,18PSO4800 Women Prisoners. Issued 28 April 2008.Available from https://www.justice.gov.uk/downloads/offenders/psipso/pso/PSO_4800_women_prisoners.docGoogle Scholar They are provided with at least two escorts, at least one of whom will be female. Escorts are not usually present in the delivery room or during intimate examinations but will remain at the exits. Birthing partners are permitted unless deemed a safety risk.6National Offender Management Service External Escorts—NSF External Prisoner Movement 7.1.Available from https://www.justice.gov.uk/downloads/offenders/psipso/psi-2015/psi-33-2015-external-prisoner-movement.pdfDate: December 2015Google Scholar Patients under mental health legislation who pose a significant risk to the public are detained in secure forensic psychiatric hospitals. Managing these patients presents similar issues to those from the prison population. Some patients are subject to additional restrictions imposed by the Justice Secretary who must grant permission for any transfer of the prisoner and may stipulate conditions such as continuous physical restraint. In a medical emergency, this is delegated to the hospital's responsible medical officer. The Mental Health Act 1983 does not authorize compulsory treatment of physical illness unrelated to their mental illness.19Mental Health Act 1983 (Amended 2007).Available from http://www.legislation.gov.uk/ukpga/1983/20/contentsGoogle Scholar This requires patient consent or treatment under the Mental Capacity Act10Mental Capacity Act 2005 Code of Practice. Department for Constitutional Affairs, The Stationary Office, London2007Google Scholar and consideration of DOLS legislation (Adults with Incapacity Act in Scotland in Scotland). The medical treatment of patients in the criminal justice system raises a number of complex issues, requiring collaboration between staff from a number of organizations. It is governed by multiple laws and policies that are occasionally conflicting and differ between the devolved nations. Anaesthetists need an awareness of the evolving legal and policy framework, the implications for their practice, and should have a low threshold for seeking expert advice.