Prison A – care provided by PPG
Stopping medications
30. Mr R complains that his medications were inappropriately stopped on admission to Prison A, without an appropriate detox regime. He says his medications has been prescribed in the community after careful consideration of his medical history and what had and had not worked in the past. He says this history was not considered by the GP at Prison A.
31. Mr R arrived with medications such as dihydrocodeine and pregabalin. These are described as controlled medications, in line with the Home Office guidance ‘List of most commonly encountered drugs currently controlled under the misuse of drugs legislation’. This means the prescribing and use of dihydrocodeine and pregabalin should be more closely monitored, as they are both medications which can be addictive and prone to misuse.
32. The RCGP guidance ‘Safer Prescribing in Prisons’ explains the risks of misuse of these medications are amplified in prison, where they can also be a useful commodity. For both pregabalin and dihydrocodeine, the guidance says:
‘In the prison setting, pregabalin and gabapentin are highly sought after because of their use in enhancing the effects of opioids and their own inherent abuse potential.’
‘Dihydrocodeine, codeine and tramadol are misused both for their euphoric potential and their sedative effect and are very popular with heroin users, as they also alleviate opiate withdrawal.’
33. The GP upon Mr R’s arrival to Prison A also noted discrepancies in the number of tablets left, where it appeared more had been taken than prescribed. In addition, Mr R tested positive for cocaine on a urine sample, for which he did not have an explanation.
34. Therefore, the risks outlined in the RCGP guidance were further increased with Mr R’s history of substance and alcohol misuse, and also his complex mental health history.
35. In considering all of the above, we consider it was appropriate the GP did not prescribe the medications immediately, whilst they awaited further information from Mr R’s previous records.
Alternative medications and detox
36. Mr R says he was left without any appropriate medication for nine days, and was then prescribed amitriptyline and fluoxetine, which were not appropriate for his needs. He says everyone experiences withdrawal differently, and his was very difficult.
37. As explained above it was appropriate not to prescribe medications before more information was available, although a sleeping tablet was prescribed in place of the promethazine.
38. Mr R’s previous probation accommodation contacted the healthcare staff at Prison A on 8 February 2022, to request a mental health assessment, as Mr R had appeared paranoid to his transfer. The information from the probation service included that alcohol and testosterone may have been factors in Mr R’s presentation. This would add to the concerns about prescribing, as there was implied substance and alcohol misuse.
39. The GP reviewed Mr R two days later, and sadly the GP summary was still not available. We can see the GP recognised Mr R was experiencing withdrawal symptoms, and codeine was prescribed to help with a possible opioid withdrawal. Our GP adviser explained prescribing codeine instead of dihydrocodeine was in keeping the RCGP guidance ‘Safer Prescribing in Prisons’. This says:
‘Codeine alone and in combination with paracetamol are the preferred weak opioids for use in secure settings… Dihydrocodeine is still widely abused. It is generally an inappropriate analgesic where individuals have a history of substance misuse, even if an individual has entered recovery.’
40. Further information became available on 10 February 2022. This referenced an earlier mental health review in October 2020 where restarting dihydrocodeine, pregabalin or gabapentin were discussed. This review also noted that dihydrocodeine was to be discontinued due to failed medication compliance and attempt to conceal and divert, which Mr R says was later proven to be incorrect.
41. We have also considered if the GP should have taken further action to help with possible pregabalin withdrawal symptoms, in line with the RCGP guidance. This says:
‘In order to minimise withdrawal symptoms on stopping gabapentinoid drugs, gradual tapering (by a maximum daily dose of 50–100mg/week of pregabalin or a maximum of 300mg every four days of gabapentin) is recommended in the Drug misuse and dependence: UK guidelines for clinical management (2017)’
42. However, our GP adviser explains it was still unclear if the Mr R was withdrawing from pregabalin, as his exact previous use remained unknown.
43. Overall, we consider the time taken to prescribe alternative medication was appropriate, when taking into account the above information.
44. Codeine was prescribed as an alternative to dihydrocodeine within two days of Mr R’s arrival. The paranoia symptoms mentioned by the probation service were not repeated after Mr R’s arrival. His main symptoms were ongoing pain, anxiety and withdrawal symptoms. On 25 February 2022, the GP prescribed two new medications, amitriptyline and fluoxetine. Amitriptyline can help with neuropathic pain and was a replacement for pregabalin. Mr R had previously tried this but at a low dose. As noted earlier, fluoxetine is an anti-depressant.
45. We do not doubt Mr R’s account of his withdrawal and how difficult this was for him. With Mr R’s complex psychiatric history, substance misuse and lack of coherent history, we consider it was appropriate for the GPs to observe and then initiate treatment. We consider this was in line with the principles of the RCGP guidance, which says doctors should prescribe appropriately for the environment in which they work, to reduce risks to the wider prison population. We therefore do not see evidence of failings in relation to this aspect.
Prison B – care provided by the Trust
Medication review
46. Mr R says his medications were not appropriately reviewed on admission to Prison B and consideration was not given to his concerns about the prescribing at his previous prison. He says the GPs at Prison B could have taken action to re-prescribe medications which had been prescribed in the community, which had been stopped at the previous prison.
47. The GP met with Mr R on 29 June 2022 and clarified the reasons why the medications had been stopped by the previous prison. The GP explained the changes were in line with the RCGP guidance ‘Safer Prescribing in Prisons’, and that a prescription of more opioids or pregabalin were not appropriate due to ‘addiction/tolerance/sedation.’
48. The GP also made a request to the mental health team for a joint consultation. This was in line with the NICE guidance ‘Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain’. This says to consider psychological therapy for chronic primary pain.
49. We therefore consider Mr R’s symptoms and history were appropriately considered during his admission to Prison B. We have not seen evidence to suggest Mr R’s previously stopped medications should have been reinstated.
Prescribing alternative medications
50. Mr R says there were significant delays in prescribing an appropriate medication. He says it took until September 2022 for him to be prescribed venlafaxine, and until November 2022 for him to be prescribed promethazine. He was later told that promethazine was inappropriate to manage his sleep, as this should have been addressed through pain management.
Venlafaxine
51. Our GP adviser says it was appropriate to await a joint medical review, as requested by the GP before prescribing medication such as venlafaxine, considering Mr R’s complex medical history.
52. The nurse prescriber was also initially reluctant to prescribe venlafaxine as the health records noted a possible previous reaction when he had taken this with amitriptyline in the past. It was therefore appropriate to await further assessment when this was noted in late June.
53. On 16 August, the GP records note the doctor ‘then asked if he [Mr R] would like to discuss venlafaxine with [the doctor] and he declined.’ The GP noted they would allow some time for discussions to sink in and then review venlafaxine again. This medication was then started on 22 August 2022.
54. Overall, we have not seen failings in the consideration of venlafaxine and consider the healthcare team took appropriate steps to ensure this medication was suitable for
Mr R. We consider the actions were in line with the GMC guidance ‘Good practice in prescribing and managing medicines and devices.’ This says doctors should only prescribe medications when they have sufficient and reliable information, to enable them to prescribe safely.
Promethazine 55. We have sought advice from our psychiatry adviser to consider the decision to prescribe promethazine. This medication was prescribed to help manage Mr R’s sleep.
56. Promethazine is a drowsy (sedative) antihistamine medication that has several uses. The BNF notes this can be used for ‘sedation’ for short term use, at a dose of 25-50mg.
57. Our psychiatry advised told us promethazine is frequently used in psychiatry for short-term management of insomnia as an alternative to use of benzodiazepines (a type of sedative medication), particularly in in-patient settings. This is because promethazine does not have the same risks of potential dependence or abuse, which is a concern with benzodiazepines.
58. The records on 4 November 2022 show Mr R was able to express his views on which medications he wished to be prescribed and the reasons for this. The notes show Mr R explained that the last time his mental health was manageable was when he was prescribed promethazine at night. He explained his major problem at this time was his sleep, as this was very disturbed.
59. Overall, we consider it was appropriate for Mr R to be offered a trial of promethazine to manage his sleep disturbance. We consider this was in line with the GMC guidance, ‘Good medical practice’, which says doctors should only prescribe medications when they have adequate knowledge of the patient’s health and are satisfied that the medication serves the patient’s needs.
Pain management
60. Mr R says he did not receive appropriate pain management in relation to his muscle and nerve damage. He says the Trust did not act on recommendations from specialists, for either pain medication or injections to provide longer term relief.
61. A MDT took place on 19 October 2022 with the GP, mental health practitioner and substance misuse team lead. The MDT discussed Mr R pain and considered any further treatment or referrals needed for this. The MDT agreed to refer Mr R for to neurology for further consideration of his neuropathic pain.
62. Mr R had a further appointment with the GP on 28 October 2022. He again requested pregabalin or gabapentin and noted these had been recommended by the pain clinic in October 2021 (this was in the community, prior to Mr R’s time at both prisons).
63. The RCGP guidance ‘Safer Prescribing in Prisons says: ‘The standard of healthcare provided in prisons should be equivalent to the standard that is delivered in the community. This equivalence is fundamental, but equivalence does not imply “sameness”.’ This guidance also sets out specific warnings for pregabalin and gabapentin.
64. In line with this, although Mr R has been prescribed these medications in the community, these medications would need to be carefully considered for their risks in being prescribing in prison. In line with our view earlier in this report, we do not consider it was a failing that these medications were not prescribed.
65. Mr R was seen by the trauma and orthopaedic team at a different Trust on 2 December 2022. This noted a number of options for treatment of Mr R’s pain, and Mr R is noted to have agreed to a steroid and local anaesthetic injection into the ankle joint. The specialist review made no recommendations for ongoing pain medication.
66. Mr R made a further request for pregabalin on 23 January 2023. The GP offered alternative medications, such as co-codamol, which he declined. Mr R’s request for pregabalin was referred to a further MDT and declined on 27 January 2023. Again, we consider this decision was in line with the RCGP guidance.
67. Mr R made staff aware he was ‘self-medicating’ with pregabalin and Subutex (a strong opioid medicine used to treat moderate to severe pain) on 7 March 2023.
68. Mr R again requested pregabalin at a further GP review on 17 March 2023. The GP declined to prescribe pregabalin and offered further pain medication alternatives.
Mr R declined these as he was either unable to take them or had tried them in the past.
69. A further review of Mr R’s records back to 2010 was completed on 1 August 2023. The GP felt Mr R had a drug dependence. This was further discussed with Mr R on 22 August 2023 and the decision to not prescribe pain medications remained in place. A hospital referral was also made for Mr R to be reviewed by the pain management team.
70. We recognise Mr R’s ongoing pain caused him considerable distress during his time at Prison B. We can see the Trust took appropriate action to try and manage this, in line with Mr R’s needs and the risks involved in prescribing in the prison setting, and Mr R’s concerns were regularly discussed at MDT meetings. We do not consider it was a failing to decline to prescribe pregabalin, in line with the RCGP guidance.
71. We can also see the Trust referred Mr R to relevant specialists to investigate and help manage his pain. This includes trauma and orthopaedics, neurology, and the pain management team. He also had adjustments to his footwear made to try and help his pain. We consider these actions were in line with the GMC guidance ‘Good medical practice’ as this says doctors must recognise and work within the limits of their competence and should refer patients to another practitioner when it serves the patient’s needs.
Mental health
72. Mr R says the lack of pain management exacerbated his mental health concerns. He says his psychiatrist made recommendations to say his pain needed to be managed before he could receive mental health care, but this was not actioned by health staff. He was therefore left without appropriate mental health support.
73. Mr R’s mental health concerns were discussed in an appointment with a GP on 29 June 2022. The GP advised Mr R would be referred for a joint mental health and GP review, to discuss and agree on re-starting any mental health medication, due to the complexity of Mr R’s needs.
74. The Trust scheduled the joint review for 16 August 2022, and it explained the delay for this was due to waiting times for a routine GP appointment. We consider it was appropriate for any decisions to wait for this review, in line with the GMC guidance ‘Good medical practice’. This says doctors must recognise and work within the limits of their competence and should refer patients to another practitioner when it serves the patient’s needs.
75. The review itself took place with a prison GP and a mental health practitioner. The mental health practitioner met with Mr R after this, to discuss the review recommendation to restart venlafaxine, to treat Mr R’s post-traumatic stress disorder (PTSD). Mr R agreed to start Venlafaxine 75mg once daily.
76. The mental health practitioner reviewed Mr R again 31 August 2022, 5 September 2022 and 14 September 2022. Mr R reported experiencing insomnia in these reviews.
77. Our psychiatry adviser notes the evidence of multi-professional involvement in Mr R’s mental health care. A multi-professionals meeting held on 19 October 2022, to discuss Mr R’s mental health difficulties.
78. On 4 November 2022, the Trust offered Mr R an initial psychiatric assessment. In the psychiatrist’s review, Mr R’s dose of venlafaxine was increased from 75 to 150mg, and a four-day trial of promethazine (25 to 50mg at night) was recommended. The psychiatrist also offered to review Mr R again in four to five weeks to assess his mental health and any progress with this.
79. Mr R had a further review with a psychiatrist on 18 November 2022. He reported that the trial of promethazine had helped with his nightmares and with his quality of sleep. The psychiatrist recommended that, subject to approval from the prison wing staff, Mr R be prescribed promethazine 25mg at night for seven nights.
80. The psychiatrist reviewed Mr R again on 23 November 2022, to check if the promethazine had continued to be effective.
81. On 21 March 2023, a further psychiatrist reviewed Mr R. At this time, Mr R reported that promethazine was no longer helping his sleep. The psychiatrist therefore recommended this be stopped.
82. The psychiatrist noted the main issue with Mr R sleep was caused by his chronic pain. The psychiatrist recommended that Mr R be discharged from the psychiatry service, and that his pain management should be discussed further with a prison GP. We consider this action was in line with the GMC guidance ‘Good medical practice’ around referring patients to another practitioner when it serves the patient’s needs.
83. We consider the psychiatrist’s action in prescribing, monitoring and reviewing Mr R were in line with the GMC guidance ‘Good practice in prescribing and managing medicines and devices.’ This says doctors must make sure that suitable arrangements are in place for monitoring, follow-up and review. They should also take account of the patients’ needs and any risks arising from the medicines, particularly when the patient is prescribed a controlled or other medicine that is commonly abused or misused.
84. Overall, we consider Mr R received appropriate support and review from the mental health service at the Trust.
Conclusion
85. We recognise this will have been a difficult time for Mr R, and do not doubt his account of his pain and mental health concerns. Whilst we have not seen failings in Mr R’s care, we hope our report provides some reassurance and clarity around the care and decisions made by PPG and the Trust.