Setting

This audit can be applied to in-patients or out-patients. It is relevant to all specialties of psychiatry, but especially psychiatry of old age and intellectual disability, where patients are more likely to lack capacity.

Background

Covert medication involves the administration of any pharmacological agent in a disguised form (usually hidden in food or drink). This leads to the patient ingesting an agent without having given explicit consent. The administration of covert medication is an ethically sensitive but pervasive practice in many healthcare settings. It has been a widely held misconception among healthcare professionals that the law allows for this practice, provided that it is in the patient's best interests. This confusion, with lack of clarity and guidance, has led to practices that could be deemed as indefensible in a court setting.

Standards

Standards were obtained from various sources including: the Royal College of Psychiatrists’ statement on the covert administration of medicines (2004); the Mental Welfare Commission for Scotland's document Covert Administration: Legal and Practical Guidance (2006); the Mental Capacity Act 2005 (Department of Constitutional Affairs, 2007); and the Nursing and Midwifery Council's Position Statement on Covert Administration of Medicines (2001).

The following were the agreed audit standards:

ᐅ There should be a covert medications policy.

ᐅ The treatment must be necessary and in the best interest of the patient.

ᐅ For patients who are given medications covertly, there should be a written care plan that has been subject to consultation with the multidisciplinary team.

ᐅ The care plan and decision for covert use should be reviewed weekly initially, unless there is good justification for not doing this.

ᐅ There should be a written record of assessment of capacity, and reasons for presumed incapacity should be clearly documented.

ᐅ Covert administration should be seen as the least restrictive option.

The target was that all of the above standards were met.

Method

Data collection

ᐅ A list of all adults with intellectual disability with mental health needs should be kept by the local community intellectual disability team, and be obtainable electronically. If numbers are large, a random selection of carers can be used. For in-patient units, carers of all in-patients can be contacted.