Covert medication guidance for inpatient service

1 Introduction

Covert medication is where medicines are administered in a disguised format without the knowledge or consent of the person receiving them, for example in food or in a drink.

Covert administration is only likely to be necessary or appropriate where:

a person actively refuses their medicine
that person is assessed not to have the capacity to understand the consequences of their refusal. Such capacity is determined by the Mental Capacity Act 2005
the medicine is deemed essential to the person’s health and wellbeing

Covert administration must be the least restrictive option after trying all other options.

2 Link to overarching policy

This document links to the overarching safe and secure handling of medicines manual.

3 Aim

This standard is intended to set the standards for the administration of medication covertly for inpatients.

4 Responsibilities, accountabilities and duties

In line the responsibilities laid out in the overarching safe and secure handling of medicines manual.

Additionally clinical staff working on the ward:

report any non-compliance with the contents of this standard

5 Legal framework and national guidance

The prescribing and administration of covert medications are subject to a legal framework and relevant professional guidance and standards. The relevant legislation on covert medications administration in England and Wales are the:

Mental Capacity Act 2005
Mental Health Act 1983

The Mental Health Act (MHA) gives authority to provide treatment of both the causes and the manifestations of mental disorder to a patient detained under its powers without their consent. Treatment powers under the MHA are limited to treating a patient’s mental health. Where the patient has capacity to make decisions about their treatment, it is never appropriate to give medicines
covertly to treat any patient’s physical health where they are refusing. Where a patient lacks capacity or refuses then a second opinion appointed doctor (SOAD) view should be sought.

For patients not detained under the MHA covert medication can be given to those who lack capacity to consent under the Mental Capacity Act 2005 (MCA) under certain circumstances. The administration of covert medication is only likely to be necessary or appropriate where:

a person actively refuses their medicine
that person is judged not to have the capacity to understand the consequences of their refusal
the medicine is deemed essential to the person’s health and wellbeing

The covert administration of medication is the practice of hiding medication in food or beverages so that it will be undetected by the person receiving the medication. Pills may be crushed or medication in liquid form may be used, if it is safe to do so.

This practice exclusively applies to patients who lack capacity to consent to the treatment. It is intended to ensure that patients refusing treatment as a result of their illness will have access to effective medical treatment this is to ensure the patient’s treatment is delivered in the least restrictive manner (for example, orally, rather than through restraint and intramuscular injection).

Medication administered covertly should only be given in exceptional circumstance as a last resort; after all reasonable efforts have been made to give the medication in the normal manner.

In the case of AG v BMBC and Anor, district Judge Bellamy stated:

‘If a person lacks capacity and is unable to understand the risks to their health if they do not take their prescribed medication and the person is refusing to take the medication then it should only be administered covertly in exceptional circumstances.’

6 Evidencing legal authority to treat a person who lacks capacity

Once a decision has been made to covertly administer medicine, nursing staff should ensure that an assessment of capacity to consent to the medication is undertaken and recorded on MCA1 on the patient’s electronic record.

If it is determined that the person lacks capacity to consent then nursing staff should arrange a best interests meeting should be held, with all interested parties. It is essential that family and cares are consulted in relation to their views as to what is in the persons best interests and where there is no family to consult an independent mental capacity advocate (IMCA) is appointed.

The outcome of the meeting and the decision made should be recorded on the MCA2. If there is any objection by interested parties to the decision to give medication covertly then the trust should consider taking the matter to the court of protection as a matter of urgency. Staff should contact the MCA Lead for further advice.

If is determined that it is in the patient’s best interests to be given the medication covertly, then consideration needs to be given as to whether it is safe to do so. Medication administered in this way can alter their therapeutic properties and effects, and they could become unsuitable or ineffective. Staff should take advice from a healthcare professional to make sure medicines are
safe and effective before it is considered whether it can be given to the patient and a covert medication care plan completed (see safe and secure handling of medicines manual).

7 Covert medication care plan

The covert medication care plan should include the type of medication review by the prescriber, advice to staff on how the medication can be given safely, and a plan to regularly review the need for continued covert administration of medicines, see below the factors to consider:

actions taken to give medicines in the normal manner
how medicines will be administered covertly
if we alter the form, for example, crushing and so on, then it becomes an off label (for example, unlicensed) use of the drug, which must be a an explicit decision by the consultant
specialist input to show suitability of the method chosen, for example crushed or mixed with certain food or drinks
whether the medicine is unpalatable
adverse effects (actual or perceived)
swallowing difficulties
lack of understanding about what the medicine is for
lack of understanding of the consequences of refusing to take a medicine
ethical, religious or personal beliefs about treatment
what to do if the person refuses food or drinks
agreed method added to the notes on the medication chart on SystmOne

As part of the planning staff should also:

consider guidance from pharmacy regarding the appropriateness of appropriate dose formats or vehicles in which to put them for that specific patient
that the movement to covert meds should involve only those drugs that are deemed to be essential rather than the entire regime
that the manner in which the drug may be given needs to be explicitly stated on the drug card (this can be done in the notes section for the drug entry)

Medicines administered under covert conditions must be administered in line with extant trust guidance in the safe and secure handling of medicines manual with particular attention to ensure that the covert dose is not left unattended or taken by someone other than the intended patient. Medicines administration records should clearly record which medicines are administered covertly and when. This is particularly important for people with fluctuating capacity.

At time of discharge medications should be assessed by the prescriber and pharmacist as GP can switch the drugs from tablet to liquid and dose must be altered. It can be for any reason to avoid unable use of medication or availability of the drug.

8 Exceptional circumstances

If the situation is urgent, it is acceptable for a less formal discussion to occur between staff, the prescriber and family or advocate and an urgent decision made. However, a formal best interests meeting should be arranged as soon as possible afterwards.

9 Lasting powers of attorney

Lasting Powers of Attorney (LPAs) can be drawn up/appointed by the patient, while he or she has mental capacity to appoint someone, to act on their behalf if they are no longer able to make decisions. If the person has a registered LPA for health and welfare then the attorney can consent to the person having the medication but if the person is refusing, a best interest’s meeting will still need to be held.

An objection to covert medication by the LPA for health and welfare must be followed. However, if it becomes apparent that the LPA is not acting in the patient’s best interests, the concern should be referred to the office of public guardian to investigate and if necessary referred to by the court of protection.

10 Objection from other parties

In An NHS Trust v XB and Ors (2020) EWCOP 71 (opens in new window), Theis J has further emphasised the thin legal ice for professionals seeking to administer medication covertly, especially where someone is objecting.

If there is any objection to the best interests decision to administer the medication covertly, then staff should seek advice from the MCA Lead about whether or not an application needs to be made to the court of protection for approval of the covert medication care plan.

Staff should not delay in seeking advice when necessary.

11 Covert medication and deprivation of liberty safeguards

Judge Bellamy, in the AB case, confirmed that covert medication should involve consideration of the least restrictive option of the person’s rights and freedom of action. He advised that where a person is subject to a DOLs authorisation a review of the authorisation should be triggered by covert medication or any change in their administration regime.

12 Flowchart

Flowchart process for administration of covert administration of medicines

Health practitioners should ensure that the following process for covert administration of medicines is followed in line with the Safe and Secure Handling of Medicines Manual and the Mental Capacity Act 2005 policy:

patient refusing medication or medicine which is deemed essential to their health and wellbeing
establish the reasons why the patient is refusing particular medication. Consult the prescriber for advice on the various alternative preparations that can be tried
if a patient is refusing medications for a mental disorder, and the person is not detained under the MHA the relevant Mental Health team needs to be consulted
- person lacks capacity to refuse medication and person detained under MHA, medication cannot be given
- person has capacity to refuse medication and detained under the MHA, medication cannot be given
- if the person is not subject to the MHA undertake an assessment of their mental capacity regarding their ability to make decisions about their medication, record on MCA1
- person lacks capacity to refuse medication and the medication cannot be given under the MHA
arrange a MCA best interest meeting of all the relevant the health professionals, the healthcare professional responsible for prescribing the medicine(s), the involved pharmacist, and any interested parties such as family, friends or any appointed attorneys or advocate. The aim of the BI meeting is to agree whether administering medicines without the patient knowing (covertly) is in the patient’s nest interest, record on MCA2
decision made that it is in the person`s best interests to be given medication covertly under the MCA and there is no objection from any interested party:
- covert medication care plan completed
- review data set
- undertake regular reviews
or:
- where there is an objection to the medication being given covertly by any interested party the trust should consider taking matter to the court of protection

or:

Decision made it is in not in the person`s best interest to be given medication covertly, medication should not be given

attorney or deputy for health and welfare objects to the decision to give covert medication, medication cannot be given without an order from the court of protection

Document control

Version: 2.
Unique reference number: 622.
Ratified by: Clinical policy review and approval group.
Date ratified: 3 October 2023.
Name of originator or author: Senior pharmacist.
Name of responsible individual: Executive medical director and medicines management committee.
Date issued: 27 October 2023.
Review date: 31 October 2026.
Target audience: Trust wide inpatient areas.

Page last reviewed: May 07, 2024
Next review due: May 07, 2025

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