Drug misuse on trust premises policy

1 Introduction

The trust has a legal requirement to provide a safe working environment for their employees under the Health and Safety at Work Act (1974). Section 8 of the Misuse of Drugs Act (1971) also places an obligation on any manager of premises to discourage and take action to prevent drug related activities occurring.

Unknown substances may be illicit in nature and in accordance with its duties under the Misuse of Drugs Act (1971), the trust does not knowingly permit the use of or dealing in illicit substances on its premises.

If colleagues have suspicions or become aware of someone (patients, visitors, colleagues or none trust employees working on trust property) on the premises having an unknown substance on them, they must follow the guidance in this policy.

2 Purpose

The purpose of this document is to provide guidance on the action to take when there is suspicion or evidence of an unknown or illicit substance being possessed used or found on trust premises.

3 Scope

These guidelines are applicable to all trust employees.

For further information about responsibilities, accountabilities and duties of all colleagues, please see appendix A.

4 Procedure

4.1 Quick guide

4.1.1 Suspected use of or possession of an illicit substance

With another colleague discuss with the patient the reason for suspecting possession or use of illicit substance and ask the patient to hand it over where appropriate.
Inform the patients consultant, request a urine sample and consider a search of the patient.
Escalate to the patients consultant if required.
Complete an incident form.

4.1.2 Unknown or illicit substance is found on trust premises

Seek advice from pharmacy and manager.
Store the substance as detailed in section 4.6.1.
Dispose of the substance.
Complete an incident form.

4.1.3 Storage of unknown or illicit substances

Placed in an envelope. The envelope must be sealed, and both the nurse or clinician or ward manager in-charge and the witnessing colleague will sign and date across the sealed flap of the envelope.
Enter the found substance into the back of the relevant controlled drugs register under the heading of unidentified or unknown substance.
This envelope must then be locked in the wards controlled drugs cupboard.
The chief pharmacist, accountable officer for controlled drugs should be notified of the unknown or illicit substance as soon as it is practicable and arrangements will be made for the removal and safe disposal of the substance by the trust pharmacy department.

4.1.4 Disposal of unknown or illicit substances

If the police collect the substance for disposal direct from the location it was found, the colleague should take note of the incident number and record this in the incident report.
If the police collect the substance for disposal from the ward or pharmacy department then the nurse or clinician or ward manager in charge of the ward or the pharmacist is to obtain a signature for the substance which is to be recorded in the back of the controlled drugs book, to correspond with the earlier entry relating to the quantity held in the controlled drugs cupboard. The officer should also detail their name and badge number.
The original incident report should be updated by the responsible manager to reflect the time, date, method and person responsible for the disposal of the substance.

4.2 Action if an unknown or illicit substance is found on trust premises

If any colleague discovers an unknown or illicit substance within trust premises they should:

consider, with support from pharmacy and a manager where appropriate, the type of substance they are dealing with.
seek advice from the trust and pharmacy department how the substance should be processed safely

If the substance is deemed safe for removal or short term storage and the police have not indicated that they will immediately collect the substance the following process should be followed:

within normal working hours (Monday to Friday, 9am to 5pm) colleagues should contact the trust pharmacy department who will advise and arrange for disposal
out of hours any unknown or illicit substances should be taken to the nearest ward for action as stated within the guidelines below (colleagues must not transport substances from one site to another for storage)
for colleagues working in the community the unknown or illicit substance should be returned to a base and locked away securely in a locked draw for example and the pharmacy should be contacted at the earliest opportunity (within hours)

An incident report must be completed by the colleague who found the unknown or illicit substance.

4.2.1 Storing the substance

The substance may be stored in the controlled drugs cupboard out of hours for safekeeping until disposal can be arranged. (for more information on how to store the substance, refer to section 4.6.1).

If the police advice that the trust dispose of the substance, disposal should be arranged via the trust pharmacy department at the earliest opportunity.

4.3 Bed based services

On admission the nurse or clinician must clearly explain to the patient that any illicit drug use is unacceptable on trust premises and preventative action will be taken, irrespective of their legal status.

All effort should be made to inform relatives, carers and visitors of the trusts’ policy regarding illicit substance use and the possession of illicit substance on trust premises, including the consequences of such actions.

There must always be good cause for suspicion that a patient is in possession of an illicit drug, for example, smell, reliable information from a fellow patient, visitor or family member, observations from other clinical colleagues and, or a change in the patient’s behaviour or mental state before taking action.

Whilst some illicit substances may be culturally acceptable it must be explained to the patient that the use of such substances whilst on a ward is not.

In line with the service level agreement between the K9 Patrol Ltd and the trust, this service will support the trust in using drug detection dog in deterring the use and supply of illegal and illicit substances. It aims to assist in detection and reducing the amount of illegal and illicit substances and will aid in the promotion and maintenance of a safe and secure environment for patients, colleagues, visitors and the public. This will be achieved by the deployment of dual purpose (passive and proactive) role drug dogs and handlers, accompanied by colleague(s) to assist in the detection of illegal and illicit substances at specific locations.

This service operates on an ad hoc and planned basis. Colleagues would need to contact 01423 551 526 to request this support. The operator will take all necessary details to despatch accordingly.

Nurse or clinician or ward manager should ensure matron has been informed of this service request.

4.3.1 Action to take when an in-patient is suspected to have used or be in possession of an illicit substance

The nurse or clinician or ward manager in charge should implement the following procedure:

immediately discuss with the patient the information that has been received and the suspicions raised.
this discussion must be held in the company of another colleague member and this colleague must witness the actions of the nurse or clinician or ward manager in-charge if the substance is handed over
ask the patient to voluntarily hand over any unknown or illicit substances for destruction and follow the procedure for their disposal
inform the patient’s consultant at the earliest opportunity following any suspected or known drug usage thus enabling the Consultant to determine how this will affect the patient’s treatment
if the patient refuses to hand over the unknown or illicit substance for destruction, they are to be placed on a 1-to-1 nursing observation and the matter discussed with the matron or service manager and the patient’s consultant
a search of the patient and their property may be required, in these circumstances the search must be undertaken following the trust searching of a person or their property policy
a urine specimen should be requested from the patient as soon as possible. It should be established from their consultant if a full drug screen is required
if the patient refuses to provide a urine specimen the nurse or clinician or ward manager in charge must notify their consultant accordingly
any prescribed medication must be withheld until the patient has been reviewed by the appropriate medical team
if an unknown or illicit substance is found or handed to colleague by an in-patient it will be removed from them by two nurses or clinicians, one of whom must be the nurse or clinician or ward manager in charge, who will explain to the patient the procedure for disposal of the substance

4.4 Action if a visitor is found or suspected to be in possession of an unknown or illicit substance

If any visitors are found or suspected to be in possession of an unknown or illicit substance, they should be asked to leave the premises.

If any visitor is seen or suspected to have passed unknown or illicit substances to a patient or other visitor, they should be asked to leave.

The nurse or clinician or ward manager in charge of the ward should consult with the matron and the trust security officer and a decision must be made if the incident is to be reported to the police. A decision will be made whether the visitor will be asked not to visit the site in the future. This is to be followed up with an incident report.

4.5 Action if trust colleagues working in premises which belong to another organisation witness incidents of unknown or illicit substance use

Within the trust there are colleagues who work in premises owned and managed by other organisations. In the event that these colleagues witness any instances of illicit substance use or possession of substances they are to immediately report it to their line manager and the buildings manager (the person responsible for the building from the owning organisation). The responsibility for taking action rests with the organisation which owns and manages the premises, however if action is not taken and trust colleagues feel that their safety is being compromised, they should seek advice from the trust health and safety lead.

If an unknown substance is found by trust colleagues working in premises which belong to other organisations, then they should seek advice from the police regarding its removal in the first instance. Colleagues should be clear about the nature of the site and that substances cannot be stored there safely. Alternatively colleagues should contact the buildings manager to arrange disposal.

4.6 Procedure for storing and disposing of unknown or illicit substances

4.6.1 Inpatient storage

Once a decision has been made to store a substance the following procedure must be undertaken by two qualified nurses or clinicians. The unknown or illicit substance must be:

placed in an envelope
the envelope must be sealed and both the nurse or clinician or ward manager in-charge and the witnessing colleague will sign and date across the sealed flap of the envelope. The envelope must be clearly marked with “Quarantined item: Not for patient use”
the nurse or clinician or ward manager in-charge will enter the found substance into the back of the relevant controlled drugs register under the heading of unidentified or unknown substance. The drug colour and quantity should also be entered
the envelope must be labelled with a reference number linking it to the entry in the controlled drugs register;
this envelope must then be locked in the wards controlled drugs cupboard
in order to maintain patient confidentiality no patient name will be documented in the controlled drugs register
the chief pharmacist, accountable officer for controlled drugs must be notified of the unknown or illicit substance as soon as it is practicable and arrangements will be made for the removal and safe disposal of the substance by the trust pharmacy department

Note, under no circumstances will any unknown or illicit substances be returned to a patient.

If colleagues involved in the removal of the substances suspect that the quantity involved indicates it was meant for more than for personal use, advice should be sought from the matron or service manager regarding the need to involve the police.
All actions taken must be recorded in the patient record, or in the event of a visitor, handed over to the team.
There may be occasions when nursing colleagues have information that indicates that unknown or illicit substances are being hidden within the unit however are unable to establish their whereabouts, in such circumstances the nurse or clinician or ward manager in charge should liaise directly with the police as a search of the ward may be required. If such a search is requested the matron or manager on call with responsibility for that area must be notified.

4.6.2 Disposal

If the police collect the substance for disposal direct from the location it was found, the colleague should take note of the incident number and record this in the incident report.

If the police collect the substance for disposal from the ward or pharmacy department then the nurse or clinician or ward manager in charge of the ward or the pharmacist is to obtain a signature for the substance which is to be recorded in the back of the controlled drugs book, to correspond with the earlier entry relating to the quantity held in the controlled drugs cupboard. The officer should also detail their name and badge number.

The original incident report should be updated by the responsible manager to reflect the time, date, method and person responsible for the disposal of the substance.

4.7 Record keeping

In all cases involving an unknown or illicit substance an incident report must be completed. In addition the modern matron or service manager must be kept up to date in relation to any incidents or concerns regarding actual and, or suspected drug misuse on trust premises.

5 Training implications

There are no specific training needs in relation to this policy. Colleagues will be made aware of the policy during their local induction

6 Equality impact assessment screening

To access the equality impact assessment for this policy, please email rdash.equalityanddiversity@nhs.net to request the document.

6.1 Privacy, dignity and respect

The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review of the NHS, identifies the need to organise care around the individual, “not just clinically but in terms of dignity and respect”.

As a consequence the trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity and respect, (when appropriate this should also include how same sex accommodation is provided).

6.1.1 How this will be met

There are no additional requirements in relation to privacy, dignity and respect.

6.2 Mental Capacity Act (2005)

Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individuals’ capacity to participate in the decision-making process. Consequently, no intervention should be carried out without either the individual’s informed consent, or the powers included in a legal framework, or by order of the court.

Therefore, the trust is required to make sure that all employees working with individuals who use our service are familiar with the provisions within the Mental Capacity Act (2005). For this reason all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act (2005) to ensure that the rights of individual are protected and they are supported to make their own decisions where possible and that any decisions made on their behalf when they lack capacity are made in their best interests and least restrictive of their rights and freedoms.

6.2.1 How this will be met

All individuals involved in the implementation of this policy should do so in accordance with the guiding principles of the Mental Capacity Act (2005).

7 Links to any other associated documents

8 References

9 Appendices

9.1 Appendix A Responsibilities, accountabilities and duties

9.1.1 The board of directors

The board of directors has a duty of care towards patients and colleagues and are responsible for the trust having policies, procedures and guidelines in place to enable colleagues to provide best practice. The trust directors are the accountable directors with responsibility for these policies.

9.1.2 Matron or service manager

Matrons or service managers are responsible for colleagues being aware of and adhering to this policy and monitoring any incidents of drug misuse within their area.

9.1.3 Nurse or clinician or ward manager in charge of the ward or department

The nurse or clinician or ward manager in-charge of the ward will be responsible for implementing this policy if illicit substance misuse is suspected within their area.

9.1.4 All colleagues

If any member of colleague finds an unknown or illicit substance on trust premises, this should be managed in accordance with the process outlined at section 4.2 of this policy. In addition, should colleagues have any suspicion that the sale of illegal or illicit substances is taking place on trust premises they must report this to the trust security advisor.

For inpatient services if any colleague suspects or is informed of drug misuse on the ward, they must inform the nurse or clinician or ward manager in charge immediately.

9.2 Appendix B Monitoring arrangements

9.2.1 Monitoring of incidents

How: IR1 system.
Who by: Matrons or managers.
Reported to: Care group leadership and quality groups or directorate meetings.
Frequency: After any incident.

9.2.2 Adherence to policy

How: Spot checks.
Who by: Managers.
Reported to: Care group leadership and quality groups or directorate meetings.
Frequency: After any incident.

Document control

Version: 8.
Unique reference number: 379.
Approved by: Clinical effectiveness meeting.
Date approved: 1 April 2025.
Name of originator or author: Clinical lead.
Name of responsible individual: Chief nurse.
Date issued: 16 April 2025
Review date: 30 April 2028.
Target audience: All trust employees.

Page last reviewed: April 17, 2025
Next review due: April 17, 2026

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