Case 24 Can you please take these handcuffs off?

Mike Turner is a 61-year-old man who is currently detained in prison at Her Majesty’s pleasure. He has been a lifelong smoker (with a 50-pack-year history) and has a strong family history of premature cardiac disease. Over the last few weeks he has noticed exertional chest discomfort which he has put down to indigestion. Today, he develops heavy central chest pain while at rest in his cell and he seeks help from the prison medical officer who decides that he should be assessed in hospital and admission is arranged. Two prison warders accompany Mr Turner, shackled to him by handcuffs and chains.

What issues will the admitting doctor likely wish to consider?

On arrival in hospital Mr Turner is seen in the Acute Medical Unit by Dr Jenkins who asks the prison officers if she may take a history and examine Mr Turner without them present but they refuse. This seems unsatisfactory to Dr Jenkins and she persists in asking the officers to leave on the grounds of patient privacy and dignity and an argument ensues but the restraints are not removed. Dr Jenkins feels browbeaten and is upset by having failed to convince the prison officers. She wants, amongst other things, to ask Mr Turner about his use of recreational drugs including cocaine but does not feel he would be likely to give a truthful answer in the presence of prison officers. Recording an ECG is made cumbersome by the restraints and she finds inserting a venous cannula difficult and settles for an antecubital site rather than the forearm which would normally have been her preference. On account of nerves, she takes several attempts to insert the line.

Mr Turner’s history is consistent with an acute coronary syndrome and his ECG shows inferolateral ST changes. A troponin taken 8 hours after the onset of pain is elevated and coronary angiography is scheduled for the next day. Treatment with aspirin, clopidogrel, low molecular weight heparin, a statin and a beta blocker are all commenced and agreed by the on-take consultant physician. Angiography subsequently demonstrates diffuse coronary disease and a decision is made to manage Mr Turner with medication rather than with coronary artery stenting or surgery in the first instance.

Six weeks after he has been discharged back to prison, the hospital receives a letter of complaint written by Mr Turner and copied to the Care Quality Commission. He appears to have been aware of the tension between Dr Jenkins and the prison officers and the main text of his complaint is that he was not offered the level of privacy and dignity which he would have received if he had been any other member of the public. He also complains that the site at which intravenous cannula which was inserted in his left antecubital fossa became inflamed and he required 7 days of antibiotics and dressings. He says Dr Jenkins appeared flustered and cross when inserting the cannula and as a result failed to take suitable antiseptic precautions or use a requisite level of skill.

Expert opinion

The investigations and management plan undertaken by Dr Jenkins seem to have been entirely appropriate. She does however concede that the argument between her and the prison officers was difficult and she was very upset by it. Mr Turner was clearly aware of the differences of opinion voiced by both parties.

Prisoners have a right to expect a level of care commensurate with that afforded to all other patients in the NHS and that this includes a right to privacy, dignity and confidentiality. However, clearly at times there may be additional concerns about maintenance of security and the safety of healthcare professionals and these have to be taken into account. Dr Jenkins should have taken advice from a more senior colleague rather than get drawn into an open argument in front of the patient. A calmer discussion may have revealed a genuine reason for anxiety on the part of the prison officers that Dr Jenkins might not have been safe in the room on her own with Mr Turner. It is a concern however that Dr Jenkins is unable to participate meaningfully in any risk assessment given that she has been given no information as to why Mr Turner is in prison (nor is she entitled to any).

The presence of handcuffs made it impossible for Dr Jenkins to insert the cannula in a vein in the hand or wrist. It is important to be alert to the effects that being under pressure or being upset may have on the performance of routine tasks. It took Dr Jenkins several attempts to insert the line and she admits she couldn’t wait to get out of the room.

Legal comment

A prisoner or person in policy custody has the same right to confidentiality and to give or withhold consent as any other patient. Healthcare professionals should insist on making a full and proper clinical assessment. Some concessions for a prisoner/patient in custody may be proper, such as accelerating the patient to the department being mindful of the balance of risk and benefit to the safety of staff and others in the Emergency Department. It is important that healthcare professionals’ integrity is not compromised. The fact that someone is a detained prisoner does not affect his right to be treated nor his right to consent or refuse to treatment nor his right to confidentiality.

It is proper to communicate details to his prison warders only if the patient consents. Dr Jenkins should have insisted on full access to the patient in order to permit her to make as full an assessment as any other patient. If a patient requires admission or any other treatment it must be offered irrespective of other considerations. If this is obstructed, it must be witnessed, documented and, if necessary, reported.

In this circumstance, taking a proper history in the presence of the prison warders was an infringement of the prisoner’s human rights and impacted upon his dignity. If Dr Jenkins was finding it difficult to make a full assessment she should have recorded that the patient had not been properly assessed. It is important for Dr Jenkins to have discharged her duty of care to the patient. It would have been appropriate to insist that the prison warders organize themselves so that proper conditions for the consultation existed even in the Emergency Department. It is essential to insist politely that a proper assessment must be made if the patient will allow it. If the patient refuses, this must be documented and senior help obtained from a Consultant.

NHS organizations have a duty to promote equality and social inclusion.

The duty to respect the individual’s privacy to the greatest extent possible is not only a professional obligation but also a requirement of the Human Rights Act 1998. Any infringement of that right must be legitimate and proportionate. The Trust as a public authority has a duty to comply with the Human Rights Act 1998 that guarantees individuals under Article 8 the right to a private life.

The need to preserve the patient’s privacy and dignity during examination or treatment must be balanced against the risk of danger to the healthcare professional. Consideration also should be had for the safety of Dr Jenkins in terms of chaperone or necessary security precautions depending on the security status of the prisoner. Some detainees have a history of violence or may become violent. In some cases the prison warder may advise the doctor to exercise caution in which case the normal practice would be to examine the prisoner with protection. Ideally the prison warder should be out of immediate earshot, although this depends on the circumstances.

In this case, the failure to obtain a proper medical history and to properly examine has resulted in pain and suffering for seven days. The prisoner therefore has a case in civil law for compensation for the Trust’s breach of its duty of care to him.

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