Food and fluid refusal in prison settings -

In our article Food and Fluid Refusal in Prison Settings we explored some of the challenges posed by patients refusing food and/or fluid in a prison setting.

Exploring the individual’s motivation and mental capacity may or may not provide a legal route to provide treatment in the absence of the patient’s consent.  

Although there is a presumption of capacity in the law, it is particularly important to establish whether or not the patient has capacity to make a decision to refuse food or fluid. If they have an inability to make a decision that is due to an impairment or disturbance in the functioning of their mind or brain, then there is a requirement to act in the patient’s best interests. This may include provision of artificial nutrition and hydration which would require transfer to outside hospital. There should also be consideration of whether the Mental Health Act applies.

Sometimes, these considerations are missed due to misconceptions about the reasons for food and fluid refusal, or confusion about whether or not it is a healthcare issue.

As lawyers called upon to support prison healthcare providers in some of these tricky cases, we have been impressed by the approach taken by Spectrum Community Healthcare CIC, and its development of the Food Refusal Toolkit. I spoke to Donna Phillips, former head of safeguarding at Spectrum, to find out more.

How was the toolkit developed?

The toolkit came into being following our success at winning a bid for NHS England funding in October 2021 to complete a safeguarding project within the prison estates.

The initial aim was to complete a quality improvement exercise, to seek out ways to improve patient safety and staff awareness of managing complex cases of food refusal in prisons, in particular when the patient may not have the capacity to make these decisions. 

Interviews were completed with staff across two secure sites in the North East and from the interviews a number of themes emerged. Staff felt that there was a lack in confidence managing some cases and that further support was needed for them when working with patients refusing food. The idea of the toolkit emerged from these interviews and was formulated based on staff feedback in terms of what they wanted, as well as clinical and legal guidance.

How would you describe the toolkit?

The toolkit is a pocket-sized set of joined flashcards containing information and guidance for staff on a number of topics relating to working with patients on food refusal. Each section is colour coded for ease of use. Sections include:

• A general definition and description of food refusal, including the risk to patients; key aspects of adult safeguarding and ‘Making Safeguarding Personal.’
• Guidance on completing a full assessment, including consideration of communication needs.
• Issues relating to mental capacity, for example, the possible impact of mental health issues, and guidance on making Best Interests Decisions. 
• Physical observations.
• Roles, responsibilities and escalation, including dealing with challenge.
• Process flow charts and further resources.

All our staff in secure estates have a copy of the toolkit; partners have also been provided with some copies (prison service and mental health teams, for example). We have also developed an interactive PDF version which has been shared widely with internal and external partners. 

What impact has the toolkit had?

When the toolkit was launched, we completed a baseline audit. This was a deep dive case file audit to establish a benchmark in terms of staff knowledge and confidence prior to the toolkits being embedded. Over the following 12 months, the safeguarding team have seen an increase in over 100% in the numbers of safeguarding incidents relating to adults in secure settings being on food refusal (categorised as self-neglect). This showed that staff awareness of the issue as a safeguarding concern had increased. In addition to this, we have seen an almost 100% increase in the number of safeguarding MDTs we as a safeguarding team have been asked to attend. We believe that this is due to staff having clear and succinct guidance which is easily accessible to them in the form of the toolkit.

The safeguarding team plan to complete another audit in Q3 which will hopefully provide some additional quantifiable data to support our belief that there has been an increase in staff confidence, knowledge, and skills in working with patients who refuse food, including with staff knowledge and understanding of mental capacity, completing assessments and making Best Interests decisions. 

We have collated a wide range of feedback over a period of time, which has given us valuable insight into the impact of the toolkit. 

Can you give examples of any feedback you have had?

“The toolkit has transformed the way we manage situations, and one of the unintended consequences is the way staff think about all complex treatment interventions.” A head of healthcare in a North East prison.

“In a high secure prison working with complex individuals on food refusal, I have found the toolkit very helpful, it has built my confidence in managing these cases.” Mental health team member, Cat A prison. 

“This is particularly helpful for those challenging situations, and it could be helpful to us in another environment, such as a hospice.” Social worker, hospice care

“It’s a good, straightforward step by step guide, that is transferable into other settings.” Designated nurse safeguarding adults, Humber and North Yorkshire ICB.

“It is a well put-together toolkit, it considers everything. There is a lot of emphasis on a person’s right of choice, which I always feel in prison is important to respect, even with the best interest meetings, there is a consideration to the wishes of the person involved. Communication barriers are also explored, and also to understand the needs and concerns the person may have.” Ex-prison service user, We Are Survivors, Manchester. 

The lawyer’s view

As lawyers, I would say that we have seen the impact in:

• fewer last-minute requests for advice in these cases; 
• well informed staff who are empowered to manage the situation; and
• less need for our input!

How can people find out more?

The toolkit is available as PDF interactive version via Spectrum’s social media and website.

Joanna Crichton | Legal Director | Hill Dickinson                 
                        
Donna Phillips | Former Head of Safeguarding at Spectrum Community Healthcare CIC | Designated Nurse, Safeguarding Adults and Children | NHS Humber and North Yorkshire ICB