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Short Notes on Secure Environments 2018 - Dr Mark Burgin

26/05/18. Dr. Mark Burgin BM BCh (oxon) MRCGP considers the elements that should be included in a primer for clinical negligence cases involving secure environments.

Secure environments have implications for doctors to not discriminate when giving care and recognise that consent may not voluntary. (1)

Confidentiality rules apply within secure environments and can only be breached if required by law, or they consent or in the public interest due to risk of harm from disease or crime. (2)

There are no guidelines for practitioners who work in secure environments which addresses how to manage these ethical issues in practice. (3)

Police custody in contrast with prison has access to forensic physicians who since 2014 have been sitting the Faculty of Forensic and Legal Medicine’s diploma in legal medicine (DLM) examination.


In most prisons requests for medical attention are made by completing details on a piece of paper ‘chit’ and triaged by the wing staff.

Once the request is accepted the patient can be told that they can only raise one issue limiting the amount of information that they feel comfortable to give to the doctor.

Where the prison has problems with recruiting doctors this can lead to urgent medical conditions missed because they are not seen in the acute phase.

Referrals out of the prison are discouraged as they are expensive to arrange and are there potential security concerns with those detainees at special risk of escape.

Delays can occur due to missed appointments if for instance there are no trained staff to accompany the patient or if the patients move prisons.

Assessing detainees

Most prisons have drug policies that encourage the doctor not to use any drugs of abuse, mainly those acting on the mu and GABA receptors when treating pain or anxiety.

These restrictions mean that there is a risk that detainees will have less treatment for their pain than a non detained person would expect.

Detainees age much faster than the average in the population so a 55-year-old is likely to have a range of illness equivalent to a person 10 to 15 years older.

The reasons for this phenomena are not fully understood but failing to consider a diagnosis in a patient because they are too young is more difficult to support.

It is generally more difficult to assess a detainee due to the expectation from both sides that the doctor will breach confidentiality.

Breaches of confidentiality

The patient’s agenda inside a secure environment may be different to one ‘on the out’ and the doctor can feel under pressure to discuss personal details with the staff.

A nurse or other staff member may be present during the consultation both to act as an independent witness if the detainee makes a complaint and to control the consultation.

The staff will normally comply if asked to leave by the doctor but medical staff can feel reluctant to challenge the status quo particularly if it comes as a part of a security measure.

Audit trailed records can answer questions such as whether staff have accessed the detainee’s medical records but are not routinely provided under requests. (4)


The problems in secure environments can occur in other areas such as mental health wards and detention centres and even work situations such as off shore oil rigs and the armed forces.

Having limited access to a single source of health care, conflicts of interest, possible breach of confidentiality and high health needs multiply the problems of these groups.

A primer in clinical negligence cases involving secure environments should address the balance between the operational requirements and the ethical obligations of the practitioners. (5)

Doctor Mark Burgin, BM BCh (oxon) MRCGP is on the General Practitioner Specialist Register.

Dr. Burgin can be contacted This email address is being protected from spambots. You need JavaScript enabled to view it. and 0845 331 3304 website

  1. GMC Consent: patients and doctors making decisions together

  2. GMC Confidentiality (2009)

  3. Gill 2014 Working with Vulnerable Groups: A clinical handbook for GPs

  4. The Data Protection Act 1998.

  5. Abbasi 2015 Torture and doctors’ dual obligation BMJ 2015;350:h589

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