together we can stamp out fraud counter fraud services brian donohoe & eddie mcginney ao case...

Together we can stamp out fraud

Counter Fraud Services

Brian Donohoe & Eddie McGinney

AO Case Study Workshop Elliot House

5 August 2011


Agenda

Work through two CFS case studies looking at the fiveinvestigation stages:

• Allegation

• Background

• Investigation

• Conclusions

• Recommendations


The Aim and Objective of this Event

• Aim:

To provide an overview of a CFS investigations • Objective:

To provide you with examples of Controlled Drugsinvestigations in order to allow you to discuss AO issues/ concerns and potential actions as a result.


Case Study 1- Allegation

Referral received from police based within a hospital regarding thepotential theft of drugs and money from a controlled drugs cabinet,located within an Out Patient’s Department.

Discrepancies were also identified in the stock levels of drugs (diazepam & dihydrocodiene).

It was believed the thefts had occurred during the hours of the service (week days 18:00 hours to 08:00 hours or week ends18:00 hours Friday to 08:00 hours Monday).

What are the issues?

What should the Clinical Manager do next?


Case Study 1- Background

CFS Investigation staff met with the police and key personnel from the HB to establish the background to the service and if any previous incidents had been reported/ recorded. Details of previous stock discrepancies which had been identified were provided, however, these were notreported as it was not known whether these were theft related, human error or computer error.

The management of the service also notified CFS of the suspected tampering of a lock of a drug cabinet located within

the treatment room.


The service employs up to seven clinicians (doctors, emergency nurse practitioners (ENPs) and sometimesparamedics) per shift. Each clinician is responsible forprescribing and dispensing drugs to patients utilising theservice. Any drugs dispensed are recorded on the internalmedicines management system.

Any initial issues/ concerns?

If so, what should happen next?


All drugs are contained within three locked cabinets in a treatment room within the department. Within one of the cabinets is a locked safe containing CD’s as per Schedule 2 of the Controlled Drugs Regulations.

At the start of each shift, an ENP accesses a secure black box and a set of three keys for the drugs cabinets,and one for the controlled drugs safe, are removed. The setof three keys are left with the receptionist and the key for theCD’s drugs safe is held by the ENP. All keys are returned at the end of the shift.


During the shift, a clinician prescribes/ dispenses drugs to a patient and thedetails are entered on the medicines management system.

To obtain the required drugs, the clinician would remove the drugs cabinet keys from the reception and access the drug cabinets within the treatment room and remove the required drug(s).

When controlled drugs were required, the clinician would action as aboveand also request the CD key from the ENP and access the CD safe.

Once the drugs were removed, a register entry is made, the safe and/orcabinets locked, the keys were returned to the appropriate key holder(s). This practice continues throughout the duration of the shift.

What are the issues/ concerns?

What should happen next?


Prior to commencing the investigation, it was established that on a weekly basis, one ENP (of six nominated)undertook a stock check of all drugs contained within thedrugs cabinets and reconciled all drugs against themedicines management system.

All discrepancies were manually adjusted on the medicinesmanagement system to reflect the physical stock held.

It was noted that discrepancies could occur as a result ofdrugs being removed and not signed for (to replenish stockin mobile bags), or drugs dispensed but not recordedagainst a patient’s record.




Case Study 1- Investigation

At the commencement of the investigation, the management of the service notified CFS of the suspected tampering of a lock of a drug cabinet located within the treatment room containing the CD cabinets.

As a result of this, various meetings took place between key HB personnel and CFS to discuss the volume of missing drugs and the potential for covert surveillance within the hospital site.


CFS considered the potential for surveillance and raised concerns in relation to the risk of collateral intrusion to both patients and staff, should surveillance activity be authorised. CFS highlighted these concerns to the HB and sought their views on the potential of installing covert recording equipment within a hospital treatment room.




The HB advised CFS that approval had been granted, however, specific conditions were attached to this approval:

The wording of the CFS application for covert surveillance must be sufficiently precise to demonstrate compliance with the

Information Commissioner’s Office Employment Practices Code (section 3.4). In addition, consultation with the HB’s Data Protection Officer would be necessary to ensure all evidence gained complies with these requirements.

The HB required an absolute guarantee that covert surveillance would not detect any patients and ensure their complete confidentiality.

The HB must receive confirmation that the information is completely destroyed after being used, and CFS must send the Board a letter stating this is the case.


CFS responded to the HB confirming:

CFS surveillance applications comply with the provisions of the Regulation of Investigatory Powers (Scotland) Act 2000 (RIP(S)Act), ensuring that the authorisation sought is

necessary, proportionate and considers and minimises any potential risk(s) of collateral intrusion.

CFS assured the HB that any covert recording equipment would be positioned to reduce or remove the risk to non-

service personnel.

CFS confirmed that any non-evidential material would be destroyed and this would be communicated to appropriate HB personnel.


CFS agreed the following actions with the HB:

- CFS would install covert equipment (in advance of agreeing who would carry out the daily stock checks).

- Once installed & arrangements in place to carry out daily stock checks, CFS would request the appropriate RIP(S)A authorisation to commence recording. - Once authorisation granted, CFS would activate the recording system. - The service personnel or the HB Controlled Drugs Governance Team would then undertake daily stock checks on six identified drugs (three of which are those where stocks were missing). - All analysis work would be carried out by CFS including daily stock check data, medicines management system data, CCTV footage and staff duty lists. - A meeting would be arranged within six to eight weeks to review any

evidence gathered.


A date was agreed to commence daily stock checks/ activate covert recording equipment.

The service’s management provided CFS with weekly data detailing levels of controlled drugs stock, extracted from the service’s medicines management system. In addition, both the service’s and the Controlled Drugs Governance Team provided daily stock check figures.

This was provided for the duration of the surveillance period authorised.


CFS undertook analysis of the data and met with key HB personnel todiscuss the findings. Analysis provided very minimal levels ofunaccounted stock.

The service’s management explained that this could be as a result of small quantities of drugs being removed and not recorded by the clinician, or drugs being used to re-stock drugs bag for mobile home visits.

It was agreed that neither the service nor the Controlled Drugs Governance Team could continue to provide the resource to continue these checks.

Agreement to cease activity.

It was agreed that the Controlled Drugs Governance Team would carry out further analysis of the services medicine management system to identify any trends of missing drugs and cross match this with the personnel employed across the services’ various bases. The results of the findings would be reported and reviewed to consider what options were available, should a concern be identified.


The HB were advised that the covert surveillance had been cancelledand that no evidence had been obtained during the period of the RIP(S)A authorisation and that the HB Controlled Drugs Governance Team would be carrying out further analysis of the service’s data and would report their findings.

The HB’s Controlled Drugs Governance Team carried out this additional analysis for a two month period.

It was agreed that should any areas of concern be identified from this data, a decision would be taken to decide who was best placed to take forward.




Case Study 1- Conclusions

1. CFS made considerable enquiries into the allegation ofthe theft of drugs from the HB’s secondary care servicebut were unable to find any evidence to support the allegationduring the period of surveillance.

2. Covert surveillance was undertaken at the site containing thecontrolled drugs cabinets used by HB service.

3. From the data provided via the HB medicine managementsystem and by the daily stock checks undertaken by theservice’s and the HB’s Controlled Drugs Governance Team’spersonnel, no high volumes of drugs were identified asmissing.

4. The service’s management provided reasons for the identifiedstock discrepancies.


5. As no instances of theft were identified, all recorded covert surveillance images were deleted from the covert equipment’s data storage.

6. The review of the service’s data analysis, undertaken by the HB’s Controlled Drugs Governance Team, was

completed and discussed by the appropriate HB personnel.

7. The outcome of these discussions resulted in no further actions requiring CFS action(s).


Case Study 1- Recommendations

Recommendation No 1 – CFS recommends that the HB service’s management continue to notify the local police regarding one-off thefts as per protocol. Consideration should be given to notifying CFS of all drug related thefts to allow monitoring of emerging trends across the wider HB area. The procedure for progressing potential drug related thefts should be included within the policy document currently being discussed by the HB’s and identified partners, local police force and CFS.

Management Response:- Agreed.


Recommendation No 2 - In relation to the alleged theft of monies from the controlled drugs cabinet. CFS suggest that service personnel’s attention is drawn to guidance previously issued, which advises that no monies should be held within drug cabinets.

Management Response:- Agreed and has been incorporated in a Standard Operating Procedure which has been written foruse in this area.


Recommendation No 3 – CFS suggest that in the event of locks being tampered with normal protocol is followed and these are replaced as soon as practicable.

Management Response:- Agreed


Recommendation No 4 – CFS suggests the keys to the drugscabinets and controlled drugs cabinet should be retained by theENP or other appointed person for the duration of the shift. Alldrugs would then be dispensed against the prescription and annotated accordingly. This would ensure minimum stock discrepancies between the drug stocks in the cabinets to that noted on the medicines management system.

Management Response:- ENPs work as independent practitioners seeing, assessing, treating and discharging patients. While it is now standard procedure for an ENP or another identified clinician to hold the keys, it is not possible for that person to interrupt consultations to dispense drugs. The ideal solution would be to have a dedicated dispenser at each of the five service sites. This would require a minimum of an additional 448 staff hoursper week; resource implications preclude this.


Recommendation No 5 - CFS suggest the service's management re-issue the medicine management system user guidance notes to all service clinicians, highlighting the requirement to record all drugs prescribed and dispensed accurately. All drugs removed from the cabinets should be accounted for.

Management Response:- Agreed in principle. The medicines management system is a software system that is regularly upgraded. Staff are made aware of changes to the system and regularly reminded of the need to record all drugs administered or supplied.


Recommendation No 6 - All mobile drugs bags should bere-stocked by a nominated service clinician for each shift and checked by the clinician removing the mobile drugs bag before each mobile visit. On return to the Base, the clinician should record and sign for the drugs dispensed, to allow appropriate re-stocking to take place. The services’ management should also take this opportunity to reinforce advice issued previously that clinicians should never, under any circumstances, use stocks of the services’ drugs to replenish personal drug bag stocks.

Management Response:- Agreed in principle. All Schedule 2 drugs are signed for when used and replenished. Supply and replacement of other drugs is recorded electronically.


Recommendation No 7 – CFS suggest ad-hoc spot checks becarried out on an identified number of controlled drugs during the services’shifts. These checks may be carried out by the services’ management, nominated clinician or the Controlled Drugs Governance Team. This would provide added assurance to both the HB and the services’ management in relation to the controls and dispensing of drugs.

Management Response:- Additional measures have been put in place since the Investigation was conducted. Daily monitoring of Schedule 2 drug checks is now more thorough and more closely supervised. Weekly stock checks are now done by a small team of pharmacy staff and no longer done by the team of 34 ENPs. Additional regular monitoring is done on any stock changes made to the electronic medicines management system. These measures have made a significant difference to errors and discrepancies which may in the past have been recorded as losses.


COUNTER FRAUD SERVICES

Earlston House

Almondvale Business Park

Almondvale Way

Livingston

EH54 6GA

We can be contacted on the following numbers:-

DIRECT LINE: 01506 705200FRAUD HOTLINE: 08000 15 16 28

WEBSITE: www.cfs.scot.nhs.uk

together we can stamp out fraud counter fraud services brian donohoe & eddie mcginney ao case...

Documents

drugs cabinets

result of drugs

required drugs

dispensing drugs

fraud cfs

controlled drugs safe

drugs cabinet keys

controlled drugs cabinet