Standards › Standard 62 › Policies
Policy · PNT-POL-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 62.2
At a glance
- Care in custody is equivalent in quality to care in the community (UN Nelson Mandela Rules, Rule 24).
- Clinical decisions are made by health professionals, on clinical grounds only.
- Consultations are private unless a security presence is needed for a recorded safety reason.
- Health records are kept apart from custodial files and are accessed only by health staff.
- Stop and get help straight away if: custodial staff override a clinical decision, or health records are open to custodial staff.
1. Purpose
To make sure people in custody receive the same quality of care as the community, and that their health information is protected (62.2 and 62.3).
2. Scope
| Applies to | Clinical and support staff in the hospital |
| Locations | All wards, clinics and departments of the facility |
| When | Whenever the activity described is carried out |
| Does not apply to | Activities covered by another document listed in section 15 |
3. Definitions
| Term | Meaning |
|---|---|
| Clinical lead | The doctor or nurse in charge of the area at the time |
4. Background
The Nelson Mandela Rules (2015, Rule 24) require that prisoners receive the same standard of health care as is available in the community, without discrimination. WHO Prisons and Health (2014) sets out the same principle of equivalence, and that clinical decisions are made by health professionals on clinical grounds.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Clinical lead in custody | Makes sure care meets community standards and decisions stay clinical | Health authority |
| Custody governor | Makes sure security does not override clinical decisions | Justice authority |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Records and forms named in this document | Current version | Checked before use |
7. Safety
- Stop and call for help if a patient is at immediate risk. Do not delay urgent care to complete paperwork.
8. Before you start
- Confirm the forms and equipment named in this document are available and current.
9. Procedure
Step 1. Decide clinically.
- Make clinical decisions on clinical grounds, and record them with the clinician name.
Key point: Decided.
Step 2. Protect privacy.
- Hold consultations privately, and keep health records apart from custodial files.
Key point: Protected.
Step 3. Share only what is needed.
- Share information with custodial staff only for a safety purpose, and only the minimum needed.
Key point: Shared.
10. Decision points
- No decision points in this procedure.
11. Special situations
| Situation | Action |
|---|---|
| Out of hours | Follow the same steps. Use the on-call contact on the wall of the area. |
12. Escalation
- Any serious problem goes to the duty clinical lead at once and to the clinical director the same day.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Clinical decisions made by health professionals | 100% | Quarterly | Clinical lead | Escalate to the health authority |
| Consultations private or with a recorded security reason | 100% | Quarterly | Clinical lead | Review the custody procedure |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| Record named in this document | Patient record or the area file | the period set by the facility’s records policy years |
15. Training
- Staff are trained in this document at induction and refreshed each year, with a recorded competency check.
16. Related documents
| ID | Title | Use |
|---|---|---|
| PNT-FRM-001 | Reception health screening record | Record |
| DIG-POL-001 | Information security and access control (existing, reused) | Policy |
17. Evidence
| Reference | Note |
|---|---|
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. |
18. Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | set Expert Committee approval |
E-learning for this document
References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)