3.3 Explain the actions to be taken if an individual does not consent to prescribed medication

This. guide will help you answer 3.3 Explain the actions to be taken if an individual does not consent to prescribed medication.

When working in health and social care, you respect each person’s right to make decisions about their treatment. Medication is often a key part of an individual’s care plan, but nobody can be forced to take prescribed medication against their wishes. This is a legal and ethical rule that supports each person’s autonomy—meaning their right to choose what happens to their own body.

This guide covers what actions to take if someone does not give consent to take prescribed medication. Each step is important for safe practice and for maintaining trust. You need to know your responsibilities and the correct process to follow. Always follow your own organisations policies and procedures. Seek advice from a medical professional.

What is Consent?

Consent means agreeing to something after being given all the necessary information. In health and social care, a person must know:

• What the medication is
• Why it’s needed
• What the risks and benefits are
• What alternatives there might be

Consent must be given freely, without pressure or bullying. It can be withdrawn at any time, even if consent was given before.

If someone has the mental capacity (the ability to make their own decisions), they have the legal right to refuse medication, even if refusing it might result in harm to their health.

Why Might Someone Refuse Medication?

There are many reasons, and understanding them is important for care workers.

• Side effects or past bad experiences with medicine
• Cultural or religious beliefs
• Lack of information or understanding about the medication
• Fear of injections or swallowing pills
• Preference for natural treatments
• Feeling a loss of control
• Misunderstanding dosage or schedule

Knowing the reason can help when responding to refusal.

Immediate Actions: Do Not Force Medication

Never force medication on someone who refuses it. Doing so is illegal and can be considered abuse or assault.

• Remain calm if a person refuses
• Record refusal accurately in daily records or medication charts
• Report the refusal to your line manager or appropriate senior staff
• Reassure the individual and let them know you respect their decision

Communicate and Listen

Effective communication is vital at this stage. Your approach must always be respectful and open.

• Use clear, simple language
• Avoid medical jargon
• Listen to the individual’s reasons for refusal without judgement
• Offer to answer questions or provide further information if needed
• Ask about any worries or past experiences that influence their decision

If someone seems confused or unable to understand, stop and review their capacity. Don’t challenge or try to persuade by force.

Recording and Reporting Refusals

Records are legal documents. You must accurately document the refusal for each medication offered. This protects both the service user and workers.

Include:

• The name and dose of the medication refused
• The date and time refusal took place
• Any reasons the individual gives for refusing
• Any advice or information given about the risks of refusal
• Your name and signature

After recording, report the refusal to the appropriate person. This is likely to be your line manager, a registered nurse, or a prescriber (such as a GP or pharmacist).

Risk Assessment and Escalation

If the medication is vital (such as antibiotics for an infection or medicine that controls seizures), escalation may be required.

Steps you should take:

• Inform your line manager immediately
• Assess if refusal puts the individual or others at immediate or serious risk
• Follow organisational procedures for urgent refusals
• If needed, seek medical advice (e.g., contact the GP or prescribe nurse)
• Encourage the person to speak directly with the prescriber if preferred

Do not leave someone at risk without following up through the proper channels.

Review Mental Capacity

If someone regularly refuses medication, check if they understand what they are refusing. This relates to mental capacity.

Mental capacity means having the ability to:

• Understand the information
• Remember it for long enough
• Weigh it up to decide
• Communicate the decision

If you suspect a person lacks capacity, follow the processes under the Mental Capacity Act 2005. Involve your manager or an appropriate professional for a formal assessment.

Best Interest Decisions

If a person genuinely lacks mental capacity, a decision may need to be made in their best interests.

Best interest decisions must:

• Involve the individual as much as possible
• Consider their past wishes and values
• Include family or friends if appropriate
• Take the least restrictive option

This process may require a meeting and professional input, especially if the medication is essential for health or life.

Never make this decision alone as a worker. You must have authority from the manager or the person with the correct power (such as a Deputy or Lasting Power of Attorney). Sometimes, doctors or multidisciplinary teams (MDT) become involved.

Involving Others and Advocacy

Some people want a family member, carer, or advocate to support them in making decisions. If consent for medication is not given, suggest that the individual confides in someone they trust.

Advocates are trained to support people’s rights and speak on their behalf if needed—especially useful for those who feel anxious or who don’t have close family.

Always check if an advocate should be involved, especially for people who find it hard to speak up for themselves.

Supporting Autonomy and Choice

Respecting a person’s decision does not mean you ignore their medical needs. Your role includes:

• Providing clear, up-to-date information on the effects of the medication
• Explaining possible consequences of not taking medicine (in plain language)
• Reviewing whether there are other forms of medication or treatments available
• Encouraging questions and providing accessible leaflets or resources

If after all this, the person still says no, you must respect that choice—unless capacity is lacking and a best interest decision is in place.

Confidentiality

Respect confidentiality at all times. Do not share reasons for refusal with anyone without consent, unless it’s to relevant staff for safety reasons.

Information around medication refusal must:

• Be kept securely
• Be discussed only with staff involved in the person’s care
• Not be shared in public or with unauthorised people

Confidentiality protects the person’s rights and dignity.

Medicines Management and Missed Doses

After a refused dose, it’s important to manage medication safely.

• Check the medication administration record (MAR) to ensure exact documentation
• Do not put leftover medication back into general stock or leave it accessible
• Know when the next dose is due and if a double dose is unsafe
• Notify the person responsible for medicines management (could be a nurse or pharmacist)

Organisations have policies on what to do with missed doses. Always follow your local policy.

Keeping Records Up to Date

Accurate records:

• Support safe care
• Give a legal account of what has happened
• Help doctors and other professionals manage ongoing treatment
• Protect you as a worker if the refusal later causes harm

Complete notes at the time or as soon as possible afterwards.

Working Within Legal and Organisational Policies

You have a duty to act within the law and your organisation’s procedures.

Legal requirements include:

• The Mental Capacity Act 2005
• The Human Rights Act 1998
• Care Quality Commission (CQC) regulations

Organisational policies give the exact process and who to contact. Read and follow these at all times. Ask your manager for an update if the policy changes.

Training and Professional Judgment

Keep your medicines training up to date.

• Know your limits—if unsure, ask
• Do not act outside your level of responsibility
• Seek guidance to make correct decisions
• Attend regular training and refresher sessions as advised

Professional judgment comes with training, support, and experience.

Practical Example

Mary is prescribed antibiotics for a chest infection. She refuses the morning dose, saying it upsets her stomach.

The worker:

• Asks Mary for more details and listens without judging
• Offers to get Mary a glass of water or a snack if that would help
• Explains why antibiotics are important and the risk of infection spreading
• Records the refusal on the medication chart
• Reports to the senior care worker
• Documents everything in the care notes

Mary later decides to take the evening dose. Her wishes have been respected, safety is maintained, and the process is recorded.

Final Thoughts

Consent around medication sits at the heart of person-centred care. You support people in their right to make choices, including the right to say no. This is not only about following rules but about respecting dignity and building trust.

Your actions after a refusal should balance the individual’s wishes against their safety and well-being. Use good communication, proper record-keeping and refer to your team leaders or managers when unsure. If you ever feel uncertain, ask for support straight away—never take chances with medication.

Remember: your approach can make a real difference to how safe, respected, and supported a person feels. Following these steps protects individuals’ rights and keeps you safe within your role. Always check training and local policies, and stay confident in seeking help when needed.