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GHNHSFT - Redirect > Self‑Administration of Medication in Maternity Services

Freedom of Information request Self‑Administration of Medication in Maternity Services

Response published: 10 June 2026
GHNHSFT - Redirect

FOI Request

Dear FOI Team, I am writing to request recorded information under the Freedom of Information Act 2000 regarding the policies, procedures, and operational use of self administration of medication (SAM) within your maternity services. Please provide the following information: 1. SAM policy documents Copies of any current or previous policies, guidelines, protocols, or standard operating procedures relating to self administration of medication in maternity services. 2. Implementation status Whether SAM is currently in use in any maternity settings within your Trust (e.g., antenatal wards, postnatal wards, day assessment units, birth centres). o If yes, please specify which sites and clinical areas. o If yes, is SAM optional or is it expected all patients do this with few exceptions (eg. Additional learning needs etc) o If yes, please specify which medication SAM is used for - e.g. analgesia only o If no, please state whether implementation is planned. 3. Eligibility criteria Any criteria, risk assessments, or decision making tools used to determine whether a maternity patient is eligible to self administer medication. 4. Training requirements Details of staff training, competencies, or mandatory modules relating to SAM in maternity services. 5. Audit or evaluation reports Any audits, evaluations, incident reports, or quality improvement reviews relating to SAM in maternity services from the past five years. 6. Patient information materials Copies of leaflets, consent forms, or information provided to maternity patients about SAM. 7. Digital systems Whether any electronic health record systems (e.g., BadgerNet) are used to record or support SAM processes, and if so, how this is documented. 8. Incidents Please give details about any incidents or adverse outcomes that have been related to SAM and what the level of harm and investigation process was. Please provide the information electronically. I understand that under the FOI Act, I should receive a response within 20 working days. If any part of this request is unclear or would exceed the cost limit, please advise me as required under Section 16 of the Act so I may refine my request. Kind regards,

FOI Response

Freedom of Information Request – Ref: FOI 177-2026

Thank you for your recent Freedom of Information request. Please find our response below.

You asked:

1. SAM policy documents Copies of any current or previous policies, guidelines, protocols, or standard operating procedures relating to self administration of medication in maternity services.

2. Implementation status Whether SAM is currently in use in any maternity settings within your Trust (e.g., antenatal wards, postnatal wards, day assessment units, birth centres).

o If yes, please specify which sites and clinical areas.
o If yes, is SAM optional or is it expected all patients do this with few exceptions (eg. Additional learning needs etc)
o If yes, please specify which medication SAM is used for – e.g. analgesia only
o If no, please state whether implementation is planned.

3. Eligibility criteria Any criteria, risk assessments, or decision making tools used to determine whether a maternity patient is eligible to self administer medication.

4. Training requirements Details of staff training, competencies, or mandatory modules relating to SAM in maternity services.

5. Audit or evaluation reports Any audits, evaluations, incident reports, or quality improvement reviews relating to SAM in maternity services from the past five years.

6. Patient information materials Copies of leaflets, consent forms, or information provided to maternity patients about SAM.

7. Digital systems Whether any electronic health record systems (e.g., BadgerNet) are used to record or support SAM processes, and if so, how this is documented.

8. Incidents Please give details about any incidents or adverse outcomes that have been related to SAM and what the level of harm and investigation process was.

Our response:

The Trust does not provide the service mentioned in your request. Please re-direct your request to Gloucestershire Hospitals NHS Foundation Trust at ghn-tr.foi@nhs.net.

Next steps:

Should you have any queries in relation to our response, please do not hesitate to contact us. If you are unhappy with the response you have received in relation to your request and wish to ask us to review our response, you should write to:

Louise Moss
Head of Legal Services / Associate Director of Corporate Governance
c/o Gloucestershire Health and Care NHS Foundation Trust
Edward Jenner Court
1010 Pioneer Avenue
Gloucester Business Park
Brockworth, GL3 4AW
E-mail: louise.moss@ghc.nhs.uk

If you are not content with the outcome of any review, you may apply directly to the Information Commissioner’s Office (ICO) for further advice/guidance. Generally, the ICO will not consider your case unless you have exhausted your enquiries with the Trust which should include considering the use of the Trust’s formal complaints procedure. The ICO can be contacted at: The Information Commissioner’s Office, Wycliffe House, Water Lane, Wilmslow, Cheshire SK9 5AF.