Includes failures in controls specifically governing Oramorph storage, handling and access prevention across institutional and community settings, including strength-based classification, secure storage, restrictions on access by others and related operational requirements.
What is not included
Excludes medication prescribing, dosing, administration, monitoring or clinical-assessment failures where Oramorph storage, handling or access control is not the unsafe condition.
Excludes generic medication-security concerns not specifically involving Oramorph storage or handling.
Excludes general opioid or controlled-drug regulation where Oramorph storage, handling or access is not materially identified.
Excludes medication-supply, dispensing or treatment-continuity failures unrelated to Oramorph storage and handling.
Trends
Reports over time
Reports mentioning this concern, over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Department of Health and Social Care1
Home Office1
Medicines and Healthcare products Regulatory Agency1
National Institute for Health and Care Excellence1
Ministerial department2
Executive non-departmental public body1
Medicines and medical devices regulator1
Reports and published responses 2 reports
See individual reports that have raised this concern, and the actions taken in response
Surrey
Concerns raised1
Lack of requirements for safe community storage of Oramorph and prevention of access by others
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked responses
Home Office
Medicines and Healthcare products Regulatory Agency
National Institute for Health and Care Excellence
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
National Institute for Health and Care Excellence
Provide national guidance on safely storing controlled drugs, including discussing storage options, access, and incident risks.
Medicines and Healthcare products Regulatory Agency
Work with Marketing Authorisation holders to update Oramorph product information on secure storage and not leaving diluted medicine unattended.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Medicines and Healthcare products Regulatory Agency
Existing Oramorph warnings and guidance were clear; the unintended recipient would not have seen the product information.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Home Office
Existing advice, patient information and controlled-drug safeguards are considered sufficient to reduce risks from oral morphine.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Home Office
Additional patient controls are not pursued because extending healthcare safeguards could criminalise patients and obstruct timely access to pain relief.
Unable to actThe respondent said that a constraint prevented them from taking the relevant action.
Manchester South
Concerns raised1
Failure to maintain consistent classification-based storage and handling arrangements for Oramorph
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Department of Health and Social Care
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Department of Health and Social Care
Implement the Controlled Drugs Regulations establishing tighter controls and mandatory governance arrangements for prescribing, records, custody, monitoring and accountable officers.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Department of Health and Social Care
Registered providers and managers are responsible for ensuring the proper and safe management of medicines in care homes.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.