Recurring concern

Inadequate safeguards for access to dangerous drugs

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First reported 30 Mar 2015•Latest report 29 Apr 2026

Definition

What this concern includes

Includes failures of controls specifically intended to regulate, authorise, supervise, audit or restrict access to dangerous drugs across healthcare, ambulance, pharmacy, online-supply and comparable drug-access settings, including the anchor's insufficient regulatory safeguards and auditing and failures involving unregulated online supply or pharmacy safeguards.

Not included

  • Excludes generic regulation, auditing or trust concerns where no dangerous-drug access or control issue is identified.
  • Excludes controls for non-drug hazardous items, weapons, chemicals or other substances unless the assertion specifically concerns dangerous drugs or drug supply.
  • Excludes clinical prescribing, administration, monitoring or treatment failures where access or supply control is not the unsafe condition.
  • Excludes the existing narrower concern concerning access to prescription-only medicines outside regulated prescribing when the assertion is specifically limited to that named prescription-only-medicine supply boundary.
Reports
14

Distinct published reports

Individual concerns
22

A report can raise multiple concerns

Date range
2015–2026

First to latest report issue date

Stated actions
36

Described in published responses

Reports over time

Reports 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 Care6
NHS England4
Home Office3
Medicines and Healthcare products Regulatory Agency3
Department for Digital, Culture, Media and Sport2
General Pharmaceutical Council2
General Practitioners Committee UK2
Recipient name withheld2
Advisory Council on the Misuse of Drugs1
Barking, Havering and Redbridge University Hospitals NHS Trust1
Boots UK Limited1
Department for Digital, Culture, Media & Sport (2017 to 2023)1
Department for Science, Innovation and Technology1
National Crime Agency1
NHS Greater Manchester Integrated Care Board1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Wiltshire and Swindon

    AI-generated summary

    Daniel James Paylor · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Daniel James Paylor, a paramedic with a history of codeine addiction and bipolar disorder, died following an opiate overdose after consuming a bottle of Oramorph kept for his private paramedic work. The report raised concerns about the regulation and control of drugs in secondary paramedic employment, including limited safeguards, auditing, peer supervision and double authorisation.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Insufficient regulatory safeguards and auditing for drugs

    Wider context from the report

    “(1) I am concerned when comparing the regulation and control of drugs, say, within an hospital and in Dan’s case insofar as his primary employer is concerned, an ambulance service, that compared to the level of control in relation to his secondary employment that the degree of regulatory control including safeguards and auditing appear to be very much dependent on trust. There appears to be little requirement for peer supervision and say double authorisation for say unlocking a safe comprising of two locks. My experience in relation to local hospitals is that in relation to drugs cabinets procedures have developed that require more than 1 health care professional’s authority to remove drugs to administer them to a patient. There have been instances whereby health care professionals with histories that have had addictions to prescription drugs however at least in that environment there is a stiff regime for supervision which appears absent in the scenario outlined above. I fully accept that even with regulation unless it includes the use of double locked safes with separate key holders that even with the most rigorous regulation that Dan’s death may not have been avoided. I was satisfied on a balance of probabilities that he consumed the whole bottle of Oramorph within that 36 hour period prior to his death. I am, however, of the view that consideration ought to be given as regards improving the regulatory regime and control with a view to the prevention of future deaths in perhaps a slightly different scenario. ”

    Source location

    Daniel James Paylor · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of dual authorisation for unlocking drug safes

    Wider context from the report

    “(1) I am concerned when comparing the regulation and control of drugs, say, within an hospital and in Dan’s case insofar as his primary employer is concerned, an ambulance service, that compared to the level of control in relation to his secondary employment that the degree of regulatory control including safeguards and auditing appear to be very much dependent on trust. There appears to be little requirement for peer supervision and say double authorisation for say unlocking a safe comprising of two locks. My experience in relation to local hospitals is that in relation to drugs cabinets procedures have developed that require more than 1 health care professional’s authority to remove drugs to administer them to a patient. There have been instances whereby health care professionals with histories that have had addictions to prescription drugs however at least in that environment there is a stiff regime for supervision which appears absent in the scenario outlined above. I fully accept that even with regulation unless it includes the use of double locked safes with separate key holders that even with the most rigorous regulation that Dan’s death may not have been avoided. I was satisfied on a balance of probabilities that he consumed the whole bottle of Oramorph within that 36 hour period prior to his death. I am, however, of the view that consideration ought to be given as regards improving the regulatory regime and control with a view to the prevention of future deaths in perhaps a slightly different scenario. ”

    Source location

    Daniel James Paylor · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. South London

    AI-generated summary

    Darren Mindham · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Darren Mindham, who worked as an assistant in a veterinary practice, died by suicide after self-administering pentobarbital at home on 28 August 2015. The principal concern was that pentobarbital was subject to less strict controls, and that access to it may facilitate suicide.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of strict control over pentobarbital

    Wider context from the report

    “Pentobarbital is a drug that is found in Schedule 3 of the Misuse of Drugs Regulations 2001, and is therefore not subject to the strict control found in Schedule 2. Whilst there may be practical difficulties in complying with stricter control, the use of pentobarbital in suicide has become commonplace. It has been shown that reducing access to the means of suicide can be effective in reducing the rate of suicide. ”

    Source location

    Darren Mindham · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Drug classification and scheduling are not matters for the Department of Health.

    Verbatim wording from the response

    “This is not however a matter for the Department of Health. The Advisory Council on the Misuse of Drugs (ACMD) makes recommendations to government on the control of dangerous or otherwise harmful drugs, including classification and scheduling under the Misuse of Drugs Act 1971 and its regulations. ACMD is an advisory non-departmental public body, sponsored by the Home Office and is the lead organisation in this area. I would therefore advise that you re-direct your Regulation 28 letter to the following contact for a response on this matter.”

    Source location

    2016-0170-Response-by-Department-of-Health
    Page 1 · response
    Published 3 May 2016

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The Advisory Council on the Misuse of Drugs, sponsored by the Home Office, is responsible for recommendations on drug classification and scheduling.

    Verbatim wording from the response

    “This is not however a matter for the Department of Health. The Advisory Council on the Misuse of Drugs (ACMD) makes recommendations to government on the control of dangerous or otherwise harmful drugs, including classification and scheduling under the Misuse of Drugs Act 1971 and its regulations. ACMD is an advisory non-departmental public body, sponsored by the Home Office and is the lead organisation in this area. I would therefore advise that you re-direct your Regulation 28 letter to the following contact for a response on this matter.”

    Source location

    2016-0170-Response-by-Department-of-Health
    Page 1 · response
    Published 3 May 2016

    Open published response

  3. Manchester West

    AI-generated summary

    Jacques Gerard Lakeman and Torin Callan Lakeman · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Jacques Gerard Lakeman and Torin Callan Lakeman, brothers, died at The Grapes Public House, Stoneclough, Bolton, on 1 December 2014. The medical cause of death for both was recorded as fatal MDMA toxicity, with the inquest conclusion being misuse of Ecstasy. The report raised concerns about the online supply and postal delivery of illicit drugs, including the unknown strength and contents of substances and the lack of regulation.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of regulation of Internet-based drug supply

    Wider context from the report

    “1. During the Inquest evidence was heard that: i. Torin had received supplies of drugs, prior to November 2014, by use of the Internet using the “Dark Internet” or “Dark Web”. The Inquest heard that access to the “Dark Internet” or “Dark Web” would be difficult without having knowledge or expertise in relation to Internet access but young persons, particular intelligent University students, would find access to the websites to be relatively easy and it would not be difficult for such persons to obtain access to illicit activities, including the supply of illicit drugs. The websites are anonymous and there is no contact information with regard to the address or location of the owners of the website nor with regard to the suppliers of illicit drugs. ii. The constituent parts of the drugs, including the strength and content of the drugs, are unknown and may contain contaminants and further illicit substances creating an additional risk. iii. There is no regulation of the supply of drugs by use of the Internet and there is no protection in place in relation to the delivery or importation of drugs using the Internet and delivery to a United Kingdom postal address by use of the Postal System. iv. The evidence raised concerns that future deaths will occur unless action is taken to review the above issues, particularly in view of the supply of illicit drugs, including Class A drugs, by use of the Internet. v. On the 30th March 2015 I reported a similar concern to you relating to the death of Jason Houghton, who died on the 30th June 2014 from the combined toxic effects of illicit drugs obtained by use of the Internet. 2. I request that you consider the above concerns particularly in regard to the following:- i. The supply and importation of drugs, including Class A drugs, in the manner and in the form described in this report, by use of the Internet. ii. The regulation of the Internet, which may be difficult if not impossible, in relation to the supply of drugs and delivery of drugs to addresses in the United Kingdom by use of the Postal System. ”

    Source location

    Jacques Gerard Lakeman and Torin Callan Lakeman · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Ease of access to illicit drug supply through Internet websites

    Wider context from the report

    “1. During the Inquest evidence was heard that: i. Torin had received supplies of drugs, prior to November 2014, by use of the Internet using the “Dark Internet” or “Dark Web”. The Inquest heard that access to the “Dark Internet” or “Dark Web” would be difficult without having knowledge or expertise in relation to Internet access but young persons, particular intelligent University students, would find access to the websites to be relatively easy and it would not be difficult for such persons to obtain access to illicit activities, including the supply of illicit drugs. The websites are anonymous and there is no contact information with regard to the address or location of the owners of the website nor with regard to the suppliers of illicit drugs. ii. The constituent parts of the drugs, including the strength and content of the drugs, are unknown and may contain contaminants and further illicit substances creating an additional risk. iii. There is no regulation of the supply of drugs by use of the Internet and there is no protection in place in relation to the delivery or importation of drugs using the Internet and delivery to a United Kingdom postal address by use of the Postal System. iv. The evidence raised concerns that future deaths will occur unless action is taken to review the above issues, particularly in view of the supply of illicit drugs, including Class A drugs, by use of the Internet. v. On the 30th March 2015 I reported a similar concern to you relating to the death of Jason Houghton, who died on the 30th June 2014 from the combined toxic effects of illicit drugs obtained by use of the Internet. 2. I request that you consider the above concerns particularly in regard to the following:- i. The supply and importation of drugs, including Class A drugs, in the manner and in the form described in this report, by use of the Internet. ii. The regulation of the Internet, which may be difficult if not impossible, in relation to the supply of drugs and delivery of drugs to addresses in the United Kingdom by use of the Postal System. ”

    Source location

    Jacques Gerard Lakeman and Torin Callan Lakeman · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Monitor online controlled-drug offers and act with industry partners to close websites trading illegally.

    Verbatim wording from the response

    “The National Crime Agency (NCA) and the police routinely monitor controlled drugs being offered for sale on the internet and take action with industry partners to close websites trading illegally in these substances. Where it has been identified, or where there is reasonable suspicion to suggest, that controlled drugs are being sold on websites, law enforcement agencies have the relevant powers under the Misuse of Drugs Act 1971 to act against suppliers of controlled drugs, whether on controlled drug charges or on suspicion of wider drug-related offences.”

    Source location

    2015-0191-Response-by-Home-Office
    Page 2 · response
    Published 15 May 2015

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Arrest suspected administrators and vendors involved in online drug marketplaces and illegal drug supply.

    Verbatim wording from the response

    “In November 2014, the NCA, working with police forces across the UK, arrested six people in strikes coordinated with international partners. Those arrested included suspected administrators for the online market place Silk Road 2.0 and another online drug market place, as well as significant vendors of illegal drugs through the dark web.”

    Source location

    2015-0191-Response-by-Home-Office
    Page 2 · response
    Published 15 May 2015

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Remove technical infrastructure hosting illegal dark-web marketplaces.

    Verbatim wording from the response

    “Simultaneously, partners from the European Cybercrime Centre, acting on intelligence developed by US counterparts, took out technical infrastructure which was key to the hosting of illegal market places on the dark web, in total over 400 hidden services taken down. The action was part of continuing operations to target the use of online market places to trade in illegal commodities such as class A drugs, firearms and false documents.”

    Source location

    2015-0191-Response-by-Home-Office
    Page 2 · response
    Published 15 May 2015

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Continue operations targeting online marketplaces trading controlled drugs and other illegal commodities.

    Verbatim wording from the response

    “Simultaneously, partners from the European Cybercrime Centre, acting on intelligence developed by US counterparts, took out technical infrastructure which was key to the hosting of illegal market places on the dark web, in total over 400 hidden services taken down. The action was part of continuing operations to target the use of online market places to trade in illegal commodities such as class A drugs, firearms and false documents.”

    Source location

    2015-0191-Response-by-Home-Office
    Page 2 · response
    Published 15 May 2015

    Open published response

  4. Manchester West

    AI-generated summary

    Jason Houghton · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Jason Houghton died on 30 June 2014 in a hotel room with a cannula connected to a homemade drip, alongside syringes, Valium vials and other drug-related items. The inquest recorded that his death involved the combined toxic effects of ketamine, heroin, diazepam and dextromethorphan and concluded misadventure. Concerns were raised about the unregulated internet supply and international importation of illicit drugs, including heroin in the form of diacetyl morphine.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of regulation of internet-based drug supply

    Wider context from the report

    “iii. There is no regulation of the supply of drugs by use of the internet and there is no protection in place in relation to the importation of drugs using the internet with delivery from an international source to a United Kingdom postal address by use of the postal system. iv. The evidence raised concerns that future deaths will occur unless action is taken to review the above issues, particularly in view of the supply of illicit Class A Drugs, being Heroin, in the form of Diacetyl Morphine, by use of the internet. 2. I request for you to consider the above concerns particularly in regard to the following:- i. The supply and importation of Class A Drugs, in the manner and form described in this report, by use of the internet. ii. The regulation of the internet, if possible, in relation to the supply of drugs and the delivery of the drugs using International Shipping and the United Kingdom postal system. ”

    Source location

    Jason Houghton · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Continue working with internet providers to ensure compliance with drug-control law.

    Verbatim wording from the response

    “Law enforcement agencies and I take the issue of unlawful advertising and sales of drugs on the internet very seriously, and we continue to work with internet providers to ensure that they comply with the law. This can include”

    Source location

    2015-0127-Response-by-Home-Office
    Page 1 · response
    Published 30 March 2015

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Examine the Medipk website, liaise with its internet service provider, and secure its closure for unlawful medicine sales.

    Verbatim wording from the response

    “I can confirm that, since Mr Houghton’s death, the MHRA has examined the website www.medipk.com and found that other prescription-only medicines were being offered without a required prescription and liaised with the internet service provider to close it down.”

    Source location

    2015-0127-Response-by-Home-Office
    Page 2 · response
    Published 30 March 2015

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Work with international partners to develop responses to overseas controlled-drug supply and emerging threats.

    Verbatim wording from the response

    “As in this case, considerable illegal activity takes place on the internet outside of UK jurisdiction. The UK continues to work with international partners to develop an effective response to the supply of controlled drugs and to react swiftly to emerging threats. In order to tackle illegally trading websites identified overseas, we are building strong partnerships with international partners. There is also ongoing work with the EU and other international regulatory agencies to ensure that, wherever possible, offending websites are amended to comply with the law.”

    Source location

    2015-0127-Response-by-Home-Office
    Page 2 · response
    Published 30 March 2015

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Build partnerships with international counterparts to address illegally trading websites identified overseas.

    Verbatim wording from the response

    “As in this case, considerable illegal activity takes place on the internet outside of UK jurisdiction. The UK continues to work with international partners to develop an effective response to the supply of controlled drugs and to react swiftly to emerging threats. In order to tackle illegally trading websites identified overseas, we are building strong partnerships with international partners. There is also ongoing work with the EU and other international regulatory agencies to ensure that, wherever possible, offending websites are amended to comply with the law.”

    Source location

    2015-0127-Response-by-Home-Office
    Page 2 · response
    Published 30 March 2015

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Work with EU and international regulatory agencies to bring offending websites into legal compliance where possible.

    Verbatim wording from the response

    “As in this case, considerable illegal activity takes place on the internet outside of UK jurisdiction. The UK continues to work with international partners to develop an effective response to the supply of controlled drugs and to react swiftly to emerging threats. In order to tackle illegally trading websites identified overseas, we are building strong partnerships with international partners. There is also ongoing work with the EU and other international regulatory agencies to ensure that, wherever possible, offending websites are amended to comply with the law.”

    Source location

    2015-0127-Response-by-Home-Office
    Page 2 · response
    Published 30 March 2015

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Existing monitoring, enforcement powers, website closures and international partnerships are considered sufficient to address illegal online drug sales.

    Verbatim wording from the response

    “The National Crime Agency (NCA), the police and the Medicines and Healthcare products Regulatory Agency (MHRA) routinely monitor controlled drugs and medicines being offered for sale on the internet and take action with industry partners to close websites trading illegally in these substances. Where it has been identified, or where there is reasonable suspicion to suggest, that controlled drugs or medicines containing controlled drugs are being sold on websites, law enforcement agencies have the relevant powers under the Misuse of Drugs Act 1971 to act against suppliers of controlled drugs, whether on controlled drug charges or on suspicion of wider drug-related offences.”

    Source location

    2015-0127-Response-by-Home-Office
    Page 2 · response
    Published 30 March 2015

    Open published response
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Data last updated 7 September 2026