First reported 14 Mar 2014•Latest report 17 Dec 2025
Definition
What this concern includes
Includes failures of the medication-security and control process, including medication brought into care, patients’ own medication, prescribed medication and medication held in healthcare or custodial settings, where the concern is preventing unauthorised access, trading, theft, overdose or misuse.
Not included
Excludes medication prescribing, review or quantity decisions unless the report directly concerns securing or controlling the medication.
Excludes generic ward, premises or physical-access security concerns that are not specifically about medication.
Excludes medication information, counselling or handover failures unless they directly result in inadequate medication security or control.
Excludes unrelated clinical governance, staffing or documentation deficiencies that are not tied to medication security or control.
Reports
30
Distinct published reports
Individual concerns
34
A report can raise multiple concerns
Date range
2014–2025
First to latest report issue date
Stated actions
62
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.
HM Prison and Probation Service6
Care UK3
Department of Health and Social Care3
Ministry of Justice3
Care Quality Commission2
Guys Marsh Prison2
NHS England2
Office of the Chief Coroner2
Advisory Council on the Misuse of Drugs1
APEX Prime Care1
Barts Health NHS Trust1
Birmingham and Solihull Mental Health NHS Foundation Trust1
Cardiff & Vale University LHB1
Central and North West London NHS Foundation Trust1
City and County Healthcare Group Limited1
NHS trust12
Ministerial department7
Executive agency6
Multi-service care provider5
Prison or young offender institution5
Healthcare site4
Care-home operator2
Coronial office2
Executive non-departmental public body2
Health and social care service regulator2
Integrated care board2
Non-ministerial department2
Private limited company2
Type not available2
Advisory non-departmental public body1
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.
Sunderland
Concerns raised1
Alternative access to controlled drugs without the required second fingerprint signature
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Using the incorrect Omnicell restock code did not allow access to controlled drug compartments, which remained protected by two-fingerprint authentication.
Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Dorset
Concerns raised2
Failure to secure in-possession medication against access by other prisoners
Failure to ensure return of excess medication after prescription discontinuation
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
Action
Ensure in-cell medication safes are available and fit for purpose where used.
Stated by HM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 28 July 2025.
Action
Assess medication and individual suitability before issuing in-possession medication, with reassessment when circumstances change.
Stated by Oxleas NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 July 2025.
Action
Conduct intelligence-led and random checks of in-possession medication to monitor compliance and safety.
Stated by Oxleas NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 July 2025.
Action
Implement a published in-possession medication compliance procedure with bi-monthly in-cell checks, discrepancy escalation and documented oversight.
Stated by Oxleas NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 July 2025.
Action
Develop and distribute prison health-promotion materials on safe medication storage and disposal of unused or discontinued medication.
Stated by Oxleas NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 28 July 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5
Position
NHS England and Oxleas NHS Foundation Trust are responsible for prisoners’ medication management, prescribing and decisions about medication held in possession.
Stated by HM Prison and Probation ServiceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Responsibility for prisoners’ in-possession medication and prescribing lies with NHS England under clinical assurance and national service specifications.
Stated by HM Prison and Probation ServiceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Existing risk assessments, compliance checks and medication procedures provide robust safeguards for in-possession medication governance.
Stated by Oxleas NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
HMPPS is responsible for prison security and safeguarding medication, including personal lockable safes for storage.
Stated by Oxleas NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Existing local procedures, national standards, contractual monitoring, inspections and regional governance provide sufficient assurance for medicines safety.
Stated by Department of Health and Social CareExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Norfolk
Concerns raised1
Failure to secure patients' own medication
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Action
Add a patient-search procedure to the Self-Harm Policy covering searches for medication and other items that could enable overdose or self-harm.
Stated by James Paget University Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 July 2025.
Action
Share the updated Self-Harm Policy and patient-search procedure with Emergency Care staff and support acknowledgement of understanding.
Stated by James Paget University Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 July 2025.
Action
Add a patient-search procedure to the Self Harm Policy, covering removal and safe storage of medications and other harmful items in Emergency Department patients at risk.
Stated by James Paget University Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 July 2025.
Action
Disseminate the updated Self Harm Policy and patient-search procedure to Emergency Care staff and promote its requirements through written and face-to-face communication.
Stated by James Paget University Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 July 2025.
East Sussex
Concerns raised1
Lack of a mechanism to report medication non-compliance to Security
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Use confidential intelligence reports to notify Security when patients may be stockpiling medication.
Stated by Practice Plus Group Health And Rehabilitation Services LimitedStated completedThe respondent said that this action was complete when they made their response on 19 January 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing information-sharing protocols and weekly meetings are considered appropriate for communication and management of complex safety concerns.
Stated by HM Prison and Probation ServiceExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Inner North London
Concerns raised1
Facilitation of dangerous medication addictions through online availability of sedative medication
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Monitor online channels, investigate and prosecute illegal medicine sellers, and remove illicit websites and criminal profits.
Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 29 December 2023.
Action
Provide public-facing #FakeMeds communications and tools to help people avoid illegally traded medicines online.
Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 29 December 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
The MHRA is responsible for enforcing regulations against the illegal sale and supply of human medicines.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Online platforms and search services are responsible for preventing and removing illegal drug-sale content under the Online Safety Act 2023.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Dorset
Concerns raised1
Lack of national guidance for managing in-possession medication
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Require medication removal during cell clearances through the amended Prisoners’ Property Policy Framework.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 8 December 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Position
HMPPS is responsible for responding to concerns about national guidance and the accessibility of key information recorded on NOMIS.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
HMPPS is responsible for conducting cell searches where there are concerns that prisoners may be hoarding or stockpiling medication.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Operational concerns should be addressed by HMPPS Director General of Operations, rather than by the Minister.
Stated by Ministry of JusticeRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Healthcare providers primarily decide which medication prisoners may hold in possession, although prison staff retain supporting responsibilities.
Stated by HM Prison and Probation ServiceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Manchester North
Concerns raised1
Ineffective searches of patients’ rooms for stockpiled medication
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Deliver training for ward staff on effective room and personal searches and record compliance.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 22 February 2023.
Action
Update the Trust search policy to incorporate learning about contraband and reinforce search procedures.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 22 February 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Room searches were conducted and found no medication; intimate searches were not indicated at the time.
Stated by Greater Manchester Mental Health NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Sefton, St Helens and Knowsley
Concerns raised1
Failure to supervise syringe medication
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Conduct weekly observations of medicine rounds.
Stated by Four Seasons Health Care GroupStated completedThe respondent said that this action was complete when they made their response on 9 January 2023.
Action
Write and share a specific medication risk assessment when medication-management risk is identified, retaining it with medication records.
Stated by Four Seasons Health Care GroupStated plannedThe respondent said that this action was planned when they made their response on 9 January 2023.
Hampshire, Portsmouth and Southampton
Concerns raised2
Failure to include medication security instructions in the digital application used by carers
Failure to keep medication in a locked box
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Action
Reassess service users’ locked medication storage and require sufficient capacity for all medication without storing other medication in the property.
Stated by APEX Prime CareStated completedThe respondent said that this action was complete when they made their response on 9 December 2022.
Action
Add medication administration and storage instructions to care plans and prevent plans being issued without this task.
Stated by APEX Prime CareStated completedThe respondent said that this action was complete when they made their response on 9 December 2022.
Action
Update the medication policy to cover medication storage and locked boxes.
Stated by APEX Prime CareStated completedThe respondent said that this action was complete when they made their response on 9 December 2022.
South Wales Central
Concerns raised1
Failure to secure medication cupboard keys
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Action
Review the medication policy and revise key-holder requirements so medication keys remain on the nominated key holder’s person.
Stated by Mirus WalesStated completedThe respondent said that this action was complete when they made their response on 28 November 2022.
Action
Update medication training for staff and managers to strengthen key-handling and prevent unauthorised access to medication.
Stated by Mirus WalesStated completedThe respondent said that this action was complete when they made their response on 28 November 2022.
Action
Implement additional quality-assurance measures to verify that the medication-key and training actions have been implemented.
Stated by Mirus WalesStated plannedThe respondent said that this action was planned when they made their response on 28 November 2022.
Action
Subject the medication-safety measures to scrutiny at leadership meetings and the March 2023 Board of Trustees meeting.
Stated by Mirus WalesStated plannedThe respondent said that this action was planned when they made their response on 28 November 2022.
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Includes failures of the medication-security and control process, including medication brought into care, patients’ own medication, prescribed medication and medication held in healthcare or custodial settings, where the concern is preventing unauthorised access, trading, theft, overdose or misuse.
