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.
Mid Kent and Medway
Concerns raised1
Failure to remove previous occupants' medication from cells
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
Reinforce cell-clearance procedures, including medication security, intelligence reporting, and documented pre-occupancy checks.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 26 January 2022.
Gwent
Concerns raised2
Failure to secure and control prisoners’ prescribed medication
Ineffective randomised checks of prisoners’ medication management
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.6
Action
Issue staff guidance on detecting, recording and reporting prescribed-medication trading.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 10 January 2022.
Action
Reissue medication-trading guidance annually to maintain staff awareness and inform new staff.
Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 10 January 2022.
Action
Monitor and collate medication-trading intelligence for consideration at weekly staff security briefings.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 10 January 2022.
Action
Apply detailed security risk assessments to prisoners working in the recycling department.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 10 January 2022.
Action
Install amnesty bins on prison wings for correct disposal of medications.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 10 January 2022.
Action
Conduct monthly random medication checks covering 10% of the prison population and address discrepancies through medication reviews.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 10 January 2022.
West London
Concerns raised1
Failure to control staff access to residents' prescribed medication
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.1
Action
Develop a robust action plan covering controlled-drug training and ongoing medication monitoring for auditors and managers.
Stated by Care OutlookStated completedThe respondent said that this action was complete when they made their response on 19 August 2021.
Stoke-on-Trent and North Staffordshire
Concerns raised1
Lack of safe medication storage for residents requiring supervision
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.7
Action
Raise safeguarding concerns where individuals may be at risk from accessing their medicines.
Stated by Comfort Call LimitedStated completedThe respondent said that this action was complete when they made their response on 30 December 2020.
Action
Review the standard Extra Care Scheme protocols template to consider secure medicines storage in tenants’ flats.
Stated by Comfort Call LimitedStated plannedThe respondent said that this action was planned when they made their response on 30 December 2020.
Action
Require Extra Care Scheme managers to review whether secure medicines storage should be raised with housing providers.
Stated by Comfort Call LimitedStated plannedThe respondent said that this action was planned when they made their response on 30 December 2020.
Action
Review the specification for lockable medication cupboards in all Extra Care Housing Scheme contracts.
Stated by City of Stoke-on-TrentStated plannedThe respondent said that this action was planned when they made their response on 30 December 2020.
Action
Review care plans for tenants unable to manage their medication, including the risk of deliberate or accidental overdose.
Stated by City of Stoke-on-TrentStated plannedThe respondent said that this action was planned when they made their response on 30 December 2020.
Action
Consider installing more secure medication storage where care-plan reviews identify it as required.
Stated by City of Stoke-on-TrentStated plannedThe respondent said that this action was planned when they made their response on 30 December 2020.
Action
Send all home-care and Extra Care providers a request to review medication storage for customers unable to manage their own medication.
Stated by City of Stoke-on-TrentStated plannedThe respondent said that this action was planned when they made their response on 30 December 2020.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5
Position
The risk of medicine-related self-harm was not reasonably foreseeable because there was no previous indication of overdose, self-harm or medicine access attempts.
Stated by Comfort Call LimitedDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Medicines could not lawfully be removed from the tenant’s flat under the provider’s care registration and the independent-living model.
Stated by Comfort Call LimitedUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
The care provider has no remit or capability to mandate, purchase or install secure fixtures in tenants’ flats.
Stated by Comfort Call LimitedOutside remitThe respondent said that this matter was outside its role or authority.
Position
The housing provider and commissioning authority are responsible for deciding and implementing fixture changes at the scheme.
Stated by Comfort Call LimitedRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Medication cupboards met contractual specifications, and co-codamol required no additional secure storage because it was not a controlled drug.
Stated by City of Stoke-on-TrentExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
County Durham and Darlington
Concerns raised1
Failure to prevent prescription medication leakage from the lawful dispensing process into criminal hands
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
PHE and ACMD are the appropriate bodies to address concerns about prescription-drug misuse and medicine availability.
Stated by Royal Pharmaceutical SocietyRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
London (West)
Concerns raised1
Inconsistent checks that detainees swallow issued medication
This report raised 13 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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Oxfordshire
Concerns raised1
Inadequate cell searching and collection of in-possession medication after a change of risk
This report raised 4 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
Remind staff to update medication-in-possession risk assessments during medication reviews so changes feed into ACCT information for dispensing and prison staff.
Stated by Midlands Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 17 October 2019.
Action
Conduct random medication spot checks and review or remove in-possession status when discrepancies or patient-safety concerns arise.
Stated by Practice Plus Group Health And Rehabilitation Services LimitedStated completedThe respondent said that this action was complete when they made their response on 17 October 2019.
Action
Issue guidance requiring ACCT case managers to discuss in-possession medication routinely and complete risk assessments with healthcare input.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 17 October 2019.
Action
Distribute a safety briefing on in-possession medication risks and required action during fabric checks or cell searches to all staff.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 17 October 2019.
Action
Include stockpiled medication and temporary removal considerations in future local ACCT case-manager training.
Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 17 October 2019.
Manchester South
Concerns raised1
Failure to remove palliative opiate medication from a bereaved person’s possession
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
South Wales Central
Concerns raised1
Failure to secure patients’ PODS while awaiting ward admission
This report raised 4 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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Dorset
Concerns raised1
Failure to monitor whether prisoners swallow dispensed 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
Operate CCTV surveillance and follow the adjudication process when medication diversion is observed.
Stated by Care UKStated completedThe respondent said that this action was complete when they made their response on 10 July 2018.
Action
Have prison staff support healthcare staff when prisoners may not have swallowed medication or are otherwise non-compliant.
Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 10 July 2018.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Universal swallowing checks are not considered practical or appropriate because queues, the physical wall and confidentiality prevent reliable checks.
Stated by Care UKUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
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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.
