Recurring concern
Failure to secure and control medication
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Request correctionFirst reported 14 Mar 2014•Latest report 17 Dec 2025
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
- Individual concerns
- 34
- Date range
- 2014–2025
- Stated actions
- 62
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
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.
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.
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Concerns raised1
Lack of limits on the amount of loperamide medication purchasable from a single store
Responses linked to these concernsEach 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.2
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Position
There is insufficient evidence that loperamide is frequently misused enough to warrant prescription-only classification.
Stated by Medicines and Healthcare products Regulatory Agency
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Position
Responsible patients’ benefit from unrestricted retail access outweighs harms to the small number who deliberately misuse loperamide.
Stated by Medicines and Healthcare products Regulatory Agency
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Concerns raised1
Failure to control access to available medication for a person at risk of overdose
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 concernsEach 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
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Action
Take action to manage the medicines-policy breach.
Stated by Birmingham and Solihull Mental Health NHS Foundation Trust -
Action
Issue a formal practice alert reinforcing suicide-risk, medicines-management and safe-medication-administration requirements, with staff acknowledgement.
Stated by Birmingham and Solihull Mental Health NHS Foundation Trust -
Action
Review the Medicines Code and supporting staff guidance to address medication-administration and risk-assessment issues, and report through internal governance.
Stated by Birmingham and Solihull Mental Health NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
The Trust is responsible for addressing concerns about medication access, risk assessment and staff recognition of available drugs.
Stated by Department of Health and Social Care
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Position
Medication checks and removal of excessive medicines are limited by service users’ capacity and willingness to disclose information and permit searches.
Stated by Birmingham and Solihull Mental Health NHS Foundation Trust
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Concerns raised1
Lack of continuous stock records and verification for non-controlled ward medications
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 concernsEach 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
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Action
Audit all clinical areas quarterly against safe and secure medicines-handling standards and discuss results with ward managers.
Stated by Bolton NHS Foundation Trust -
Action
Use the NHS Protect Medicines Security Ward/Department checklist to audit medicines security, collate divisional results and agree action plans.
Stated by Bolton NHS Foundation Trust -
Action
Operate one-stop dispensing to use patients’ own medicines, reduce stock-medicine use and record dispensing and stock-review information electronically.
Stated by Bolton NHS Foundation Trust
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Action
Introduce a new Wardex recording pharmacists’ clinical reviews and medicine supply.
Stated by Bolton NHS Foundation Trust -
Action
Develop and implement a pharmacy policy endorsing Wardex entries, including medicine supply and quantity details.
Stated by Bolton NHS Foundation Trust -
Action
Present Safe and Secure Handling of Medicines audit results to the Medicines Safety Group for discussion and agreement of action plans.
Stated by Bolton NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Existing systems were considered sufficient to ensure ward medicines are stored securely and their stock can be verified.
Stated by Bolton NHS Foundation Trust
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Concerns raised1
Failure to audit and track the use of non-controlled medication
Responses linked to these concernsEach 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
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Action
Conduct unannounced spot audits of theatre drug storage and documentation.
Stated by the Royal Orthopaedic Hospital NHS Foundation Trust -
Action
Review controls governing controlled and non-controlled medicines.
Stated by the Royal Orthopaedic Hospital NHS Foundation Trust -
Action
Continue monitoring drug-usage trends across all Trust areas to identify potential diversion risks.
Stated by the Royal Orthopaedic Hospital NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Existing controls and professional responsibilities are considered sufficient to mitigate the small residual risk of medicine diversion.
Stated by the Royal Orthopaedic Hospital NHS Foundation Trust
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Concerns raised1
Failure to audit and monitor non-controlled potent 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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to safely secure medication brought into hospital
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to secure 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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to secure medication prescribed to one family member from access by another family member with a history of overdoses
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 concernsEach 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
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Action
Require comprehensive collaborative risk-management care plans for identified medication-hoarding or overdose risks and share them with the involved care team.
Stated by Surrey and Borders Partnership NHS Foundation Trust -
Action
Develop and use a local protocol for safe medication management, including safety plans with people and families where medication-overdose history is identified.
Stated by Surrey and Borders Partnership NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Limited influence over how the public stores medication makes it unrealistic to fully mitigate overdose risk through medication security.
Stated by Surrey and Borders Partnership NHS Foundation Trust
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Concerns raised2
Unauthorised appropriation, trading and stockpiling of patient medication
Failure to ensure medication is handed directly to the intended patient
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 concernsEach 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
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Action
Implement procedures to stop administering medication by sliding it under cell doors.
Stated by Care UK -
Action
Develop and obtain clinical-governance approval for a formal policy governing NIP medication when staff cannot open a cell door.
Stated by Care UK
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
There is no evidence that issuing in-possession medication under cell doors was common practice at HMP Durham.
Stated by Care UK
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Concerns raised1
Failure to monitor consumption of prescribed controlled drugs
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026