First reported 14 Mar 2014•Latest report 27 Oct 2025
Definition
What this concern includes
Includes failures of controls dedicated to medication quantity governance, including prescribing, dispensing, online supply, transaction verification, ordering frequency, and adjustment of quantities to overdose or lethal-dose risk.
Excludes medication counselling or clinical review failures when the report does not identify unsafe access to excessive quantities as the shared condition.
Excludes shortages, delays or insufficient access to medication.
Excludes unrelated failures in care, staffing, emergency response or other operational processes.
Reports
29
Distinct published reports
Individual concerns
33
A report can raise multiple concerns
Date range
2014–2025
First to latest report issue date
Stated actions
41
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 Care5
NHS England4
Medicines and Healthcare products Regulatory Agency3
1st For Health International Limited1
Advisory Council on the Misuse of Drugs1
Axminster Medical Practice1
Bolton NHS Foundation Trust1
Cardiff & Vale University LHB1
Clinical Commissioning Group (Devon)1
c/o Mark Reynolds Solicitors1
Dartford and Gravesham NHS Trust1
Department for Digital, Culture, Media and Sport1
Devon Partnership NHS Trust1
Eltham Medical Practice1
General Medical Council1
Healthcare site10
NHS trust6
Type not available6
Ministerial department5
Executive non-departmental public body4
Medicines and medical devices regulator3
Private limited company3
Health and care professional regulator2
Integrated care board2
Advisory non-departmental public body1
Health professional body1
Health-sector membership body1
Local health 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.
Black Country
Concerns raised1
Continued prescribing of repeat medications in large amounts at 28-day frequency after overdose disclosure
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.3
Action
Amend the self-harm follow-up policy to require medication review and consideration of reducing prescription quantities where ongoing risk exists.
Stated by Your Health Partnership PCNStated plannedThe respondent said that this action was planned when they made their response on 29 October 2025.
Action
Amend the self-harm risk-assessment template to record medication review discussions, stockpiling, medication safety, prescription quantity, and medication supervision options.
Stated by Your Health Partnership PCNStated plannedThe respondent said that this action was planned when they made their response on 29 October 2025.
Action
Expand the annual proactive self-harm follow-up audit to record medication reviews and discussions about prescribed medication quantities.
Stated by Your Health Partnership PCNStated plannedThe respondent said that this action was planned when they made their response on 29 October 2025.
Suffolk
Concerns raised1
Failure to limit online prescription quantities according to possible lethal dose
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The prescriber is responsible for decisions on prescription quantities, while service providers must maintain adequate controls and may advise on prescription duration.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Cheshire
Concerns raised1
Inability to prescribe smaller quantities of insulin
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
The MHRA is the more appropriate organisation to respond to concerns about the insulin doses currently available to patients.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Derby and Derbyshire
Concerns raised1
Failure to limit prescription quantities to an appropriate 3- or 4-day supply
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.3
Action
Implement and circulate a standard operating procedure for safely managing three- and four-day prescriptions, including clinician-only issuing, scheduling, alerts, coding and regular review.
Stated by Park SurgeryStated completedThe respondent said that this action was complete when they made their response on 4 July 2024.
Action
Consult local practices and the ICB prescribing team about managing frequent prescriptions and incorporate relevant learning into the practice SOP.
Stated by Park SurgeryStated completedThe respondent said that this action was complete when they made their response on 4 July 2024.
Action
Review the three- and four-day prescribing SOP in July 2025.
Stated by Park SurgeryStated plannedThe respondent said that this action was planned when they made their response on 4 July 2024.
Rutland and North Leicestershire
Concerns raised2
Sale of online drugs in doses and quantities larger than ordinarily prescribed
Failure to control duplicate, excessive or frequent online drug purchases
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.4
Action
Investigate the illicit website through the MHRA criminal enforcement process.
Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 14 June 2024.
Action
Disrupt access to the illicit website through search-engine delisting, parental-control blocking, industry referrals and registry takedown requests.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 14 June 2024.
Action
Develop targeted ISP filtering with search engines and UK internet service providers to block harmful online medicines content.
Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 14 June 2024.
Action
Explore preventative online-safety measures with Ofcom under the Online Safety Act.
Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 14 June 2024.
Inner North London
Concerns raised1
Failure to maintain daily amitriptyline dispensing to mitigate overdose 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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Inner South London
Concerns raised1
Failure to limit quantities of Propranolol prescribed to people at risk of overdose
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Sunderland
Concerns raised1
Failure to prevent full-pack dispensing of Zuclopenthixol to patients prescribed weekly doses with suicidal risk and previous overdose attempts
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
Raise concerns with the Department of Health and Social Care about clopixol pack sizes and special container status at forthcoming meetings.
Stated by National Pharmacy AssociationStated plannedThe respondent said that this action was planned when they made their response on 19 March 2024.
Action
Provide stability data for Lundbeck zuclopenthixol tablets to support assessment of special container status.
Stated by Lundbeck LimitedStated completedThe respondent said that this action was complete when they made their response on 19 March 2024.
Action
Consider communications to raise pharmacy-profession awareness of special-container quantity exceptions.
Stated by General Pharmaceutical CouncilStated plannedThe respondent said that this action was planned when they made their response on 19 March 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.7
Position
Determining whether a particular medicine has special container status is outside the respondent’s influence and authority.
Stated by National Pharmacy AssociationOutside remitThe respondent said that this matter was outside its role or authority.
Position
The Department of Health and Social Care is ultimately responsible for the regulatory system and is the more appropriate body to address the matter.
Stated by National Pharmacy AssociationRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Responsibility for action on the Prevention of Future Deaths report rests with the General Pharmaceutical Council, whose response closes the regulatory review.
Stated by Medicines and Healthcare products Regulatory AgencyRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The manufacturer does not specify or classify the product as requiring special container status in its regulatory documents.
Stated by Lundbeck LimitedOutside remitThe respondent said that this matter was outside its role or authority.
Position
The NHS Business Services Authority independently assigns special container status under the applicable Drug Tariff criteria.
Stated by Lundbeck LimitedRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Licensing, medicine status and pack size fall outside the respondent’s direct regulatory role.
Stated by General Pharmaceutical CouncilOutside remitThe respondent said that this matter was outside its role or authority.
Position
The MHRA, Department of Health and Social Care, and manufacturer are responsible for medicine licensing, status and pack size.
Stated by General Pharmaceutical CouncilRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Mid Kent and Medway
Concerns raised1
Failure to document and communicate discharge medication recommendations
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
Record when a reduced medication quantity should be prescribed because of self-harm or overdose risk.
Stated by Dartford and Gravesham NHS Trust and Kent and Medway Mental Health NHS TrustStatus unclearThe respondent did not make the status of this action clear when they made their response on 14 March 2024.
Action
State in discharge notifications when medication has been reduced and record the reason.
Stated by Dartford and Gravesham NHS Trust and Kent and Medway Mental Health NHS TrustStatus unclearThe respondent did not make the status of this action clear when they made their response on 14 March 2024.
Suffolk
Concerns raised1
Failure to limit medication dispensing in line with overdose-risk controls
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.2
Action
Add a Summary Care Record sentence limiting controlled medication following an overdose diagnosis to no more than a 48-hour supply.
Stated by Rosedale SurgeryStated plannedThe respondent said that this action was planned when they made their response on 19 January 2024.
Action
Change prescriptions to daily dispensing for patients admitted with more than one overdose within three months, until the risk period ends.
Stated by Rosedale SurgeryStated plannedThe respondent said that this action was planned 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.2
Position
James Paget University Hospitals NHS Trust should provide information about the deceased’s care, including prescribing policies and the concerns raised.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The Trust disputes that 28 days of medication were supplied, stating that the first discharge involved only a 10-day fluoxetine supply.
Stated by James Paget University Hospitals NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
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Includes failures of controls dedicated to medication quantity governance, including prescribing, dispensing, online supply, transaction verification, ordering frequency, and adjustment of quantities to overdose or lethal-dose risk.
