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.
Manchester North
Concerns raised1
Easy online access to large amounts of medication, including prescription-only drugs
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 Yorkshire (Eastern)
Concerns raised2
Lack of procedures to monitor and manage repeat prescriptions exceeding prescribed dosages
Lack of procedures to manage access to medication amounts exceeding prescribed quantities
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.7
Action
Identify patients prescribed tramadol and other potentially harmful medicines, review prescribing indications, doses and issue patterns, and recommend contact, early review or no change.
Stated by Manor Field SurgeryStated completedThe respondent said that this action was complete when they made their response on 11 August 2017.
Action
Convert electronic prescriptions to paper prescriptions requiring doctor review before signing.
Stated by Manor Field SurgeryStated completedThe respondent said that this action was complete when they made their response on 11 August 2017.
Action
Seek medicines-management, drugs-and-alcohol, and pharmacist input on difficult or potentially problematic prescriptions.
Stated by Manor Field SurgeryStated completedThe respondent said that this action was complete when they made their response on 11 August 2017.
Action
Call patients identified as potential over-users of tramadol for early review.
Stated by Manor Field SurgeryStated completedThe respondent said that this action was complete when they made their response on 11 August 2017.
Action
Complete a thorough review of medication ordering and review procedures to identify safety problems.
Stated by Manor Field SurgeryStated completedThe respondent said that this action was complete when they made their response on 11 August 2017.
Action
Change repeat-prescribing policy for all medicines and implement amended repeat-prescribing and acute-prescribing protocols with strengthened electronic prompts and consultation processes.
Stated by Manor Field SurgeryStated completedThe respondent said that this action was complete when they made their response on 11 August 2017.
Action
Explain the amended prescribing protocols and procedures to all practice staff during protected time within 10 days.
Stated by Manor Field SurgeryStated plannedThe respondent said that this action was planned when they made their response on 11 August 2017.
Berkshire
Concerns raised1
Failure to limit the amount of antidepressant medication prescribed to patients with suicidal thoughts
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.3
Action
Require GPs to conduct repeat-prescription issuance and depression reviews.
Stated by Woodley Centre SurgeryStated completedThe respondent said that this action was complete when they made their response on 4 August 2017.
Action
Require the assessing or reviewing GP to add a major alert when concerned about a patient’s risk.
Stated by Woodley Centre SurgeryStatus unclearThe respondent did not make the status of this action clear when they made their response on 4 August 2017.
Action
Discuss the significant event at the next clinical meeting.
Stated by Woodley Centre SurgeryStated plannedThe respondent said that this action was planned when they made their response on 4 August 2017.
Brighton and Hove
Concerns raised1
Excessive quantities of Dihydrocodeine prescribed
This report raised 7 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
Work with partner agencies to consolidate regulatory and professional guidance on online prescribing and medicine supply.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 18 September 2016.
Manchester South
Concerns raised1
Failure to control the quantity of Oramorph solution prescribed
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
Raise concerns about prescribed controlled-drug volumes and strengths through the network and provide guidance to prescribers.
Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 10 March 2016.
Action
Examine the controlled-drug incident reporting system to identify high-volume prescribers and question the reasons for high-volume prescribing.
Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 10 March 2016.
Action
Operate a web-based controlled-drug incident reporting system with real-time data and provider alerts for possible abuse.
Stated by NHS Greater Manchester Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 10 March 2016.
Action
Highlight high-volume controlled-drug prescribing in the Care Quality Commission’s next national Controlled Drugs Vigilance Newsletter.
Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 10 March 2016.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5
Position
Prescribers, rather than the respondent, are responsible for deciding appropriate Oramorph prescriptions and volumes.
Stated by NHS Greater Manchester Integrated Care BoardRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Existing prescribing guidance advises keeping drug volumes to a minimum while allowing higher volumes for patients with legitimate end-of-life needs.
Stated by NHS Greater Manchester Integrated Care BoardExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Restricting Oramorph volumes could disadvantage legitimate patients who require high doses at the end of life.
Stated by NHS Greater Manchester Integrated Care BoardDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
A daily maximum morphine dose cannot be set because individual pain-relief needs vary and a limit could harm patient care.
Stated by Home OfficeUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
The ACMD has been commissioned to examine harms from diversion and illicit supply of medicines, including controlled drugs.
Stated by Home OfficeRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Exeter and Greater Devon
Concerns raised1
Failure to limit medication supplies for patients with a history of prescribed-medication 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 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.3
Position
The practice does not agree that too many zopiclone pills were prescribed, as no single prescription exceeded one month’s supply.
Stated by Axminster Medical PracticeDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Existing computer prescribing prompts and pharmacist or dispenser alerts are considered sufficient safeguards for zopiclone prescribing.
Stated by Axminster Medical PracticeExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Restricting prescriptions cannot prevent patients from stockpiling regular medication or accessing other toxic medicines, including over-the-counter drugs.
Stated by Axminster Medical PracticeUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Manchester West
Concerns raised1
Failure of staff training and Trust procedures to prevent prescribing and dispensing excessive paracetamol doses
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
Review and revise paracetamol prescribing practice to require regular monitoring by the responsible clinical team.
Stated by Bolton NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 10 December 2014.
Action
Distribute the SBAR safety communication to medical staff, wards and services using paracetamol, including through staff newsletters and bulletins.
Stated by Bolton NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 10 December 2014.
Action
Amend the Medicines Management e-learning module to reflect the improved paracetamol prescribing process and circulate the message continually to clinical staff.
Stated by Bolton NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 10 December 2014.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
All reasonably practicable steps have been taken to improve paracetamol prescribing and address the identified concerns.
Stated by Bolton NHS Foundation TrustNo action considered necessaryThe respondent said that no further action was needed.
Exeter and Greater Devon
Concerns raised1
Prescribing medication in quantities sufficient for a fatal dose
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Inner South London
Concerns raised1
Availability of potentially fatal quantities of morphine for 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.
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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.
