Recurring concern
Medication quantity controls failing to prevent unsafe access to excessive amounts
First reported 14 Mar 2014•Latest report 27 Oct 2025
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.
Not included
- Excludes generic medication record-keeping failures unless they directly undermine medication quantity control.
- 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
- Individual concerns
- 33
- Date range
- 2014–2025
- Stated actions
- 41
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
Reliance on default prescription quantities without adequate quantity validation
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.1
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Action
Add colchicine safety alerts to patient records, recommending quantity limitation and risk assessment for patients with relevant mental-health histories.
Stated by Green Porch Medical Centre
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Concerns raised1
Failure to maintain medication supplies within the maximum 7-day limit
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.
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 limit prescription quantities and avoid duplicate prescribing for patients at high risk of medication 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 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.1
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Position
The Trust disputes that Mrs Brady was oversupplied with medication, stating supplies were limited or not dispensed.
Stated by Sandwell and West Birmingham Hospitals NHS Trust
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Concerns raised1
Availability of prescription drugs in vast quantities for illegal dealing to vulnerable people
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.
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
PHE and ACMD are the appropriate bodies to address concerns about prescription-drug misuse and medicine availability.
Stated by Royal Pharmaceutical Society
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Concerns raised2
Lack of a verification process limiting transaction amounts and ordering frequency
Availability of large quantities of medication for online purchase by an individual
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.
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Concerns raised2
Failure to regulate online suppliers of prescription-only medication
Failure to prevent uncoordinated quantities of prescription-only medication from online suppliers
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
Work with regulators to improve oversight of online prescribers and address legislative regulatory gaps.
Stated by Department of Health and Social Care -
Action
Work with regulators to identify options for addressing online providers’ attempts to circumvent regulatory scrutiny.
Stated by Department of Health and Social Care
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
Oversight of online providers outside CQC regulation may fall to the General Pharmaceutical Council or Medicines and Healthcare products Regulatory Agency.
Stated by Department of Health and Social Care
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Concerns raised1
Availability of many boxes of different repeat-prescribed tablets posing an 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 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
Employ a full-time clinical pharmacist to oversee and improve prescribing governance and patient monitoring.
Stated by West Quay Medical Centre -
Action
Raise medication-review frequency as a practice issue with the Primary, Community and Intermediate Care Clinical Board for consideration.
Stated by Cardiff & Vale University LHB
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
Medication review for patients managed in primary care is a matter for the GP practice and Primary, Community and Intermediate Care Clinical Board.
Stated by Cardiff & Vale University LHB
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Concerns raised1
Prescribing patterns allowing access to significant amounts of 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 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
Inappropriate prescribing of large medication quantities during an initial medication switch
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 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 prescribe safe quantities of discharge medication for patients at risk of stockpiling 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 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.1
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Action
Assess medications prescribed on discharge across the Trust.
Stated by Norfolk and Suffolk NHS Foundation Trust
Data last updated 7 September 2026