Unreliable controlled-drug custody, documentation and audit controls
First to latest report 13 Oct 2017 — 25 Feb 2020
Reports that mention this concern
4
Times this concern has been raised
8
Stated actions linked to this concern
3
What this concern includes
Includes failures in controlled-drug administration records, custody documentation, chain-of-custody rules, stock reconciliation, double-checked audits and reporting of schedule-specific discrepancies.
What is not included
Excludes clinical monitoring of patients after controlled-drug administration where custody, documentation or audit controls are reliable.
Excludes prescribing or dose-selection failures unrelated to controlled-drug accountability.
Excludes medicines not subject to controlled-drug custody and audit requirements.
Trends
Reports over time
Reports mentioning this concern, 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.
Care Quality Commission2
General Pharmaceutical Council2
NHS England2
Boots UK Limited1
General Practitioners Committee UK1
Manchester University NHS Foundation Trust1
Executive non-departmental public body2
Health and care professional regulator2
Health and social care service regulator2
NHS trust1
Private limited company1
Sub-organisation1
Reports and published responses 4 reports
See individual reports that have raised this concern, and the actions taken in response
Manchester South
Concerns raised2
Failure of controlled drug checks to identify unaccounted drugs
Lack of a clear process for handling and recording controlled drug use
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
London Inner (West)
Concerns raised3
Lack of physical checking of prescription-box contents during controlled-drug audits
Lack of double-checking in controlled-drug audits
Lack of pharmacy reporting requirements for schedule 2 controlled-drug discrepancies
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Manchester City
Concerns raised2
Failure of the system for audit of controlled-drug processes
Failure of the system for documentation of controlled drugs
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Care Quality Commission
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Care Quality Commission
Review the Trust’s controlled drugs policy and share proposed improvements with the Trust.
Care Quality Commission
Monitor the Trust’s audit of opioid patch monitoring form implementation through quarterly engagement and consider it at the next inspection.
Care Quality Commission
Review the Trust’s controlled drug standard operating procedures through ongoing engagement.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Care Quality Commission
The controlled drugs policy is of an acceptable standard, although improvements to incident-investigation responsibilities have been suggested.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Care Quality Commission
The information currently held provides no evidence that the concerns reflect a systemic issue.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Care Quality Commission
No further regulatory action is considered necessary regarding this matter based on the information currently held.
No action considered necessaryThe respondent said that no further action was needed.
Manchester North
Concerns raised1
Lack of specific guidance defining when, where and how the chain of custody for controlled drugs is completed
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
General Pharmaceutical Council
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
General Pharmaceutical Council
The Home Office is best placed to provide information about controlled drug legislation and chain of custody.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.