First reported 13 Oct 2017•Latest report 25 Feb 2020
Definition
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.
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.
Reports
4
Distinct published reports
Individual concerns
8
A report can raise multiple concerns
Date range
2017–2020
First to latest report issue date
Stated actions
3
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.
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
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 South
Concerns raised2
Failure of controlled drug checks to identify unaccounted drugs
Lack of a clear process for handling and recording controlled drug use
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.
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.
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.
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.
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 the Trust’s controlled drugs policy and share proposed improvements with the Trust.
Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 28 November 2017.
Action
Monitor the Trust’s audit of opioid patch monitoring form implementation through quarterly engagement and consider it at the next inspection.
Stated by Care Quality CommissionStated plannedThe respondent said that this action was planned when they made their response on 28 November 2017.
Action
Review the Trust’s controlled drug standard operating procedures through ongoing engagement.
Stated by Care Quality CommissionStated plannedThe respondent said that this action was planned when they made their response on 28 November 2017.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
The controlled drugs policy is of an acceptable standard, although improvements to incident-investigation responsibilities have been suggested.
Stated by Care Quality CommissionExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
The information currently held provides no evidence that the concerns reflect a systemic issue.
Stated by Care Quality CommissionDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
No further regulatory action is considered necessary regarding this matter based on the information currently held.
Stated by Care Quality CommissionNo 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.
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 Home Office is best placed to provide information about controlled drug legislation and chain of custody.
Stated by General Pharmaceutical CouncilRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
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Includes failures in controlled-drug administration records, custody documentation, chain-of-custody rules, stock reconciliation, double-checked audits and reporting of schedule-specific discrepancies.
