Reporting incidents related to Controlled drugs 

Information for: Pharmacies, GP and Dental Practices 

Controlled drugs (CDs) are subject to high levels of regulation as they are addictive and harmful.  Pharmacies, Dental and GP practices must report incidents involving CDs to the Controlled Drugs Accountable Officer at NHS England, ideally within 48 hours of identifying the incident.   

Incidents to report include suspected theft or behaviour to misappropriate CDs (by patients and health and care workers), patient harm from prescribing, dispensing or administration errors involving CDs. 

Reporting these issues enables risks to be mitigated and trends to be seen and acted on – to prevent harm to the public and staff, as well as provide support to the health and care workers. 

The following are examples to be curious about, and if concerned can be reported at www.cdreporting.co.uk.   

• Prescribers prescribing controlled drugs for themselves, family or friends 

• Noticing a trend of cancelled prescriptions for controlled drugs (i.e. prescribed and then cancelled) 

• Staff who have allowed their SMART card to be used by other staff to generate prescriptions for themself or to fraudulently use patients’ names to prescribe controlled drugs 

• FP10s (controlled stationery) left unattended or in printers where patients can access  

• Concerns of a professional’s or employee’s attitude, health or competence with safe use of controlled drugs.  

• Prescriber, receptionist, practice nurse, paramedic etc collecting controlled drugs from the pharmacy on behalf of patients 

• Discrepancies in pharmacy invoices for controlled drugs against stock levels  

• Pharmacy staff ordering controlled drugs outside usual processes (e.g. phone orders instead of online so no audit trail) 

• Patients with potential drug seeking behaviours (e.g. temporary residents who request CDs from GP, NHS111 referrals for CDs)  

Examples of common Controlled Drugs include: 

The North West Controlled Drugs Accountable Officers Team 

Karen O’Brien and Devina Halsall are the Controlled Drugs Accountable Officers for NHS England Northwest Region, and their team oversees the following ICSs: 

• Cheshire and Merseyside 

• Lancashire and South Cumbria  

• Greater Manchester  

Report incidents or concerns immediately, via the CD reporting website: www.cdreporting.co.uk 

For support or queries contact the team: england.nwcdreporting@nhs.net.

Regulatory context 

In 2006, the Health Act was enacted and this formed part of the Government’s response to the Shipman Inquiry’s Fourth Report. The Controlled drugs (Supervision of Management and Use) Regulations 2006 were introduced and the regulations were renewed in 2013 and 2020. 

Controlled drugs are essential to modern clinical care. The aim of the regulations is to strengthen the governance arrangements for the use and management of controlled drugs. It is essential that NHS England enforces robust arrangements for the management and use of controlled drugs to minimise patient harm, misuse and criminality. 

These regulations require Primary care organisations to share information about the misuse of controlled drugs within healthcare settings.