Controlled Drugs – Learning from incidents

  1. Missing CDs

There has been an increase in reported incidents involving controlled drugs where either:

  • prescriptions have gone missing having been collected from practices by pharmacies or patients’ representa-tives (sometimes without the patient’s consent)
  • medicines have gone missing at the point of delivery by community pharmacies due to theft of medicines from delivery vans
  • patients claiming not to have received their medicines

Advice to Community Pharmacies re the delivery of medicines

As security is paramount, the delivery of CDs should be prioritised to reduce the possibility of theft etc. There is a need for a clear audit trail. This will allow for any checks to be carried out and will be of bene-fit in the light of any discrepancies. Some key points are shown below:

  • Controlled drugs should remain in the pharmacy stock balance until they have been delivered.
  • A book, ‘CD delivery book’ should be kept and retained within the pharmacy, detailing the CDs re-ceived by the delivery driver. The CDs should be signed for by the driver and the time and date should be recorded (copy labels of the drugs can be stuck onto the page).
  • A daily ‘CD delivery sheet’ should be produced. This sheet should have a copy of the bag label attached. This sheet accompanies the medication to the delivery address, and is returned to the pharmacy for retention. Be mindful of patient confidentiality issues.
  • Once the CDs have been handed to the patient/representative, he/she should be asked to sign the receipt section of the delivery sheet. This signature should be timed and dated. A number of indi-vidual deliveries can be shown on one sheet with the patient signing only against those drugs re-ceived by them. Be mindful of patient confidentiality issues.
  • If the delivery is unsuccessful and the CDs are returned to the pharmacy, the delivery book should be endorsed accordingly (time and date).
  • If the delivery is successful, details of the supply can then be written into the CD register.
  • Medication bags should never be on show in the delivery vehicle. Ideally they should be locked in the boot or out of sight. Vehicles should always be locked when unattended.
  • Household key codes should not be recorded on medicines delivery sheets.


NICE Guideline NG46 : The safe use and management of controlled drugs:

NICE published their latest guideline in April 2016. It can be found at:

The guidance is complex as it covers all settings and summarises all legislation related to CDs. It contains links to useful documents and websites where further specific information about CDs is required. The guidance brings together legislation, policy advice, good practice advice and published evidence along with committee experience and opinion in developing the recommendations. The guideline covers 5 key areas: prescribing, obtaining and supplying CDs, administration, handling CDs, and monitoring. Key messages are shown below:

NG46 advice re prescribing CDs:

  • record prescribing decisions
  • provide information and advice to the person
  • review repeat prescriptions and anticipatory CDs
  • consider the balance of benefits, risks and harms

NG46 advice re supplying CDs:

  • follow professional standards and carry out necessary safety checks
  • provide information and advice to the person
  • inform recipient and make a record if part supplies are made

2. Destruction of CDs

There have also been a number of reports of dispensary staff destroying out of date schedule 2 stock without an authorised witness. On some occasions this was an error, but on others, staff weren’t aware of the different requirements for the destruction of stock CDs and of patients’ returned medicines

Destruction of stock controlled drugs

Stock schedule 2 e.g. morphine, methylphenidate, oxycodone

  • An authorised person must witness the destruction of stock schedule 2 controlled drugs
  • Authorised witnesses are appointed by the Controlled Drugs Accountable Officer for the North East and Cumbria, Dr James Gossow
  • To request an authorised witness for the destruction of expired and obsolete stock schedule 2 controlled drugs, please contact the Medicines Optimisation Team (see overleaf)
  • Record in the CD register: the name, strength and form of the controlled drug, quantity, date of destruction, signature of the person destroying the CDs and signature of the authorised person witnessing the destruction

Stock schedule 3 e.g. temazepam, tramadol, and 4 (part1) e.g. diazepam, zopiclone

  • Although not legally required, it is considered good practice to have a witness present (this does not need to be an authorised person), and to record the details e.g. in the patient CD medicine returns book

Destruction of patient returned controlled drugs

Any schedule

  • Consider asking a second member of staff (preferably a registered health professional) to witness the destruction
  • Consider recording the destruction and disposal of returned controlled drugs in a separate patient returns book for this purpose, and record: the date of receipt of the CDs, date of destruction, sig-natures of the person destroying the CDs and any witness

Reminder to pharmacies: ensure you have enough destruction kits on site for staff to carry out patient returns, and for authorised witnesses coming to carry out a stock destruction. Also ensure that enough waste bins are available for them to be disposed in. See overleaf for contact numbers of suppliers of de-naturing kits

Examples of suppliers of CD denaturing kits

  • NHS Supply Chain (Product code KYA003) Tel: 01773 724 000 Fax: 01773 724 225
  • PHS Waste Management Tel: 01204 704 633 Fax: 01204 704641
  • Denward Manufacturing Ltd Tel: 01245 492986 Fax: 01245 496939
  • Select environmental services Tel: 0188 975900

Please note, this list is not exhaustive. The most commonly used kit is 250ml size and a pack of three can be obtained for approximately £10.

To request an authorised witness for the destruction of stock schedule 2 controlled drugs, or if you need advice, contact a member of the Controlled Drugs Team:

Newcastle Tyne & Wear Emma Post 0191 2172983

Durham Darlington & Tees Victoria Bennett 01642 745429

Cumbria Phil Utting 01228 603050

CD Liaison Officer for all areas Ken Dale 07919071655