Source: The CCQ 11.07.24
Next year will mark 20 years since the publication of the final report of the Shipman Inquiry.
Since the reports were published, we have seen a significant shift in clinical and governance practices in
relation to controlled drugs to support better care for patients both in the NHS and independent sector.
Legislative changes, such as the 2006 and 2013 updated versions of the Safer Management of Controlled
Drugs (Supervision and Use) Regulations, have also helped.
However, with capacity demands on the health and care system at an all-time high, it is important not to
be complacent about the significance of the learning from this Inquiry, or from the events at
Gosport War Memorial Hospital. In Gosport, poor culture, lack of clinical challenge and a failure to speak
up meant that patients were placed on an end of life pathway indiscriminately and irrespective of their
individual clinical needs.
Risks associated with controlled drugs are still present within health and care systems, which are constantly
changing. Commissioning arrangements can also be complex and opportunities for communication and
collaboration are sometimes reduced because of capacity constraints or incompatible digital systems.
Closed cultures and clinical isolation can increase risks associated with the use of controlled drugs. We are
also aware of the significant pressure on health and care staff, including those who are not registered with
a professional regulator. This can lead to tragic outcomes for all involved, including the staff and the people
they are caring for.
Within services, safer care can be promoted through a combination of a welcoming attitude towards
professional challenge and speaking up, combined with the approach that the safer management of
controlled drugs needs to be “everyone’s business,” – not just that of medicines or pharmacy teams.
In our 2022 report, we emphasised the importance of working collaboratively to improve the prescribing,
managing and monitoring of controlled drugs, particularly through partnership working as part of local
integrated care systems. The systems we now have in place should help us to identify concerning behaviour
or practice sooner. It is vitally important to make the most of these systems, with collaborative working,
effective communication and information sharing central to their effectiveness. This includes those
organisations providing frontline health and care services, but also other local, regional and national
level stakeholders, such as integrated care boards (ICBs), regulators, commissioners and professional bodies.
Click here for the source.
