Date Published: 27 August 2009

CQC says health services are responding to tragedy of Shipman with better monitoring of controlled drugs

The Care Quality Commission (CQC) has published a report detailing significant progress in implementing regulations introduced in response to the Shipman Inquiry, to monitor controlled drugs.

The Shipman Inquiry found that ineffective monitoring had allowed Dr Harold Shipman to obtain large quantities of diamorphine, which he used to kill at least 15 and possibly up to 200 patients.

The Controlled Drugs (Supervision of Management and Use) Regulations 2006 were introduced in January 2007. This is the second report on implementation of the regulations and covers progress made during 2008.

CQC said that the majority of healthcare organisations comply with the regulations and that many of the problems experienced during the first year of the new system have been resolved. It said healthcare workers are now better trained to deal with concerns about controlled drugs and to identify problems sooner.

But CQC said there are still important parts of the system that need to be improved. It cautioned healthcare providers not to lose the substantial gains, but to build on them and to ensure they continue to embed the practices into routine activity.

The CQC made the following recommendations:

  1. Organisations should have mechanisms to replace accountable officers immediately when vacancies arise and to notify CQC of the change. Almost all relevant health organisations now have accountable officers in place who are responsible for monitoring controlled drugs. However, there has been significant turnover of accountable officers, particularly in PCTs where 41% changed their accountable officer at least once between January 2007 and December 2008.
  2. That a more robust method to ensure that 72-hour fetanyl patches, which are used to manage chronic pain, are applied at appropriate intervals is explored. Fetanyl patches are applied to relieve pain and last for 72 hours. They are often used in palliative care situations both in care homes and where care is provided by visiting carers in a person's home. The former adult social care regulator, the Commission for Social Care Inspection, advised that it in some cases it was difficult to manage and monitor the use of the three-day patches as the days to change the patches are different each week. This could mean that patches are changed too late, leaving the patient in pain.
  3. Organisations should ensure there are enough "authorised witnesses" for destroying obsolete drugs. Organisations must appoint authorised witnesses to be present when obsolete drugs are destroyed. The Royal Pharmaceutical Society of Great Britain advised that earlier problems relating to accumulation of obsolete controlled drugs had improved as more authorised witnesses were appointed. However, it said that some organisations need to both appoint additional witnesses and recognise existing witnesses in order to prevent accumulation of drugs, which could create a risk to security.
  4. Local intelligence networks must make sure they inform relevant bodies about their formation and leadership and that they know where to submit reports. The Royal Pharmaceutical Society of Great Britain reports that effectiveness of local intelligence networks is variable and information sharing between organisations and the networks requires further development. During 2008, some PCTs changed the set-up of their local intelligence networks, sometimes establishing networks that cover more than one PCT. This created uncertainty about leadership and reporting. While these issues have now been resolved, it is important that local intelligence networks are clear about their remit and responsibilities.

Cynthia Bower, CQC's chief executive, said:

" This is an example of how the healthcare system can learn from past events and make necessary changes to minimise risks to patients. There is no doubt that England's healthcare system is better equipped than ever to spot irregularities in the handling of controlled drugs early and to take action where problems arise.

The important thing about these new systems is that they keep everyone talking to each other. Healthcare staff are better trained and more aware of issues relating to controlled drugs. We also have access to more information about prescribing patterns. Organisations should keep building on this good work and continue to reduce risks to patients as much as they possibly can. "

The regulations require relevant healthcare organisations to have an accountable officer who is responsible for monitoring controlled drugs. They also require providers, regulatory bodies and agencies to share information and investigate serious concerns.

The government handed overarching responsibility for external scrutiny of the new system to the former healthcare regulator, the Healthcare Commission. This responsibility was passed to the new regulator, CQC, on 1 April this year.


Source: The CareQuality Commission (England, UK).

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