MUSN Monthly Webinar – Controlled Drugs: Gosport Then and Now – 9 October 2019


The report of the independent panel into failings at Gosport War Memorial Hospital highlighted what went wrong when controlled drugs were prescribed and administered inappropriately for patients at the end of their life in the 1990s. At least 450 people, and possibly a further 200, had their lives shortened due to a culture of blanket prescribing of diamorphine and subsequent inappropriate judgements that patients were at the end of their life.

In this webinar, we look at what happened then; the Government response and the issues this raises for providers of pharmacy services (whether in-house or outsourced) together with areas for action. We also cover the importance of the culture of an organisation and the responsibility of healthcare professionals to speak up on areas of concern that might negatively affect patient safety. Presented by:

Sarah Dennison is a registered pharmacist who worked in hospital pharmacy in the NHS, independent sector and overseas before going into regulation. She joined CQC’s controlled drugs team, responsible for delivering CQC’s controlled drug responsibilities in 2010 and has held the post of National Controlled Drugs Manager since 2012.

Jon Hayhurst trained and worked in hospital pharmacy in the NHS before working in Australia as a renal pharmacist for a time. Since returning to the UK he has been employed in adult social care, primary care commissioning, and medicines optimisation before moving to his current regulatory role as a Controlled Drugs Accountable Officer and Medication Safety Officer for NHS England & NHS Improvement in the South West.

CQC  The safer management of controlled drugs – Webpage

The safer management of controlled drugs – Annual update 2018 pdf

A RECORDING of the webinar is now available.  You need to be logged in with your nhs email address to access this page.

A pdf of the presentation is also available below.


Confirmed minutes