Pharmacists have been urged to tighten their controlled drug (CD) procedures after 98 pain-relief tablets went missing during deliveries from a Sunderland pharmacy to patients' homes.

Packs of oxycodone and zomorph, used by cancer patients, were packaged in three separate monitored-dosage systems when they disappeared from an unattended delivery van, the North of England Commissioning Support Unit (NECS) told C+D on Monday (August 5).

An investigation by the NECS showed there was no forced entry into the van on July 3 and there was no credible explanation as to how the tablets had gone missing, a spokesperson said. There were no arrests resulting from the incident.

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	NECS controlled drug liaison officer Ken Dale issued a warning to Gateshead and South Tyneside LPC last month, urging pharmacists to review their standard operating procedures.

The NECS's investigation showed that the systems in place for CD deliveries were "not robust enough", he said. Mr Dale advised pharmacists to ensure that delivery drivers provided timed and dated signatures in the pharmacy's CD register, that their vans were fit for purpose and that they received patient signatures at the point of delivery. He also recommended pharmacists prioritise the delivery of CDs to "reduce the risk of loss by opportunist thieves". 

Gateshead and South Tyneside LPC communications officer and contractor Sami Hanna told C+D that incidents like this were "quite unusual" and pharmacists were vigilant about controlled drugs. He said the warning had gone out to highlight a review of the CD procedures.

The missing haul comprised of 14 x 10mg, 28 x 20mg and 14 x 80mg oxycodone tablets along with 28 x 10mg and 14 x 30mg zomorph tablets. Replacements were delivered to the patients on the same day.