NHS England
AI-generated response summary
NHS England's National CDAO function will address drug disposal methods at a national learning event in September 2026, and regional CDAOs have already communicated learning and shared the report with local ICB pharmacy leads. For doctor working patterns, NHS England reiterates the expectation for doctors to declare all work to ensure compliance with working time regulations.
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Dear Ms Griffin, Re: Regulation 28 Report to Prevent Future Deaths – Naeem Ahmed who died on 21 June 2025 Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 24th June 2026 concerning the death of Dr Naeem Ahmed on 21st June 2025. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Dr Ahmed’s family and loved ones. NHS England is keen to assure the family and yourself that the concerns raised have been listened to and reflected upon. Your Report raised the following concerns:
1. Depending on the methods adopted by hospitals in England and Wales when disposing of unused liquids in sharps bin, there is a risk that the liquids could be used and lead to fatal consequences.
2. There is no legal requirement for doctors to notify NHS Trusts of their private work patterns or notify private providers of their NHS work patterns which can result in continuous periods of working without rest which could put both patient and doctors’ lives at risk.
1. The process for the disposal of drugs in Trusts NHS England recognises the risk of obsolete controlled drugs being recovered from sharps bins, whether from discarded syringes or where their contents have been squirted into them. NHS England has previously reminded organisations and individuals of the need to render obsolete controlled drugs irrecoverable as part of any disposal process, as is now the case in Poole hospital with the use of gels in sharps bins. The National Controlled Drugs Accountable Officer (CDAO) function will address this matter again at an upcoming national learning event on 22nd September 2026. We will remind designated bodies of their obligations under both the misuse of drugs and health and safety legislation which require that controlled drugs are securely disposed of and not ordinarily capable of being accessed accidentally or deliberately.
[Page 2] In addition, we recognise the risk to colleagues’ health and wellbeing where life stresses, including any associated with work, may increase their risk of misusing controlled drugs where they have access to them. We routinely remind organisations and colleagues of the need to ensure that there is adequate support for their employees especially those working in potentially stressed and/or traumatic clinical environments. NHS England will also raise this case with the Care Quality Commission as the medicines governance component of their inspection will include the disposal of controlled drugs in operating departments.
2. Doctor’s working patterns and requirements to inform of other NHS and private work NHS England would expect doctors to declare and review their full scope of practice to their appraiser, for the purpose of licensing and revalidation. This forms part of their appraisal which is shared with their Responsible Officer (RO) which should include appraisal of any work they are undertaking, including the location and frequency of any work. This includes any private work they are undertaking. As Dr Ahmed was working in secondary care their RO would be a senior clinician (typically the Medical Director) of their main clinical employer, which is usually their NHS Trust where they have their substantive NHS contract. The European Working Time Directive (EWTD) is an EU initiative to prevent employers from requiring their workforce to work excessively long hours, with implications for health and safety. The UK version of the EWTD is also known as the Working Time Regulations (WTR). Post Brexit the UK remains bound by core rules originating from the European Union's law, but under domestic UK legislation rather than direct EU authority. The WTR, which implements the EWTD in law, came into force on 1 October 1998, with full compliance by 2009. These safeguards are particularly relevant to workers in the health service:
• a limit of an average of 48 hours worked per week, over a reference period
• a limit of 8 hours worked in every 24-hour period for night work
• a weekly rest period of 24 hours every week
• an entitlement to 11 hours consecutive rest per day
• an entitlement to a minimum 20-minute rest break where the working day is longer than 6 hours
• a requirement on the employer to keep records of hours worked. However, it is still possible for doctors to work longer hours by signing an opt-out clause. It is not possible to opt out of the rest requirements, so doctors still need to ensure they take the necessary breaks, and their employer still needs to monitor the hours they work. NHS England therefore expects doctors to declare their full scope of work, including any additional work undertaken for other employers, to their Clinical Director
[Page 3] or line manager, to ensure compliance with the WTR for the safety of both the doctor, and for the patients they treat. Regional Response NHS England’s South West regional colleagues have been in contact with the South West CDAO who has informed us that the following actions have been taken:
• They have written to South West CDAOs (South West NHS Trusts, Independent Hospitals, Hospices) regarding the learning around the disposal of medicines.
• They have also shared the report with South West Integrated Care Board (ICB) Pharmacy Leads for their awareness.
• They have raised the issue at a recent National CDAO network meeting and shared this learning with regional NHS England CDAO colleagues (England only). I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Dr Ahmed, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action. Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.
1. Depending on the methods adopted by hospitals in England and Wales when disposing of unused liquids in sharps bin, there is a risk that the liquids could be used and lead to fatal consequences.
2. There is no legal requirement for doctors to notify NHS Trusts of their private work patterns or notify private providers of their NHS work patterns which can result in continuous periods of working without rest which could put both patient and doctors’ lives at risk.
1. The process for the disposal of drugs in Trusts NHS England recognises the risk of obsolete controlled drugs being recovered from sharps bins, whether from discarded syringes or where their contents have been squirted into them. NHS England has previously reminded organisations and individuals of the need to render obsolete controlled drugs irrecoverable as part of any disposal process, as is now the case in Poole hospital with the use of gels in sharps bins. The National Controlled Drugs Accountable Officer (CDAO) function will address this matter again at an upcoming national learning event on 22nd September 2026. We will remind designated bodies of their obligations under both the misuse of drugs and health and safety legislation which require that controlled drugs are securely disposed of and not ordinarily capable of being accessed accidentally or deliberately.
[Page 2] In addition, we recognise the risk to colleagues’ health and wellbeing where life stresses, including any associated with work, may increase their risk of misusing controlled drugs where they have access to them. We routinely remind organisations and colleagues of the need to ensure that there is adequate support for their employees especially those working in potentially stressed and/or traumatic clinical environments. NHS England will also raise this case with the Care Quality Commission as the medicines governance component of their inspection will include the disposal of controlled drugs in operating departments.
2. Doctor’s working patterns and requirements to inform of other NHS and private work NHS England would expect doctors to declare and review their full scope of practice to their appraiser, for the purpose of licensing and revalidation. This forms part of their appraisal which is shared with their Responsible Officer (RO) which should include appraisal of any work they are undertaking, including the location and frequency of any work. This includes any private work they are undertaking. As Dr Ahmed was working in secondary care their RO would be a senior clinician (typically the Medical Director) of their main clinical employer, which is usually their NHS Trust where they have their substantive NHS contract. The European Working Time Directive (EWTD) is an EU initiative to prevent employers from requiring their workforce to work excessively long hours, with implications for health and safety. The UK version of the EWTD is also known as the Working Time Regulations (WTR). Post Brexit the UK remains bound by core rules originating from the European Union's law, but under domestic UK legislation rather than direct EU authority. The WTR, which implements the EWTD in law, came into force on 1 October 1998, with full compliance by 2009. These safeguards are particularly relevant to workers in the health service:
• a limit of an average of 48 hours worked per week, over a reference period
• a limit of 8 hours worked in every 24-hour period for night work
• a weekly rest period of 24 hours every week
• an entitlement to 11 hours consecutive rest per day
• an entitlement to a minimum 20-minute rest break where the working day is longer than 6 hours
• a requirement on the employer to keep records of hours worked. However, it is still possible for doctors to work longer hours by signing an opt-out clause. It is not possible to opt out of the rest requirements, so doctors still need to ensure they take the necessary breaks, and their employer still needs to monitor the hours they work. NHS England therefore expects doctors to declare their full scope of work, including any additional work undertaken for other employers, to their Clinical Director
[Page 3] or line manager, to ensure compliance with the WTR for the safety of both the doctor, and for the patients they treat. Regional Response NHS England’s South West regional colleagues have been in contact with the South West CDAO who has informed us that the following actions have been taken:
• They have written to South West CDAOs (South West NHS Trusts, Independent Hospitals, Hospices) regarding the learning around the disposal of medicines.
• They have also shared the report with South West Integrated Care Board (ICB) Pharmacy Leads for their awareness.
• They have raised the issue at a recent National CDAO network meeting and shared this learning with regional NHS England CDAO colleagues (England only). I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Dr Ahmed, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action. Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.