Advances in safeguarding patients that came out of the Shipman inquiry must not be lost amid NHS reforms, says a report on the management of controlled drugs.

The annual report by the Care Quality Commission warned changes, including the formation of primary care trust clusters, could “challenge” efforts to share vital information including concerns about the activities of individual healthcare professionals.

Under rules prompted by the Harold Shipman case, all trusts are required to appoint controlled drugs accountable officers (CDAOs) and share information via controlled drug local intelligence networks (CD LINS), currently let by PCTs.

CQC checks on the register of more than 1,150 CDAOs at the end of 2011 found just over half of entries were accurate with the rest out of date.

Some officers said they did not know which CD LIN their organisation was part of, “suggesting ongoing changes may have led to some breakdown of communication”, said the report.

“Ongoing changes in the structure of the health service are creating opportunities and challenges for the work of CDAOs and CD LINS.”

Quarterly reports used to flag any concerns about the management or use of controlled drugs “might not be scrutinised appropriately”, it added.

Some CD LINs are now “very large” as a result of PCT clustering, said the report. It added that it was important to ensure the networks remained “fit for purpose” with robust procedures that could be passed on in the new NHS structure.

“It remains important that the developments in safeguarding patients made over the first five years are not overlooked or lost in reorganisation of the NHS,” said the report. “An important part of this will be continued engagement of CDAOs in CD LINs.”

Overall the analysis showed little change in the volume of controlled drugs prescribed in NHS primary care in 2011 – an increase of one per cent compared with 2010.

Nearly 50 million controlled drug items were prescribed last year, costing about £443 million. Spending was down three per cent on last year.