An ambulance trust has admitted it needs to change its medicines management to be “legally compliant”, including withdrawing a potentially life saving drug from volunteers.

Allowing staff who are not paramedics and community first responders (members of the public with limited training) to administer some medications has “no specific legal basis”, South East Coast Ambulance Service Foundation Trust has said in a new report.

The trust board will now be asked to approve changes to procedures including a six month moratorium on community first responders and responders from other emergency services giving patients salbutamol. The drug is used for severe asthma attacks and other breathing difficulties.

Other proposals include limiting a drug used in myocardial infarctions to paramedics and other healthcare professionals, with other staff and volunteers being limited to using aspirin, and developing patient group directions and protocols to allow staff to administer some other medications.

In a report to the board, chief pharmacist Carol-Anne Davies-Jones and consultant paramedic Andy Collen said only London Ambulance Service also allowed community first responders to use salbutamol and this was being reviewed.

It described salbutamol as “a potentially life saving medication, which is generally thought to be safe”, but highlighted that when it was administered by volunteers there was no access to incident reporting, problems in auditing use and volunteers had to have the medicines signed out for long durations rather than on each shift. Salbutamol was used by community first responders 124 times in 2016-17.

The report recommended withdrawing salbutamol for community first responders and co-responders for six months and only reintroducing it when governance was in place around training, handling, incident reporting and auditing.

It said some of the proposed changes, due to be discussed by the board today, could mean more incidents needed a paramedic in attendance.

The Care Quality Commission warned the trust last year over its medicine management. Since then it has been reviewing how medications are stored and used.