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You can view all medicines management procedures by visiting the Policies and Procedures section of YourSpace and selecting Trust Wide (for aligned procedures) or the relevant Division from the drop-down bar, and search with the relevant key word.

If a procedure cannot be found for a Division, check that this has not been superseded by a Trust wide policy/procedure.

Divisional procedures may also be found on:

  • SharePoint - Local / Secure / LD
  • SIRS - Community Division Services

A list of Trust Wide procedure can be found on the Trust Wide Medicines Related Policies and Procedure tab below.

The policies and procedures listed below are available on YourSpace.

Trust Wide procedures

MMP01 Safe Management of Controlled Drugs (this will be live 1st July 2022)

MMP02 Safe Management of Unidentifiable and Suspected Illicit Substances

MMP03 Administration of Discretionary Medicines








MMP11 Discharge Medicines Services (DMS)

MMP12 Use of Buprenorphine Injection (Buvidal)

MMP13 Non Medical Prescribing within the Anticoagulation Service


MMP15 Administration of the Covid-19 and Seasonal Influenza Vaccination to Trust Inpatients


Trust Wide Policies

SD12 Safe and Secure Medicines

SD11 Rapid Tranquillisation

MCT08 Controlled Drugs

MM05 Non Medical Prescribing

SD50 Patient Group Directions

SD36 Use of Unlicensed & Off-label Medicines

Record of Delivery (single patient use form) - to be used when delivering medication directly to a patient (i.e. not to a Trust site) to provide an accurate audit trail of receipt of the medication. This should be uploaded to the patient's electronic record.