In early 2009 PHAST was asked to conduct a Serious Untoward Incident report into the self-prescription of controlled drugs by a GP. The investigation team developed a chronology of events and collated and reviewed the evidence using root cause analysis. They also identified and made recommendations to address the fundamental causes of this incident. PHAST produced an Incident Report and an Action Plan for the PCT, outlining actions to take in order to ensure this does not happen again.