First reported 27 Oct 2014•Latest report 14 Oct 2025
Definition
What this concern includes
Includes failures to check prescription status before issuing a subsequent prescription, prevent repeat prescribing of discontinued medication, or reconcile hospital and primary-care prescriptions to prevent duplicate medication supply.
Not included
Excludes clinically inappropriate medication choice, dose or indication where duplication or continuation after cancellation or discontinuation is not the unsafe condition.
Excludes ordinary medication administration, dispensing, supply, monitoring or adherence failures after prescription duplication or discontinuation has not occurred.
Excludes medication-quantity controls and overdose-risk prescribing safeguards where the issue is excessive quantity rather than duplicate or discontinued prescriptions.
Excludes generic record-keeping, communication or electronic-system deficiencies unless they directly allow a duplicate or discontinued medication prescription to be issued.
Reports
10
Distinct published reports
Individual concerns
11
A report can raise multiple concerns
Date range
2014–2025
First to latest report issue date
Stated actions
23
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
NHS England3
Royal Pharmaceutical Society2
Belmarsh Prison1
Clare House Surgery1
Egton Medical Information Systems Limited1
Eltham Palace Surgery1
General Medical Council1
Greater Manchester1
Isle of Wight NHS Trust1
Lewisham and Greenwich NHS Trust1
Medical Centre1
Medicines and Healthcare products Regulatory Agency1
NHS Hampshire and Isle of Wight Integrated Care Board1
Nursing and Midwifery Council1
Oracle Corporation UK Limited1
NHS trust4
Executive non-departmental public body3
Private limited company3
Healthcare site2
Health professional body2
Domiciliary care provider1
Health and care professional regulator1
Integrated care board1
Medicines and medical devices regulator1
Prison or young offender institution1
Social-care provider1
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
Inner South London
Concerns raised1
Failure to prevent concurrent prescriptions of paracetamol-containing drugs
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.13
Action
Commission and maintain the ePRASE toolkit, including therapeutic duplication scenarios in its finalised 2025 release.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 19 December 2025.
Action
Review therapeutic-duplication scenarios as a priority for the 2026 ePRASE release.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 19 December 2025.
Action
Liaise with NHS England about preventing prescribing systems from dispensing two concurrent medicines containing paracetamol.
Stated by Medicines and Healthcare products Regulatory AgencyStated completedThe respondent said that this action was complete when they made their response on 19 December 2025.
Action
Complete a detailed review of Millennium’s duplicate-prescription and paracetamol overdose alert functionality.
Stated by Oracle Corporation UK LimitedStated completedThe respondent said that this action was complete when they made their response on 19 December 2025.
Action
Continue augmenting the content and functionality of Millennium alert notifications, including overdose-related alerts.
Stated by Oracle Corporation UK LimitedStated in progressThe respondent said that this action was in progress when they made their response on 19 December 2025.
Action
Continue working with Trust clients to inform and educate them about available alert functionality.
Stated by Oracle Corporation UK LimitedStated in progressThe respondent said that this action was in progress when they made their response on 19 December 2025.
Action
Discuss safeguards against paracetamol dosing incidents with Trust clients through quarterly meetings.
Stated by Oracle Corporation UK LimitedStated completedThe respondent said that this action was complete when they made their response on 19 December 2025.
Action
Introduce the UK Administration Alert Notification and explain its triggers, operation and implementation options to Trusts through a Special Interest Group meeting.
Stated by Oracle Corporation UK LimitedStated completedThe respondent said that this action was complete when they made their response on 19 December 2025.
Action
Present updates to the Administration Alert Notification, including patient-weight-based maximum-dose calculations, to Trust clients.
Stated by Oracle Corporation UK LimitedStated completedThe respondent said that this action was complete when they made their response on 19 December 2025.
Action
Continue reviewing and monitoring Trust-client awareness of duplicate-prescription and paracetamol overdose alert functionality.
Stated by Oracle Corporation UK LimitedStated in progressThe respondent said that this action was in progress when they made their response on 19 December 2025.
Action
Continue discussing potential software or configuration enhancements with clients, including their appropriateness and workflow impact.
Stated by Oracle Corporation UK LimitedStated in progressThe respondent said that this action was in progress when they made their response on 19 December 2025.
Action
Maintain electronic prescribing alerts preventing duplicate or excessive paracetamol prescribing and administration.
Stated by Lewisham and Greenwich NHS TrustStated completedThe respondent said that this action was complete when they made their response on 19 December 2025.
Action
Seek assurance that Epic will implement iCare paracetamol safety features when introduced across the three Trusts.
Stated by Lewisham and Greenwich NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 19 December 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5
Position
NHSE is responsible for incorporating incident learning into commissioning the ePRaSE prescribing system.
Stated by Medicines and Healthcare products Regulatory AgencyRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Building electronic prescribing alerts requires national oversight to coordinate work with secondary-care system suppliers.
Stated by Royal Pharmaceutical SocietyRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
No evidence has been identified that the software contains a defect or deficiency relevant to duplicate paracetamol prescribing.
Stated by Oracle Corporation UK LimitedDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Existing prescribing and administration alert functionality is considered appropriate and functioning as designed, so further alert-notification code development is unnecessary.
Stated by Oracle Corporation UK LimitedExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
The client decides whether to adopt particular code or configuration enhancements, taking account of clinical and commercial considerations.
Stated by Oracle Corporation UK LimitedRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Devon, Plymouth and Torbay
Concerns raised2
Submission of subsequent prescriptions despite knowledge that the first prescription was cancelled or to be cancelled
Failure or inability to ascertain prescription status before issuing a subsequent prescription
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
Action
Publish and make available the Repeat Prescribing Toolkit with guidance on reviewing and safely managing high-risk repeat medicines.
Stated by Royal Pharmaceutical SocietyStated completedThe respondent said that this action was complete when they made their response on 2 December 2024.
Action
Require prescription cancellation to be treated as a last resort.
Stated by Partners of Amicus Health GroupStated completedThe respondent said that this action was complete when they made their response on 2 December 2024.
Action
Require prescription staff to email Pharmacy2U about prescription cancellations.
Stated by Partners of Amicus Health GroupStated completedThe respondent said that this action was complete when they made their response on 2 December 2024.
Action
Monitor rejected electronic cancellation notifications daily and act on them when required.
Stated by Partners of Amicus Health GroupStated completedThe respondent said that this action was complete when they made their response on 2 December 2024.
Action
Eliminate non-auditable messaging systems for clinical information in prescription management.
Stated by Partners of Amicus Health GroupStated completedThe respondent said that this action was complete when they made their response on 2 December 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5
Position
Without direct contact from the prescriber, the pharmacy could not reasonably establish that an already downloaded prescription was intended to be cancelled.
Stated by Pharmacy2UUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Reminding prescribers about cancellation guidance may be a matter for the professional leadership body for GPs.
Stated by Pharmacy2URedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The initial advice to contact Pharmacy2U was considered correct, and no error had occurred at that interaction.
Stated by Partners of Amicus Health GroupDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
The existing policy of asking patients to arrange pharmacy changes directly was considered sufficient where the request is patient-initiated.
Stated by Partners of Amicus Health GroupExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
The practice cannot easily cancel prescriptions after pharmacy download because cancellation routes and pharmacy communications are not sufficiently accessible.
Stated by Partners of Amicus Health GroupUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Lincolnshire
Concerns raised1
Failure to prevent duplicate medication prescriptions between hospital and GP
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The Trust’s 14-day discharge-supply policy and associated arrangements remain appropriate despite accepted overlapping prescriptions.
Stated by United Lincolnshire Teaching Hospitals NHS TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Surrey
Concerns raised1
Failure of ended repeat prescriptions to be removed from pending medication-management queues
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Maintain cancellation warnings, workflow task visibility, and restart-or-reject controls for ended repeat prescriptions.
Stated by EMIS GroupStated completedThe respondent said that this action was complete when they made their response on 3 July 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing EMIS Web functionality is sufficient to mitigate the identified medication-management risks, so no software developments are required.
Stated by EMIS GroupExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
West Sussex
Concerns raised1
Failure of providers to check existing prescriptions across providers before issuing new prescriptions
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Define common medicines-information standards and support their adoption across health and care organisations.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 18 May 2021.
Action
Deliver minimum shared-record view access to currently digitally available medicines information.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 18 May 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing GMC prescribing guidance sets information and safety responsibilities for NHS and private prescribers.
Stated by NHS EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Black Country
Concerns raised1
Failure to limit prescription quantities and avoid duplicate prescribing for patients at high risk of medication overdose
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The Trust disputes that Mrs Brady was oversupplied with medication, stating supplies were limited or not dispensed.
Stated by Sandwell and West Birmingham Hospitals NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Isle of Wight
Concerns raised1
Failure to check the medicines database before prescribing duplicate medication doses
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Manchester South
Concerns raised1
Lack of standard directions for managing requests to restart a discontinued medication
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Legal responsibility for prescribing lies with the doctor who signs the prescription.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Inner South London
Concerns raised1
Failure to cancel discontinued medication prescriptions in the computerised record
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Inner South London
Concerns raised1
Failure of the repeat-prescribing system to prevent prescriptions of discontinued medication
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Carry out quarterly medication reviews through the CCG Prescribing Advisor.
Stated by Eltham Palace SurgeryStated completedThe respondent said that this action was complete when they made their response on 27 October 2014.
Action
Carry out twice-yearly medication reviews using the practice computer records and electronic prescribing system.
Stated by Eltham Palace SurgeryStated completedThe respondent said that this action was complete when they made their response on 27 October 2014.
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Includes failures to check prescription status before issuing a subsequent prescription, prevent repeat prescribing of discontinued medication, or reconcile hospital and primary-care prescriptions to prevent duplicate medication supply.
