Recurring concern
Failure to identify clinically significant medication risks
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Request correctionFirst reported 30 Jul 2013•Latest report 3 Jun 2026
What this concern includes
Includes failures in medication review, reconciliation, prescribing or screening that concern recognising the clinical significance of a medicine, contraindication, interaction, toxicity, side-effect or existing medication.
Not included
- Excludes failures to administer, monitor or supply medication where the concern is not specifically the identification of medication-related risk.
- Excludes illicit or general drug-use hazards not tied to a medication-safety control.
- Excludes generic failures to recognise symptoms or deterioration unless the report explicitly links them to medication-related risk.
- Excludes generic communication, documentation or staffing deficiencies that are not dedicated to identifying medication risks.
- Reports
- 54
- Individual concerns
- 58
- Date range
- 2013–2026
- Stated actions
- 100
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
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.
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.
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Concerns raised1
Failure to undertake a medication review in response to known excessive, hoarded and erratic medication use
Responses linked to these concernsEach 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
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Action
Recruit two clinical pharmacists to support patient medication reviews.
Stated by Alvaston Medical Centre -
Action
Conduct structured, holistic medication reviews covering compliance, understanding, social history, lifestyle and medication changes.
Stated by Alvaston Medical Centre -
Action
Prevent high-risk scheduled drugs from forming part of repeat prescriptions wherever possible.
Stated by Alvaston Medical Centre
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Action
Prevent prescriptions from being ordered automatically too far in advance of their due dates.
Stated by Alvaston Medical Centre -
Action
Continue assessing medications and prescribing areas that would benefit from additional surveillance.
Stated by Alvaston Medical Centre
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Concerns raised1
Failure to account for significant alcohol use when prescribing powerful painkillers
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 concernsEach 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
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Action
Share up-to-date opiate prescribing guidance across Stockport practices.
Stated by NHS Greater Manchester Integrated Care Board -
Action
Work with system colleagues to ensure adherence to best-practice opiate prescribing guidance.
Stated by NHS Greater Manchester Integrated Care Board
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Existing prescribing safeguards are considered sufficient to ensure safe opiate prescribing across the individual practice and wider Stockport GP community.
Stated by NHS Greater Manchester Integrated Care Board
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Concerns raised1
Failure to document risk-benefit analysis for pertinent respiratory-affecting medication
This report raised 19 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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
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Action
Highlight the potential adverse link between Promethazine and obesity hypoventilation syndrome through departmental clinical governance.
Stated by Norfolk and Norwich University Hospitals NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Medication changes or recommendations were not specified because clinicians judged Promethazine unlikely to have caused the patient's decline or attendance.
Stated by Norfolk and Norwich University Hospitals NHS Foundation Trust
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Concerns raised1
Failure to account for addiction, self-harm and poor substance use when prescribing 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 concernsEach 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
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Action
Continue discussions with Primary Care Network leads to explore Stockport Integrated Pharmacy Service support for optimising medication reviews.
Stated by NHS Greater Manchester Integrated Care Board -
Action
Remind Stockport GPs about available opioid-prescribing resources and how to seek support through the next pharmacy newsletter.
Stated by NHS Greater Manchester Integrated Care Board
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Existing prescribing guidance and clinician adherence are considered sufficient because the incident is regarded as isolated.
Stated by NHS Greater Manchester Integrated Care Board
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Concerns raised1
Failure to identify and correct inappropriate antibiotic continuation during ward transfer and medical reviews
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to assess the risk of mixing alcohol with prescribed medication
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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.3
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Action
Flag patients at risk from neuropathic medication and alcohol dependence, conduct medication reviews, and contact them about medication and alcohol consumption.
Stated by NHS Greater Manchester Integrated Care Board and Tameside Borough Council -
Action
Develop and distribute guidance to practices on identifying and managing patients prescribed neuropathic drugs or opioids who may be alcohol-dependent.
Stated by NHS Greater Manchester Integrated Care Board and Tameside Borough Council -
Action
Issue an alert to all GP practices about alert notes, follow-up reviews and considering systems to identify high alcohol use during prescribing.
Stated by NHS Greater Manchester Integrated Care Board
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
The named Clinical Commissioning Group is responsible for addressing the concerns raised about GP practice alert systems and prescribing risk assessment.
Stated by NHS Greater Manchester Integrated Care Board
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Concerns raised1
Under-appreciation of clozapine side effects relating to smoking and pneumonia
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
CCG classification of the drug as green despite known side effects
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised2
Potential contraindication to clozapine from familial lipid disorder
Failure to distinguish clozapine overdose signs from unresolved schizophrenia symptoms
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 concernsEach 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
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Action
Apply NICE-aligned physical-health monitoring arrangements for patients taking Clozapine.
Stated by Cardiff & Vale University LHB
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Existing medicines reconciliation, pharmacist support, NICE monitoring and promoted polypharmacy reviews address medication interaction and prescribing risks.
Stated by Cardiff & Vale University LHB
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Concerns raised1
Failure to consider discharge medication and prescribing risk
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026