First reported 30 Jul 2013•Latest report 3 Jun 2026
Definition
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
Distinct published reports
Individual concerns
58
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
100
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.
Department of Health and Social Care8
NHS England6
NHS Greater Manchester Integrated Care Board5
Care Quality Commission4
Medicines and Healthcare products Regulatory Agency4
NHS Surrey and Sussex Integrated Care Board3
Royal College of General Practitioners3
Betsi Cadwaladr University LHB2
General Medical Council2
Greater Manchester Health and Social Care Partnership2
Herefordshire and Worcestershire Health and Care NHS Trust2
Nursing and Midwifery Council2
Royal College of Psychiatrists2
Adelaide Medical Centre, London1
Alvaston Medical Centre1
Healthcare site18
NHS trust17
Integrated care board9
Ministerial department8
Executive non-departmental public body7
Health and social care service regulator4
Health professional body4
Local health board4
Medicines and medical devices regulator4
Health and care professional regulator3
Health-system partnership3
Clinical commissioning group2
Multi-service care provider2
Professional body2
Company limited by guarantee1
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.
West Yorkshire Eastern
Concerns raised1
Failure of hospital systems to review and safeguard medication prescribing and administration
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 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
Actions taken following the Serious Incident Report are considered sufficient to address identified issues and prevent similar future deaths.
Stated by Inmind HealthcareExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Cornwall and Isles of Scilly
Concerns raised1
Unavailability of practice warning flags at the three-month stage of morphine prescribing
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 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 West London
Concerns raised1
Failure to account for reduced opiate tolerance and synergistic agents when prescribing methadone
This report raised 5 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.3
Action
Update the national service specification using learning from the case to strengthen prescribing and supply of sedating medicines.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 6 March 2024.
Action
Revise and disseminate the withdrawal-treatment policy, including sedation safeguards, tolerance assessment, urine screening and clinical review requirements.
Stated by Oxleas NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 6 March 2024.
Action
Discuss the case in a prescriber reflective-practice forum, focusing on individual history, clinical signs, investigations and cautious methadone dosing.
Stated by Oxleas NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 6 March 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
National guidance already addresses reduced opioid tolerance and reducing or withholding methadone when sedation is present.
Stated by NHS EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Essex
Concerns raised1
Failure to establish medication doses and apply appropriate conversion factors
This report raised 14 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
Conduct a GIRFT review visit to Mid and South Essex NHS Foundation Trust’s neurology department.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 6 March 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
The consultant had time to establish Chloe’s dose because it was documented and clinic capacity was available before the appointment.
Stated by Mid and South Essex NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Consultants already had 24/7 pharmacy support and online resources for dosage-conversion queries, although the available support was not accessed.
Stated by Mid and South Essex NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Many concerns about Chloe’s care fall within the NHS Foundation Trust’s remit rather than NHS England’s national programme or policy remit.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
North West Wales
Concerns raised1
Failure to conduct regular medication reviews when prescribing medicines that can depress the central nervous system
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 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
Risk-stratify patients lacking recent medication reviews to prioritise review according to medication-related risk.
Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 22 February 2024.
Action
Develop a Health Board policy defining medication-review standards and risk-priority levels for managed practices.
Stated by Betsi Cadwaladr University LHBStated in progressThe respondent said that this action was in progress when they made their response on 22 February 2024.
West Sussex, Brighton and Hove
Concerns raised1
Failure by ambulance crews to consider possible medication toxicity
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
Intervention is limited to patient-safety issues arising from concerns about the GP practice, not ambulance-service matters.
Stated by NHS Surrey and Sussex Integrated Care BoardOutside remitThe respondent said that this matter was outside its role or authority.
East London
Concerns raised1
Failure to review Zopiclone use despite high-risk medication-taking behaviour
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.12
Action
Review Zopiclone prescriptions within two weeks, identify existing patients for review, provide senior clinical oversight, and audit compliance six-monthly.
Stated by North East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 15 September 2023.
Action
Train staff in the safe prescribing and management of Z-drugs and benzodiazepines through repeat sessions.
Stated by North East London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 15 September 2023.
Action
Coordinate primary and secondary care medication monitoring through an established integrated-care-system workstream and improve information sharing.
Stated by North East London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 15 September 2023.
Action
Improve team handovers by documenting patient information, care plans and professional responsibilities, including primary-care prescribing arrangements, and audit effectiveness.
Stated by North East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 15 September 2023.
Action
Increase Crisis and Home Treatment team staffing through additional pharmacist posts.
Stated by North East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 15 September 2023.
Action
Use additional pharmacy capacity to improve discharge medication reconciliation, monitor and reconcile Zopiclone prescriptions, and provide medication education during transfers.
Stated by North East London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 15 September 2023.
Action
Audit patients prescribed Zopiclone or Zolpidem to identify those requiring medication review.
Stated by PracticeStated completedThe respondent said that this action was complete when they made their response on 15 September 2023.
Action
Review identified patients’ Zopiclone or Zolpidem medication and develop reduction, cessation or safer-alternative plans.
Stated by PracticeStated in progressThe respondent said that this action was in progress when they made their response on 15 September 2023.
Action
Code completed medication plans in EMIS so healthcare professionals and administrators can follow them.
Stated by PracticeStated completedThe respondent said that this action was complete when they made their response on 15 September 2023.
Action
Conduct medication reviews every four weeks where possible, focusing on reduction according to withdrawal symptoms, risk and support.
Stated by PracticeStated plannedThe respondent said that this action was planned when they made their response on 15 September 2023.
Action
Review Zopiclone and Zolpidem prescriptions as acute rather than repeat prescriptions and limit quantities to a maximum two-week supply.
Stated by PracticeStated completedThe respondent said that this action was complete when they made their response on 15 September 2023.
Action
Apply the acute-prescription policy to new Zopiclone and Zolpidem requests.
Stated by PracticeStated plannedThe respondent said that this action was planned when they made their response on 15 September 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Prescribing and medication review decisions rest with the GP or responsible clinician, who must determine treatment with the patient.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
West Yorkshire (Western)
Concerns raised2
Failure to reference the potential rare side effect when prescribing Ciprofloxacin and Quinolone antibiotics
Lack of prescribing doctors’ awareness of the potential rare side effect
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Milton Keynes
Concerns raised1
Failure to actively identify patients taking high-risk medication combinations and rationalize or reduce their medications
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.8
Action
Audit high-dose opioid patients, arrange reviews, and consider dose reduction where appropriate.
Stated by Hilltops Medical CentreStated in progressThe respondent said that this action was in progress when they made their response on 28 February 2023.
Action
Identify and review patients prescribed opioids with gabapentinoids and benzodiazepines or Z-drugs.
Stated by Hilltops Medical CentreStated completedThe respondent said that this action was complete when they made their response on 28 February 2023.
Action
Maintain three-monthly medication reviews using recall systems, preferably face to face and with a named clinician.
Stated by Hilltops Medical CentreStated in progressThe respondent said that this action was in progress when they made their response on 28 February 2023.
Action
Use the Arden’s Opioid Initiation and Monitoring template during medication reviews.
Stated by Hilltops Medical CentreStated plannedThe respondent said that this action was planned when they made their response on 28 February 2023.
Action
Operate a national programme to reduce harm from high-dose opioids prescribed for non-cancer pain.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 28 February 2023.
Action
Support Integrated Care Systems to develop, implement, adapt and share effective improvements in chronic pain and opioid prescribing care.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 28 February 2023.
Action
Develop national resources supporting consistent repeat-prescribing processes and structured medication reviews for patients at risk from multiple medicines.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 28 February 2023.
Action
Publish a national framework to help systems improve personalised care for adults prescribed dependence- or withdrawal-associated medicines.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 28 February 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
ICBs are responsible for commissioning chronic pain and opioid-withdrawal support services for their geographically covered populations.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Inner North London
Concerns raised1
Failure to recognise prescribed medicines as a possible cause of harm
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.
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
Investigated how the incident occurred to inform members and help prevent recurrence.
Stated by Ayurvedic Professionals AssociationStated completedThe respondent said that this action was complete when they made their response on 27 September 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
AYUSH is identified as the authority able to assess whether the Ayurvedic herbs used could cause harm.
Stated by Ayurvedic Professionals AssociationRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Providing individual advice on treatment protocols and identifying herbal harms through training are outside the association’s remit.
Stated by Ayurvedic Professionals AssociationOutside remitThe respondent said that this matter was outside its role or authority.
Pin
Get email alerts
Request correction
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.
