First reported 29 Jul 2014•Latest report 2 Feb 2026
Definition
What this concern includes
Includes failures to provide, explain, tailor, document or reinforce clinically significant medication-risk information to patients or their families or carers, including serious psychiatric, overdose, bleeding, toxicity or other medication-related risks where communication is needed for safe use.
Not included
Excludes prescriber-only medication guidance, formularies and clinical decision support where patients are not the intended recipients.
Excludes medication packaging or product-labelling warnings as a standalone deficiency; those belong to the dedicated product or medication-packaging warning concerns.
Excludes failures of prescribing, dispensing, administration, monitoring or treatment where patient-facing medication-risk communication is not the unsafe condition.
Excludes generic communication or health-literacy deficiencies without a clinically significant medication-risk context.
Reports
19
Distinct published reports
Individual concerns
21
A report can raise multiple concerns
Date range
2014–2026
First to latest report issue date
Stated actions
40
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.
Betsi Cadwaladr University LHB2
Department of Health and Social Care2
Medicines and Healthcare products Regulatory Agency2
NHS Devon Integrated Care Board2
NHS England2
Bayer plc1
Care Quality Commission1
Clinical Commissioning Group (Devon)1
Devon Partnership NHS Trust1
East Kent Hospitals University NHS Foundation Trust1
Essex Partnership University NHS Foundation Trust1
Farnham Park Health Group1
General Medical Council1
Hampshire and Isle of Wight Healthcare NHS Foundation Trust1
Informa Healthcare1
NHS trust8
Integrated care board4
Executive non-departmental public body3
Healthcare site3
Type not available3
Local health board2
Medicines and medical devices regulator2
Ministerial department2
Executive agency1
Fire and rescue service1
Health and care professional regulator1
Health and social care service regulator1
Health professional body1
Health-system partnership1
National fire and rescue body1
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.
Surrey
Concerns raised1
Failure to document warnings about Mirtazepine side-effects and increased suicidal ideation risk
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.7
Action
Share suicide and self-harm documentation and assessment learning with all Frimley GP practices through bulletins, meetings, clinical leads and prescribing updates.
Stated by NHS Frimley ICBStated plannedThe respondent said that this action was planned when they made their response on 19 May 2022.
Action
Deliver a recorded virtual training session on mental health assessment and documentation, then distribute the recording to all practices.
Stated by NHS Frimley ICBStated plannedThe respondent said that this action was planned when they made their response on 19 May 2022.
Action
Update the local formulary to highlight national guidance on increased suicidal behaviour risk after antidepressant initiation.
Stated by NHS Frimley ICBStated plannedThe respondent said that this action was planned when they made their response on 19 May 2022.
Action
Develop a point-of-prescribing alert reminding prescribers about national guidance on increased risk in young people.
Stated by NHS Frimley ICBStated plannedThe respondent said that this action was planned when they made their response on 19 May 2022.
Action
Add clearer initiation advice requiring discussion of possible worsening depression and increased suicidal thoughts for relevant patients receiving new antidepressants.
Stated by NHS Frimley ICBStated plannedThe respondent said that this action was planned when they made their response on 19 May 2022.
Action
Remind local prescribers about the clearer antidepressant-initiation advice through ICB communication channels.
Stated by NHS Frimley ICBStated in progressThe respondent said that this action was in progress when they made their response on 19 May 2022.
Action
Audit patient use of the specified medication, present the results, and identify any required patient-safety actions.
Stated by Farnham Park Health Group and Recipient name withheldStated plannedThe respondent said that this action was planned when they made their response on 19 May 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.7
Position
The circumstances were a specific case, not widespread poor care, and the care provided was not unsafe.
Stated by Care Quality CommissionDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
No further action is currently considered necessary because the provider’s actions are expected to protect service users from harm.
Stated by Care Quality CommissionExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Regulatory action can target registered managers or providers, but not failings attributed solely to individuals.
Stated by Care Quality CommissionOutside remitThe respondent said that this matter was outside its role or authority.
Position
Existing clinical guidance, professional standards, revalidation and training arrangements are considered sufficient to support appropriate prescribing and diagnosis.
Stated by Department of Health and Social CareExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
The GP’s prescribing choices were in line with guidance, despite identified risks associated with antidepressants.
Stated by NHS Frimley ICBDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
The concerns do not indicate that the doctor poses a patient risk or undermines public confidence in doctors.
Stated by General Medical CouncilDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
No further investigation is considered necessary, although the concerns will be shared for discussion during revalidation.
Stated by General Medical CouncilNo action considered necessaryThe respondent said that no further action was needed.
County Durham and Darlington
Concerns raised1
Failure to provide patients with information about Lamotrigine side effects
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
Develop and obtain approval for a Medication Safety Series document on prescribing resources and patient information sources.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 26 October 2020.
Action
Provide the approved Medication Safety Series document and related communications to prescribers and relevant staff through Trust communications and the intranet.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 26 October 2020.
Inner North London
Concerns raised1
Failure to provide explicit discharge advice about the fatal consequences of district nursing visits and medication administration not taking place
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
Write to doctors, senior nurses and pharmacists highlighting learning points for embedding in clinical practice.
Stated by Whittington Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 5 March 2017.
Action
Share learning with inpatient pharmacists to support patients’ understanding of medication significance at discharge.
Stated by Whittington Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 5 March 2017.
Berkshire
Concerns raised1
Failure to clearly communicate ciprofloxacin’s potential psychiatric and suicidal effects to patients
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.4
Action
Review all UK package leaflets for generic ciprofloxacin products for consistent presentation of the identified safety information.
Stated by Medicines and Healthcare products Regulatory AgencyStated plannedThe respondent said that this action was planned when they made their response on 19 February 2017.
Action
Examine New Zealand Ciproxin product information to verify warnings about possible suicidal behaviour for prescribers and patients.
Stated by Bayer plcStated completedThe respondent said that this action was complete when they made their response on 19 February 2017.
Action
Review UK product information issued by generic ciprofloxacin manufacturers for adequacy of warnings about suicidal behaviour.
Stated by Bayer plcStated completedThe respondent said that this action was complete when they made their response on 19 February 2017.
Action
Keep Bayer’s product information for its medicines under constant review.
Stated by Bayer plcStated in progressThe respondent said that this action was in progress when they made their response on 19 February 2017.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
Existing Ciproxin product information is comprehensive and up to date on psychiatric risks and advises immediate contact with the prescriber.
Stated by Medicines and Healthcare products Regulatory AgencyExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Existing UK and New Zealand product information adequately warns prescribers and patients about suicidal behaviour risks, so greater prominence is not appropriate.
Stated by Bayer plcExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
The content of a generic New Zealand ciprofloxacin product's information cannot be altered because it is controlled by another manufacturer.
Stated by Bayer plcUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
East London
Concerns raised1
Failure to communicate medication risks to patients and families
This report raised 16 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.
West Sussex
Concerns raised1
Failure to communicate paraffin-emollient fire risk to patients
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.
South Lincolnshire
Concerns raised1
Failure of medicines information to instruct patients to exercise caution and seek advice before using medicines with potential interactions with drugs of misuse
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.
North Wales (East and Central)
Concerns raised1
Failure to communicate the warning signs of clozapine 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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Exeter and Greater Devon
Concerns raised1
Failure to ensure awareness of medication dangers when ingested by others
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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Includes failures to provide, explain, tailor, document or reinforce clinically significant medication-risk information to patients or their families or carers, including serious psychiatric, overdose, bleeding, toxicity or other medication-related risks where communication is needed for safe use.
