Recurring concern
Failure to communicate clinically significant medication risks to patients
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Request correctionFirst reported 29 Jul 2014•Latest report 2 Feb 2026
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
- Individual concerns
- 21
- Date range
- 2014–2026
- Stated actions
- 40
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 raised3
Lack of advice about medication risks when considering having a child
Failure to provide specific advice to stop Candesartan and identify its pregnancy risk
Failure to provide additional medication safety advice during antenatal care
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.5
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Action
Implement and apply an SOP covering pregnancy-related safety checks for new medicines, including stopping or replacing medicines unsafe in pregnancy.
Stated by Riverview Surgery -
Action
Warn women taking Candesartan or other ARB medicines about pregnancy risks and the need to stop immediately if pregnancy occurs.
Stated by Riverview Surgery -
Action
Maintain a mandatory prescribing assessment within GP specialty training that assesses prescribing for pregnancy and other special groups.
Stated by Royal College of General Practitioners
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Action
Provide pregnancy-prescribing information resources and links through the RCGP Women’s Health toolkit.
Stated by Royal College of General Practitioners -
Action
Use reception tasks to trigger pregnancy coding, midwife referral checks and medication reviews, with duty-GP cover when unavailable.
Stated by Riverview Surgery
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Concerns raised1
Failure to provide and implement specific warnings about the risks of over-sedation from additional non-prescribed 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
Remind secure-environment prescribers to discuss medication purposes, risks, interactions, follow-up, and document contemporaneous consultation advice.
Stated by Northamptonshire Healthcare NHS Foundation Trust -
Action
Introduce and routinely provide patients with a harm-minimisation leaflet covering polypharmacy, illicit substances, substance use alone, reduced tolerance, and medication initiation or titration risks.
Stated by Northamptonshire Healthcare NHS Foundation Trust
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Concerns raised1
Failure to ensure patients retain advice about Elvanse adverse side effects
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
Discuss case-related prescribing issues at the College webinar on common and complex prescribing scheduled for 12 November 2025.
Stated by Royal College of Psychiatrists
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Concerns raised1
Limited provision of Clozapine side-effect and red-flag information to patients attending GP practices
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.7
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Action
Establish specialist Clozapine clinics providing monthly side-effect screening and patient discussions during phlebotomy appointments.
Stated by Devon Partnership NHS Trust -
Action
Develop a business case to increase resources for dedicated specialist Clozapine clinics across Devon.
Stated by Devon Partnership NHS Trust -
Action
Bring patients receiving Clozapine under Trust care onto dedicated specialist clinics across Devon, excluding Plymouth.
Stated by Devon Partnership NHS Trust
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Action
Review clozapine product information and consider improving its clarity for healthcare professionals, patients, families and carers.
Stated by Medicines and Healthcare products Regulatory Agency -
Action
Engage relevant stakeholders during the clozapine product-information review to ensure regulatory documents meet patients’ and prescribers’ needs.
Stated by Medicines and Healthcare products Regulatory Agency -
Action
Withdraw from the agreement to provide clozapine phlebotomy services.
Stated by Pembroke Medical Group -
Action
Cascade additional funding to support more Clozapine clinics and increase access to specially trained professionals.
Stated by NHS Devon Integrated Care Board
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Concerns raised1
Failure to communicate the risk of death from Olanzapine depot injections to patients or their representatives
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.1
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Action
Review the olanzapine depot policy to explicitly highlight the small risk of death from post-injection syndrome.
Stated by North London NHS Foundation Trust
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Concerns raised1
Failure to issue patients specific advice about associated medication risks
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.2
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Action
Provide medication-risk warnings on pharmacy labels and patient information leaflets with advice for relevant opioid and patch-related scenarios.
Stated by Betsi Cadwaladr University LHB -
Action
Add the Faculty of Pain Medicine opioid leaflet to the clinical system and provide it to patients at opioid reviews, initiation, or dose changes.
Stated by Betsi Cadwaladr University LHB
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Concerns raised1
Failure to discuss alcohol and medication interaction risks
This report raised 8 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
Refer patients at high risk of alcohol misuse to drug and alcohol services and document discussions of alcohol-related medication risks with patients and, where consented, families.
Stated by Essex Partnership University NHS Foundation Trust
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Concerns raised1
Failure to routinely discuss medication relapse and worsening risks with 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 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
Recirculate NICE antidepressant guidance and GMC prescribing guidance to clinicians, highlighting discussion of medication risks.
Stated by Stretton Medical Centre -
Action
Add a medication-label warning advising patients not to stop antidepressant or anti-anxiety medication without medical advice.
Stated by Stretton Medical Centre -
Action
Remind GPs to discuss antidepressant risks and arrange follow-up, incorporating the requirement into new-starter and locum induction materials.
Stated by Stretton Medical Centre
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Action
Provide 20-minute appointments for patients booking to discuss mental health concerns so medication risks can be discussed adequately.
Stated by Stretton Medical Centre -
Action
Cascade Significant Event Analysis outcomes to clinical, reception and administration staff to support appropriate appointment booking and patient communication.
Stated by Stretton Medical Centre
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Concerns raised1
Failure to provide advice on possible medication withdrawal symptoms
This report raised 7 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 raised1
Failure to provide written and family-shared bleeding-risk advice for direct oral anticoagulant medication
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.
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
Create and implement a generic anticoagulant discharge leaflet covering bleeding risks, warning signs and when to seek medical attention.
Stated by East Kent Hospitals University NHS Foundation Trust
Data last updated 7 September 2026