First reported 30 Jul 2013•Latest report 19 Mar 2026
Definition
What this concern includes
Includes failures of the assessment or review process to directly verify medication information, including checking medicines or medication records against the person's actual medicines and confirming the information needed by changing carers, school staff or other responsible caregivers.
Not included
Excludes medication reconciliation across hospital or other care transitions where the concern is broader transfer and reconciliation of medication information rather than verification during an assessment or review.
Excludes medication prescribing, dosage, administration, supply or monitoring failures where medication information was reliably verified but a later control failed.
Excludes generic documentation, communication or care-planning deficiencies unless they directly cause failure to verify medication information during the assessment or review.
Excludes verification of non-medication care needs or equipment.
Reports
6
Distinct published reports
Individual concerns
6
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
18
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 Care2
Alexander Court Care Centre1
Bow School1
Bromley by Bow Health Centre1
Coastal Homecare – Hove Branch1
Compass Wellbeing Tower Hamlets1
Essex Partnership University NHS Foundation Trust1
London Ambulance Service NHS Trust1
NHS Essex Integrated Care Board1
NHS Greater Manchester Integrated Care Board1
Royal London Hospital1
Steel's Lane Health Centre1
Sussex Community NHS Foundation Trust1
The British Society For Allergy & Clinical Immunology1
The Uplands Medical Practice1
NHS trust4
Healthcare site2
Integrated care board2
Ministerial department2
Domiciliary care provider1
Maintained school1
Multi-service care provider1
Nursing home1
Registered charity1
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 Sussex, Brighton and Hove
Concerns raised1
Insufficient medication verification during care-needs assessment
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 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
Strengthen escalation pathways by referring complex medicines-reconciliation issues to senior clinicians and SCFT pharmacy support.
Stated by Sussex Community NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
Action
Provide staff with Plexus shared-care-record access for real-time GP medication summaries.
Stated by Sussex Community NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
Action
Embed pharmacy support within the UCR and General Virtual Ward model for complex or unclear medication regimes.
Stated by Sussex Community NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
Action
Revise and implement UCR referral documentation to require receiving agencies to reconcile medicines with prescribers and pharmacies and clarify that UCR MAR charts are for SCFT staff only.
Stated by Sussex Community NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 26 March 2026.
Action
Strengthen referral-pathway expectations that medicines reconciliation is confirmed when care responsibility transfers.
Stated by Sussex Community NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
Action
Photograph all medicines present at assessment and onboarding for every new care package.
Stated by Coastal Homecare (Hove) Ltd.Stated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
Action
Require staff to cross-check medicines against prescribing records, administration records, and referral documentation during handover.
Stated by Coastal Homecare (Hove) Ltd.Stated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
Action
Integrate GP Connect into the digital platform and current practice to verify medicines and identify recent changes.
Stated by Coastal Homecare (Hove) Ltd.Stated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Receiving care agencies are responsible for medicines reconciliation with prescribers and pharmacies; SCFT MAR charts are not definitive records for external providers.
Stated by Sussex Community NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Essex
Concerns raised1
Reliance on patients’ accounts of current medication without routine verification
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.
Manchester North
Concerns raised1
Failure to ask patients about over-the-counter medication during medication 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 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
Create a standardised medication-review questionnaire prompting enquiries about over-the-counter medicines and supplements at prescribing and annual reviews.
Stated by The Uplands Medical PracticeStated in progressThe respondent said that this action was in progress when they made their response on 24 May 2021.
Action
Share the medication-review questionnaire with partner practices and Manchester Health and Social Care Partnership for feedback and good-practice dissemination.
Stated by The Uplands Medical PracticeStated plannedThe respondent said that this action was planned when they made their response on 24 May 2021.
Action
Recruit three additional permanent salaried GPs.
Stated by The Uplands Medical PracticeStated plannedThe respondent said that this action was planned when they made their response on 24 May 2021.
Action
Employ a permanent pharmacist with medication-review competency and responsibility for improving the prescribing policy and questionnaire.
Stated by The Uplands Medical PracticeStated plannedThe respondent said that this action was planned when they made their response on 24 May 2021.
Action
Engage Royal College of General Practitioners practice-development support to review Practice processes and planned safety measures.
Stated by The Uplands Medical PracticeStated in progressThe respondent said that this action was in progress when they made their response on 24 May 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The questionnaire may not be embeddable in the current clinical system because of its limitations, until the Practice moves to a new system.
Stated by The Uplands Medical PracticeUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Inner North London
Concerns raised1
Failure to verify school medication directly during medication reviews
This report raised 12 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.4
Action
Remind staff that medication must be physically present for reviews and treat comparable breaches as gross misconduct with professional referral.
Stated by Compass Wellbeing CICStated completedThe respondent said that this action was complete when they made their response on 3 May 2023.
Action
Introduce and scan a medication-review checklist into each child’s health record, with completion checked through biannual IHCP audits.
Stated by Compass Wellbeing CICStated completedThe respondent said that this action was complete when they made their response on 3 May 2023.
Action
Review all pupil Individual Health Care Plans and verify that emergency-box medicines are prescribed and in date.
Stated by Bow SchoolStated completedThe respondent said that this action was complete when they made their response on 3 May 2023.
Action
Use Safeguarding Committee governance, scheduling, spot checks and compliance reporting to monitor Individual Health Care Plans and medicines.
Stated by Bow SchoolStated completedThe respondent said that this action was complete when they made their response on 3 May 2023.
London (East)
Concerns raised1
Failure of General Practitioners to review and approve care home residents’ Medication Administration Records
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.1
Action
Have the duty nurse accompany GPs on rounds and review medication administration charts and care plans to share relevant information.
Stated by Orchard Care HomesStated completedThe respondent said that this action was complete when they made their response on 14 July 2016.
West Sussex
Concerns raised1
Failure to complete medication reconciliation on admission and pre-assessment
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.
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Includes failures of the assessment or review process to directly verify medication information, including checking medicines or medication records against the person's actual medicines and confirming the information needed by changing carers, school staff or other responsible caregivers.
