Recurring concern

Failure of electronic prescription systems to support reliable prescribing and dispensing

First to latest report 23 May 2016 — 26 Jun 2023

Reports that mention this concern: 3
Times this concern has been raised: 4
Stated actions linked to this concern: 1

What this concern includes

Includes failures of electronic prescribing and electronic prescription-access controls that prevent or risk preventing prescriptions from being issued, retained, downloaded or accessed by the intended pharmacy or clinical users, including system-state changes and setting-specific unavailability.

What is not included

Excludes clinically inappropriate prescribing, medication selection, dosage, repeat-prescribing or prescription-review failures where electronic prescription-system reliability is not the unsafe condition.
Excludes failures of dispensing, supply or medication administration occurring after an electronic prescription was reliably made available to the intended pharmacy.
Excludes generic electronic-record, IT, staffing, training or communication deficiencies unless they directly impair the electronic prescribing or prescription-access process.
Excludes paper-prescription processes and general communication of prescription urgency unless the report specifically identifies an electronic prescription-system failure.

Trends

Reports over time

Reports mentioning this concern, over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

East Lancashire Hospitals NHS Trust1

Egton Medical Information Systems Limited1

NHS England1

NHS South Yorkshire Integrated Care Board1

Royal Hallamshire Hospital1

Upwell Street Surgery1

Reports and published responses 3 reports

See individual reports that have raised this concern, and the actions taken in response

26 Jun2023
Surrey
Concerns raised1
1. Failure of ended repeat prescriptions to be removed from pending medication-management queues
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

EMIS Group
Stated actions 1
1. EMIS Group
  Maintain cancellation warnings, workflow task visibility, and restart-or-reject controls for ended repeat prescriptions.
Respondent positions 1
1. EMIS Group
  Existing EMIS Web functionality is sufficient to mitigate the identified medication-management risks, so no software developments are required.
  Existing arrangements considered sufficient
AI-generated summary

Matthew William Thomas Power · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Matthew William Thomas Power, a 33-year-old man living in supported accommodation, died at a house in Redhill after taking illicit and prescribed drugs over the previous 36 hours; the medical cause of death was recorded as mixed drug toxicity. The concerns identified related to the EMIS prescribing system, including cancelled prescriptions remaining pending, prescriptions being grouped in a way that obscured prescribing history, and difficulty determining what had been prescribed and issued.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure of ended repeat prescriptions to be removed from pending medication-management queues
Wider context from the report
“1. The GP practice uses EMIS for patient records and prescribing. From the evidence it appears that when one doctor ends a repeat prescription on EMIS, it remains in the 'pending' Medication Management box of the doctor to whom it was originally sent. Creating the risk, as in this case, that as a pending prescription it is actioned and issued instead of cancelled. ”
Source location
Matthew William Thomas Power · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Maintain cancellation warnings, workflow task visibility, and restart-or-reject controls for ended repeat prescriptions.

Verbatim wording from the response
“When a clinician ends a prescription (including, any repeat prescription) in the Medication module of the System (End Course), this action ends that prescription if there are no outstanding associated Workflow tasks (as discussed in further detail below).”

Source location
Response from EMIS
Page 1 · response
Published 3 July 2023
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Existing EMIS Web functionality is sufficient to mitigate the identified medication-management risks, so no software developments are required.

Verbatim wording from the response
“Based upon the information provided in the Report and our subsequent review, we do not believe there are any software developments that are required in order to mitigate risks relating to this case beyond the”

Source location
Response from EMIS
Page 4 · response
Published 3 July 2023
Open published response
6 Nov2019
South Yorkshire (Western)
Concerns raised2
1. Failure of electronic prescriptions to remain available for download after system details are reset
2. Lack of awareness among medical professionals of the electronic prescribing system peculiarity
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Sandra Dawne Scott · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Sandra Dawne Scott was prescribed treatment for a urinary infection, but the prescription was not available for collection after changes were made to the electronic prescribing system. She was admitted to hospital with worsening symptoms on 22 April 2019, deteriorated, and died on 23 April 2019. Concerns included the failure to act on hospital urine-test results and the lack of awareness among healthcare professionals of the electronic prescribing system issue; the evidence was that receiving the prescribed or indicated medication would have meant she did not die when she did.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure of electronic prescriptions to remain available for download after system details are reset
Wider context from the report
“1. The GP issued a prescription to a nominated chemist, but a few minutes later put the system details back to what they were before the prescription was issued. Unknown to the GP these changes meant the prescription was no longer available for download by the chemist. 2. This resulted in the patient not getting required medication. 3. The evidence was that the GPs colleagues were also unaware of this peculiarity of the system. 4. Other medical professionals are also likely to be unaware. ”
Source location
Sandra Dawne Scott · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of awareness among medical professionals of the electronic prescribing system peculiarity
Wider context from the report
“1. The GP issued a prescription to a nominated chemist, but a few minutes later put the system details back to what they were before the prescription was issued. Unknown to the GP these changes meant the prescription was no longer available for download by the chemist. 2. This resulted in the patient not getting required medication. 3. The evidence was that the GPs colleagues were also unaware of this peculiarity of the system. 4. Other medical professionals are also likely to be unaware. ”
Source location
Sandra Dawne Scott · Prevention of Future Deaths report
Page 2 · concerns
Open source report
23 May2016
Blackburn, Hyndburn and Ribble Valley
Concerns raised1
1. Unavailability of electronic prescribing for drugs prescribed in the Accident & Emergency Department
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Karen Ravenscroft · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Karen Ravenscroft fell at home on 11 March 2016 and fractured her left arm and leg. She was assessed as being at high risk of venous thromboembolism but was not prescribed appropriate prophylaxis, subsequently developed a deep vein thrombosis, and died from a fatal pulmonary embolus. Concerns included the absence of thromboprophylaxis, failure to reassess VTE risk or provide mechanical prophylaxis, and limitations in electronically prescribing drugs from the Accident & Emergency Department.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Unavailability of electronic prescribing for drugs prescribed in the Accident & Emergency Department
Wider context from the report
“3. Evidence revealed that drugs prescribed in the Accident & Emergency Department could not be done electronically without the doctor going on the ward in order to be able to do that. ”
Source location
Karen Ravenscroft · Prevention of Future Deaths report
Page 1 · concerns
Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

Data last updated 7 September 2026

What this concern includes

Trends

Reports mentioning this concern, over time

Concerns raised1

Failure of ended repeat prescriptions to be removed from pending medication-management queues

Linked response

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised2

Failure of electronic prescriptions to remain available for download after system details are reset

Lack of awareness among medical professionals of the electronic prescribing system peculiarity

Concerns raised1

Unavailability of electronic prescribing for drugs prescribed in the Accident & Emergency Department

Stated actions 1

Respondent positions 1