First reported 14 Mar 2018•Latest report 3 Sep 2025
Definition
What this concern includes
Includes failures in guidance, lists, alerts, policies or decision criteria specifically governing prescribing when they create inconsistent requirements, unclear responsibilities or uncertainty about safe prescribing decisions across services or settings.
Not included
Excludes unsafe prescribing decisions where the applicable guidance is clear and the failure is only in clinical judgement or compliance.
Excludes guidance for a separately named medication, condition or specialist process when that named concern provides the more specific supported boundary.
Excludes generic clinical-policy updating, training or communication deficiencies that are not specifically tied to clarity or consistency of prescribing guidance.
Excludes pharmacy-operational guidance concerning dispensing or pharmacy practice where prescribing guidance is not the unsafe condition.
Reports
8
Distinct published reports
Individual concerns
8
A report can raise multiple concerns
Date range
2018–2025
First to latest report issue date
Stated actions
15
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 Care4
Medicines and Healthcare products Regulatory Agency2
NHS England2
NHS Greater Manchester Integrated Care Board2
Alliance Pharmaceuticals Limited1
Barts Health NHS Trust1
Bayer plc1
Bradford District Care NHS Foundation Trust1
Care Quality Commission1
East Suffolk and North Essex NHS Foundation Trust1
Farnham Park Health Group1
General Medical Council1
Greater Manchester Combined Authority1
Heaton Moor Medical Group1
National Institute for Health and Care Excellence1
Ministerial department4
NHS trust4
Executive non-departmental public body3
Integrated care board3
Healthcare site2
Medicines and medical devices regulator2
Health and care professional regulator1
Health and social care service regulator1
Mayoral policing body1
Private limited company1
Public limited company1
Trade association1
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.
South Wales Central
Concerns raised1
Lack of guidance preventing CIWA-based prescribing of unnecessary sedatives at significant dose and frequency
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.2
Action
Review the alcohol-withdrawal guidance topic and conclude that an update should be considered.
Stated by National Institute for Health and Care ExcellenceStated completedThe respondent said that this action was complete when they made their response on 16 September 2025.
Action
Reconsider the alcohol-withdrawal guidance, including CIWA-Ar and pharmacological treatment, at the February–March 2026 prioritisation board meeting.
Stated by National Institute for Health and Care ExcellenceStated plannedThe respondent said that this action was planned when they made their response on 16 September 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Individual clinicians retain responsibility for treatment decisions and applying guidance appropriately to each patient’s circumstances.
Stated by National Institute for Health and Care ExcellenceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
NICE cannot amend the CIWA-Ar protocol because it was not produced by NICE.
Stated by National Institute for Health and Care ExcellenceUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Surrey
Concerns raised1
Lack of prescribing policy for Mirtazapine, antidepressants and anxiolytics
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.3
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
Circulate NICE prescribing, treatment and patient-information guidance, CCG guidance, and Frimley ICS medicines-optimisation guidance to all clinicians.
Stated by Farnham Park Health Group and Recipient name withheldStated completedThe respondent said that this action was complete 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.8
Position
Existing NICE, Clinical Knowledge Summaries, BNF, GP training and continuing professional development sufficiently support depression assessment and prescribing without a separate policy.
Stated by NHS EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
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
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
Prescribing decisions are assigned to the responsible clinician, who must consider the patient’s needs, guidance and local commissioning decisions.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
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.
Position
The Practice relied on NICE recommendations, BNF information and NICE CKS guidance despite there being no specific CCG prescribing guideline.
Stated by Farnham Park Health Group and Recipient name withheldExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Manchester South
Concerns raised1
Lack of local guidance on safe GP oversight of high-dose multiple analgesic prescribing in the community
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.7
Action
Provide high-risk medication review support through Medicines Optimisation processes and practice-based pharmacists conducting structured medication reviews.
Stated by NHS Greater Manchester Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 23 November 2021.
Action
Review Trafford’s repeat-prescribing guidance, with completion scheduled by 31 March 2022.
Stated by NHS Greater Manchester Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 23 November 2021.
Action
Ask Greater Manchester CCGs to report through the Quality Board on reducing overprescribing, including analgesia, and supporting implementation of DHSC guidance.
Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 23 November 2021.
Action
Provide every Trafford practice with a practice-based pharmacist to undertake structured medication reviews.
Stated by NHS Greater Manchester Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 23 November 2021.
Action
Prioritise patients taking high doses or multiple analgesics for structured medication review through collaboration between medicines optimisation and practice-based teams.
Stated by NHS Greater Manchester Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 23 November 2021.
Action
Complete the review of Trafford’s repeat-prescribing guidance by 31 March 2022.
Stated by NHS Greater Manchester Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 23 November 2021.
Action
Disseminate the case’s prescribing risks, clinical guidance and available chronic-pain resources to Trafford primary-care staff through the Practice Briefing.
Stated by NHS Greater Manchester Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 23 November 2021.
Essex
Concerns raised1
Drug chart design failing to provide clear titration instructions for one-off IV morphine doses
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.1
Action
Roll out the approved Morphine Prescription sticker across inpatient prescription charts and audit its use.
Stated by East Suffolk and North Essex NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 23 November 2020.
Inner North London
Concerns raised1
Unclear prescribing advice for concurrent pain-relieving medications
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Manchester North
Concerns raised1
Lack of guidance for clinicians on prescribing highly addictive and potentially harmful drugs alongside one another
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
Review opioid medicines product information and seek expert advice on benefit-risk and regulatory recommendations.
Stated by Medicines and Healthcare products Regulatory AgencyStated in progressThe respondent said that this action was in progress when they made their response on 30 October 2018.
West Yorkshire (Western)
Concerns raised1
Inconsistent fire-risk alerts and warnings across NHS prescribing systems
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.1
Action
Create a SystmOne alert identifying patients at risk when emollient treatment is entered in the clinical record.
Stated by Bradford District Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 October 2018.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Other recipients of the report will address concerns about healthcare warnings, prescribing systems, incident data and fire-safety training.
Stated by Bayer plcRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Manchester South
Concerns raised1
Lack of consistent and clear prescribing guidance across local and national lists
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing CCG and Greater Manchester medication lists have the same interpretation, and practices may appropriately work with either list.
Stated by NHS Greater Manchester Integrated Care BoardExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
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Includes failures in guidance, lists, alerts, policies or decision criteria specifically governing prescribing when they create inconsistent requirements, unclear responsibilities or uncertainty about safe prescribing decisions across services or settings.
