First reported 13 Dec 2008•Latest report 3 Feb 2026
Definition
What this concern includes
Includes failures of arrangements or systems intended to make a patient’s current or relevant medication history available to clinicians, carers or other staff responsible for safe care, including inaccessible prescription documentation, unavailable electronic medication histories and reliance on potentially incomplete verbal histories because the underlying record cannot be accessed.
Not included
Excludes medication prescribing, dispensing, administration, monitoring or reconciliation failures where access to the medication history is not the unsafe condition.
Excludes general clinical-record access problems where medication history is not the material information needed for care.
Excludes failures to act on an accurate and accessible medication history.
Excludes medication-history deficiencies confined to a named transition or reconciliation process when that process provides the more specific supported boundary.
Reports
12
Distinct published reports
Individual concerns
12
A report can raise multiple concerns
Date range
2008–2026
First to latest report issue date
Stated actions
11
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 Care3
NHS England2
Betsi Cadwaladr University LHB1
Birmingham Women'S and Children'S NHS Foundation Trust1
Bupa Care Homes1
Bupa UK Provision1
Carewatch (Mid Bucks)1
Digital Health and Care Wales1
Dorset Council1
Essex Partnership University NHS Foundation Trust1
General Pharmaceutical Council1
James Paget University Hospitals NHS Foundation Trust1
Mildmay Medical Practice1
NHS Dorset Integrated Care Board1
NHS Essex Integrated Care Board1
Ministerial department3
Multi-service care provider3
NHS trust3
Executive non-departmental public body2
Healthcare site2
Integrated care board2
Devolved government1
Domiciliary care provider1
English unitary authority1
Health and care professional regulator1
Local health board1
Special health authority1
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
Limited access for community pharmacists to patients’ drug histories and recent test results
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.1
Action
Write to pharmacy owners, pharmacists and pharmacy technicians with patient-safety concerns, recommended safeguards and supporting resources.
Stated by General Pharmaceutical CouncilStated completedThe respondent said that this action was complete when they made their response on 4 February 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Digital Health and Care Wales is responsible for explaining pharmacy access requirements and planned changes to patient records in Wales.
Stated by General Pharmaceutical CouncilRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Birmingham and Solihull
Concerns raised1
Lack of access to all clinical records when planning treatment
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
Implement an electronic patient record providing staff with accessible medication details and individual patient risk factors.
Stated by Birmingham Women'S and Children'S NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 13 January 2025.
Suffolk
Concerns raised1
Lack of accident and emergency staff access to medication records and dispensing rationale
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.3
Action
Continue transferring users from the legacy Summary Care Record application to the National Care Records Service to improve access to national patient information.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 19 January 2024.
Action
Add a Summary Care Record sentence limiting controlled medication following an overdose diagnosis to no more than a 48-hour supply.
Stated by Rosedale SurgeryStated plannedThe respondent said that this action was planned when they made their response on 19 January 2024.
Action
Procure a shared electronic patient-record system across the three acute trusts.
Stated by James Paget University Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 January 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Position
Norfolk and Waveney Integrated Care Board is responsible for delivering local Shared Care Records relevant to local information sharing.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The Trust’s investigative action and prescribing policy are considered to address concerns about A&E access to medication records.
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
NHS England is responsible for delivering health services and considering further responses concerning access to medical records.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The Trust disputes that emergency department staff lacked access to relevant medical records, stating that staff could access Summary Care Record and SystmOne.
Stated by James Paget University Hospitals NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Dorset
Concerns raised1
Lack of access to patients’ prescribed medication and medication review information
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
Consult health professionals about medication, its use, storage and risks at assessment and review points, including options appraisal and safe-management planning.
Stated by Dorset CouncilStated plannedThe respondent said that this action was planned when they made their response on 23 January 2023.
Action
Share the Coroner’s findings with relevant teams to inform future Dorset Care Record improvements.
Stated by NHS Dorset Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 23 January 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Full integration of Mosaic and SystemOne is constrained because separate data controllers own and regulate systems that are not designed to communicate.
Stated by Dorset CouncilUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
North Wales (East and Central)
Concerns raised1
Failure to access medication charts routinely
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.1
Action
Conduct and document medication reviews at every local district nursing visit using a checklist countersigned by the care home.
Stated by Betsi Cadwaladr University LHBStated completedThe respondent said that this action was complete when they made their response on 27 April 2022.
Essex
Concerns raised1
Failure of primary and secondary care systems to provide timely access to definitive medication and concordance records
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.
Suffolk
Concerns raised1
Lack of a comprehensive database of patients’ prescription-only medication
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
Failure to make complete lists of current and recent prescriptions readily accessible
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 West
Concerns raised1
Unavailability of accurate prescription documentation requiring reliance on verbal medication histories
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.3
Action
Roll out the Electronic Patient Record and Electronic Prescribing to enable clinicians to access current prescribed medication in outpatient clinics.
Stated by The TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 November 2017.
Action
Ensure outpatient appointment invitation letters request that patients bring their current medication.
Stated by The TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 November 2017.
Action
Launch an information campaign related to bringing current medication to outpatient appointments.
Stated by The TrustStated plannedThe respondent said that this action was planned when they made their response on 27 November 2017.
Inner North London
Concerns raised1
Unavailability of patients’ past medical and medication history to attending medical crews
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 of arrangements or systems intended to make a patient’s current or relevant medication history available to clinicians, carers or other staff responsible for safe care, including inaccessible prescription documentation, unavailable electronic medication histories and reliance on potentially incomplete verbal histories because the underlying record cannot be accessed.
