Recurring concern

Unreliable access to patients’ medication histories

First to latest report 13 Dec 2008 — 3 Feb 2026

Reports that mention this concern
12
Times this concern has been raised
12
Stated actions linked to this concern
11

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.

What is 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 and published responses 12 reports

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

  1. London (East)

    AI-generated summary

    Roy Joseph Godfrey · 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

    Roy Joseph Godfrey, a 71-year-old resident of a residential care home, suffered an unwitnessed fall and head injury while taking long-term warfarin. He was later found unresponsive and died from a fatal subdural haematoma. Concerns included insufficient awareness of the bleeding risk associated with head injury and warfarin, inadequate overnight neurological checks and recording, and shortcomings in the care home's investigation documentation.

    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 nursing staff to establish a fallen patient’s medical and medication history

    Wider context from the report

    “5. The Deputy Manager confirmed that the qualified member of staff who attended when Mr Godfrey sustained his fall should have been aware of the increased risk of bleeding as a result of the long term warfarin. She confirmed that he may not have had access to the medication chart. It is my view that a qualified member of the nursing staff who attends a patient who has suffered a fall should make themselves aware of both the patient’s medical history and medication history. ”

    Source location

    Roy Joseph Godfrey · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Buckinghamshire

    AI-generated summary

    Heather Beatrice Planner · 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

    Heather Beatrice Planner died at Wycombe Hospital on 1 April 2019 from a gastrointestinal bleed in the context of large bowel ischaemia. The report states that she had not received her prescribed apixaban anticoagulation at home for two days before admission, and identifies concerns about medication administration, communication and record-keeping processes for carers, as well as the subsequent investigation.

    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 access to patients’ medication histories

    Wider context from the report

    “(5) There does not appear to be any electronic system or record to enable carers to access a patient’s medication history, the records at the patient’s home being only paper records. ”

    Source location

    Heather Beatrice Planner · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

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

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Data last updated 7 September 2026