Recurring concern

Unreliable review and monitoring of repeat prescriptions

First to latest report 26 Mar 2014 — 2 Feb 2026

Reports that mention this concern
14
Times this concern has been raised
18
Stated actions linked to this concern
36

What this concern includes

Includes failures in the repeat-prescription review and monitoring process, including detailed scrutiny before approval, review against applicable guidance, regular monitoring of ongoing repeat medication, consideration of relevant patient circumstances and follow-up of continued prescribing.

What is not included
  • Excludes medication-quantity controls where the specific concern is excessive supply or transaction limits without a repeat-prescription review or monitoring failure.
  • Excludes prescribing, dispensing, administration or supply failures unrelated to repeat prescriptions or their review and monitoring.
  • Excludes long-term medication reviews where repeat prescribing is not the supported process boundary.
  • Excludes failures to obtain patient wishes before a pharmacist requests a repeat prescription unless the assertion also identifies deficient clinical review or monitoring of the repeat prescription.
  • Excludes generic electronic-record, staffing, documentation or communication deficiencies unless they directly impair repeat-prescription review or monitoring.

Reports and published responses 14 reports

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

  1. Surrey

    AI-generated summary

    Matthew RUSSELL · 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 Russell was a serving prisoner who was found hanging by a ligature from his cell door and died in hospital the following day. The jury concluded that multiple failures in the management and application of the ACCT plan procedure materially contributed to his death, including concerns about medication monitoring, care planning, multidisciplinary reviews, staff training, risk assessment and communication.

    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 to properly and regularly monitor repeat-prescription medication

    Wider context from the report

    “Central and North West London Foundation Trust a. The proper and regular monitoring of all medication that is prescribed by way of a repeat prescription. ”

    Source location

    Matthew RUSSELL · 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

    Review SystmOne use with partner agencies and develop a multi-agency protocol for risk communication and medicines optimisation.

    Verbatim wording from the response

    “CNWL has been appointed as the Lead provider for Primary Care Services in HMP Highdown and across the Surrey prisons cluster. As part of the mobilization and transfer process, CNWL will undertake a full review of the system in conjunction with partner agencies to optimise system usage and risk assessment and management processes across prescribing and pharmacy services. This will include the development of a multi-agency protocol on the use of SystmOne that includes communication of risk and medicines optimisation.”

    Source location

    2016-0430-Response-by-Central-and-North-West-London-NHS-Trust
    Page 6 · response
    Published 26 February 2017

    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

    Ongoing monitoring of repeat antidepressant medication is the responsibility of the prescribing GP or CNWL prescriber, rather than solely CNWL mental health services.

    Verbatim wording from the response

    “The prescriber is responsible for ensuring that a treatment plan is in place for the ongoing monitoring of repeat anti-depressant medication. In HMP Highdown we work in conjunction with other prescribers with the clear understanding that the prescriber is responsible for ensuring the ongoing monitoring of compliance and”

    Source location

    2016-0430-Response-by-Central-and-North-West-London-NHS-Trust
    Page 2 · response
    Published 26 February 2017

    Open published response

  2. Birmingham and Solihull

    AI-generated summary

    Edna May CLEATON · 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

    Edna May CLEATON died at home after serious pressure sores became septic. The report raised concern that she had not seen a doctor for over three years while receiving repeat citalopram prescriptions, and that systems were needed to ensure appropriate medical reviews before repeat prescriptions were 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 to ensure appropriate medical reviews of patients on citalopram before repeat prescriptions are issued

    Wider context from the report

    “(1) The evidence heard at the inquest was that patients on citalopram should be reviewed by a doctor every 3 – 6 months. This lady had not been reviewed for over 3 years. The practice need systems in place to ensure patients received appropriate medical reviews before repeat prescriptions are issued. Had regular reviews been undertaken it is possible that medical staff would have identified deterioration in the deceased and a care plan could have been instigated which may have avoided the pressure sores that developed. ”

    Source location

    Edna May CLEATON · Prevention of Future Deaths report
    Page 1 · 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

    Implement a repeat-prescribing protocol requiring antidepressant reviews at least every six months before further prescriptions are issued.

    Verbatim wording from the response

    “When a repeat prescription for antidepressants is set up it is usually only for a maximum of six months. After this period a review must take place.”

    Source location

    Edna-Cleaton-Response
    Page 1 · response
    Published 17 December 2015

    Open published response

    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

    Configure an electronic clinical-system prompt that prevents depression-coded repeat prescriptions without a documented review in the preceding six months.

    Verbatim wording from the response

    “We also have an automatic electronic protocol that has been built into the clinical system that is activated if repeat prescription is generated with a read code of depression. If a review has not taken place, then an automatic prompt will appear, reminding the prescriber of the need for a review before the prescription can be issued.”

    Source location

    Edna-Cleaton-Response
    Page 2 · response
    Published 17 December 2015

    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 repeat-prescribing protocols and electronic prompts are considered sufficient to ensure timely antidepressant reviews.

    Verbatim wording from the response

    “This has been agreed by all the doctors at Jockey Road Medical Centre. When a repeat prescription is generated, that person must ensure that an appropriate review has happened in the previous six months.”

    Source location

    Edna-Cleaton-Response
    Page 2 · response
    Published 17 December 2015

    Open published response

  3. Manchester South

    AI-generated summary

    David Glyn Price · 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

    David Glyn Price suffered a heart attack in early June 2011 and underwent surgery at Wythenshawe Hospital, during which a swab was inadvertently left inside his body attached to his heart; this gradually formed an abscess. Concerns included continued warfarin prescribing despite missed anticoagulation appointments, poor handwritten clinical records, failure to act on imaging showing a foreign body, and inadequate swab-count procedures.

    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 to review or discontinue repeat prescriptions when medicines are no longer needed or when required monitoring is missed

    Wider context from the report

    “1.Before he was admitted to hospital his G.P. was prescribing warfarin and this continued over many months despite the fact that he failed on three occasions to attend the anti- coagulation clinic. There is apparently no system to prevent this happening. I have noted in many inquests that people who have “repeat prescriptions” continue to get all the drugs prescribed even if they are no longer needed or wanted, thus potentially placing the patient at considerable health risk but also costing the NHS a vast amount of money for unwanted and unused drugs.(For the Secretary of State) ”

    Source location

    David Glyn Price · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. West Sussex

    AI-generated summary

    Lee Hollman · 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

    Lee Hollman, who had a long history of intermittently severe mental ill-health, died after taking an overdose of Quetiapine, Trazodone and alcohol on 28 February 2014. The report identified concerns about inaccurate and outdated medical records, the repeat-prescription system, and failure to review patients in line with relevant guidelines.

    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 to review patients within their own guidelines for repeat prescriptions

    Wider context from the report

    “5. Failure to review patients within their own guidelines with regard to repeat prescriptions ”

    Source location

    Lee Hollman · 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

    Rewrite the repeat prescribing policy for psychotropic medications and require an additional prescribing-doctor review to confirm dose and reduce harm.

    Verbatim wording from the response

    “As a surgery we are keen to learn from this tragic event and have reflected at great length on the medication errors which occurred. The policy for the issuing of repeat medications has been reviewed and re-written, particularly in respect to psychotropic medications. I enclose the new policy for your review.”

    Source location

    2014-0135-Response-by-Riverside-Surgery
    Page 2 · response
    Published 26 March 2014

    Open published response

    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

    Require CMHT correspondence before changing medication, record medication changes, and prompt GPs to reconcile surgery and CMHT medication lists.

    Verbatim wording from the response

    “The medication prescribing process for patients under the care of the CMHT has been revised in the following key respects:”

    Source location

    2014-0135-Response-by-Riverside-Surgery
    Page 3 · response
    Published 26 March 2014

    Open published response

    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

    Limit psychotropic medication issues to one month and require GP re-issue and review against current CMHT correspondence before further supply.

    Verbatim wording from the response

    “The key aspects of the new procedure are as follows:”

    Source location

    2014-0135-Response-by-Riverside-Surgery
    Page 4 · response
    Published 26 March 2014

    Open published response

    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

    Continue holding specific mental-health reviews and reviewing patients through specialist correspondence, case meetings, and face-to-face consultations.

    Verbatim wording from the response

    “Throughout the year the GP’s have and continue to hold specific Mental Health Reviews. In the most recent Quality Outcome Framework (QOF - 2013/2014) review of our clinical records confirmed that reviews were being carried out in accordance with the relevant guidelines.”

    Source location

    2014-0135-Response-by-Riverside-Surgery
    Page 5 · response
    Published 26 March 2014

    Open published response

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