Recurring concern
Unreliable management of medication doses not taken
- Reports that mention this concern
- 12
- Times this concern has been raised
- 12
- Stated actions linked to this concern
- 22
What this concern includes
Includes dedicated processes for identifying, recording, monitoring and escalating prescribed medication doses that patients do not take, including self-administered medication not taken at dispensing and medication refusal or omission procedures where the failure can leave treatment interruption or associated risk unmanaged.
What is not included
- Excludes general medication prescribing, dispensing, administration or supply failures where an omitted or refused dose is not the material concern.
- Excludes medication-adherence problems that are not linked to a failure to detect, monitor or respond to doses not taken.
- Excludes failures to manage medication effects, toxicity or treatment response after medication has been taken reliably.
- Excludes generic staffing, communication, documentation or training deficiencies unless they directly impair management of medication doses not taken.
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
Most frequent recipients
Reports about this concern sent to each recipient.
Reports and published responses 12 reports
See individual reports that have raised this concern, and the actions taken in response
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Concerns raised1
Failure to maintain an audit trail for omitted medication doses
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
- NHS England
- University Hospitals of North Midlands NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
-
University Hospitals of North Midlands NHS Trust
Implement electronic prescribing and medicines administration across both Trust sites to record medication omissions, reasons and decision-makers.
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University Hospitals of North Midlands NHS Trust
Require staff to document reasons for drug omissions in patient records through a circulated Patient Safety Learning Alert.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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NHS England
Electronic prescribing systems and existing nursing record requirements address accountability and escalation risks for omitted medication doses.
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NHS England
Further NHS England comment on the reported concerns is not possible based on the information provided.
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Concerns raised1
Failure to identify and escalate unrequested antipsychotic medication
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
- Essex Partnership University NHS Foundation Trust
- Mid and South Essex NHS Foundation Trust
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
-
Essex Partnership University NHS Foundation Trust
Train Mental Health Practitioners to locate current and historical prescriptions in SystmOne.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Mid and South Essex NHS Foundation Trust
Concerns about care before 6 June 2023 do not relate to the respondent, so it has identified no action concerning them.
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Essex Partnership University NHS Foundation Trust
The Line Manager would not have prescribed medication because prescribing for this case was outside the manager’s remit.
-
Concerns raised1
Lack of a mechanism to report medication non-compliance to Security
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
- HM Prison and Probation Service
- Practice Plus Group Health And Rehabilitation Services Limited
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
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Practice Plus Group Health And Rehabilitation Services Limited
Use confidential intelligence reports to notify Security when patients may be stockpiling medication.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
HM Prison and Probation Service
Existing information-sharing protocols and weekly meetings are considered appropriate for communication and management of complex safety concerns.
-
Concerns raised1
Lack of a clear escalation process for omitted critical medicines
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- NHS England
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
NHS England
Lancashire Teaching Hospitals NHS Foundation Trust is the appropriate organisation to respond to concerns one to seven.
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Concerns raised1
Failure of the electronic patient system to flag uncollected or undispensed medication for early identification of non-compliance
Linked response
- NHS England
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
-
NHS England
Investigate HJIS reporting functions to identify a mechanism for detecting non-collection of in-possession medicines.
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NHS England
Write to Health and Justice regional teams and request commissioners remind prison healthcare staff to monitor uncollected in-possession medicines using available HJIS and local processes.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
NHS England
An automated medication non-compliance flag would not improve safety because it would be seen only when a clinician opens the patient record.
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Concerns raised1
Lack of guidance for monitoring self-administered medications not taken at dispensing
Linked response
- University Hospitals Sussex NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
University Hospitals Sussex NHS Foundation Trust
The Trust considers there is no ongoing patient-safety risk concerning medication administration.
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Concerns raised1
Failure to ensure administration and escalation of missed antibiotic doses
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
- NHS England
- Tameside and Glossop Integrated Care NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
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Tameside and Glossop Integrated Care NHS Foundation Trust
Audit omitted medication doses through pharmacy, ward quality-assurance and accreditation processes, reporting results and sharing learning for improvement.
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Tameside and Glossop Integrated Care NHS Foundation Trust
Issue a staff poster explaining how to prevent medication omissions and obtain unavailable medicines.
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Tameside and Glossop Integrated Care NHS Foundation Trust
Redesign the medication kardex to highlight time-critical medicines and streamline ward medication-ordering and emergency supply arrangements.
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Tameside and Glossop Integrated Care NHS Foundation Trust
Provide each ward with an allocated pharmacist and pharmacy technician to review treatment sheets daily and support timely medication ordering.
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Tameside and Glossop Integrated Care NHS Foundation Trust
Provide medication-omission induction and refresher training, with medication-management assessment for nurses new to the Trust.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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NHS England
The concerns fall under the Trust’s remit rather than NHS England’s functions.
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NHS England
The Trust is the appropriate organisation to respond, with the Greater Manchester Integrated Care Board responsible for commissioning.
-
Concerns raised1
Lack of electronic alerts escalating non-administration of prescribed anticoagulation medication to the medical team
Linked response
- Barts Health NHS Trust
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
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Barts Health NHS Trust
Update Millennium training so multidisciplinary teams understand and use visual flags to prevent omission of critical medications.
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Concerns raised1
Lack of a defined escalation process for refusal of medication and fluids
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
- Care Quality Commission
- Department of Health and Social Care
- NHS Greater Manchester Integrated Care Board
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
-
Care Quality Commission
Undertake an unannounced targeted inspection of Lisburne Court covering the concerns raised in the prevention of future death report.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
-
NHS Greater Manchester Integrated Care Board
Existing arrangements requiring contact with the GP provide the escalation route when care-home patients refuse medication or fluids.
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Department of Health and Social Care
When patients refuse prescribed medication or fluids, their GP should decide the appropriate next steps.
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Concerns raised1
Failure to maintain a consistent and accessible medication-refusal procedure across Homes
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
- Crystal Care Norfolk Ltd
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
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Crystal Care Norfolk Ltd
Amend the company-wide medication policy to require condition-specific escalation after the first refusal and define emergency responses and generic-medication escalation.
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Crystal Care Norfolk Ltd
Introduce medication-refusal quick-reference reminders attached to medication administration records across all homes.
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Crystal Care Norfolk Ltd
Create a transfer and unfamiliar-staff checklist requiring policy familiarisation, signatures, allocated reading time and a named mentor.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026