Recurring concern

Unreliable management of medication doses not taken

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First reported 29 Apr 2015•Latest report 11 Mar 2025

Definition

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.

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.
Reports
12

Distinct published reports

Individual concerns
12

A report can raise multiple concerns

Date range
2015–2025

First to latest report issue date

Stated actions
22

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.

NHS England4
HM Prison and Probation Service2
Barts Health NHS Trust1
Care Quality Commission1
Care UK1
Crystal Care1
Department of Health and Social Care1
Essex Partnership University NHS Foundation Trust1
Greater Manchester Health and Social Care Partnership1
Guys Marsh Prison1
Lancashire Teaching Hospitals NHS Foundation Trust1
Mid and South Essex NHS Foundation Trust1
Practice Plus Group1
Royal Stoke University Hospital1
Sapphire House1

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.

  1. Dorset

    AI-generated summary

    Andrew Craig · 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

    Andrew Craig, a serving prisoner at HMP Guys Marsh, was found collapsed and unresponsive in his cell on 16 September 2016. The inquest concluded that the medical cause of death was the toxic effects of buprenorphine and diazepam, with a conclusion of misadventure. The principal concerns were illicit drug use at the prison and weaknesses in the dispensing and monitoring of medication, which could facilitate the redistribution of prescription drugs.

    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 monitor whether prisoners swallow dispensed medication

    Wider context from the report

    “ii. Evidence was given by the Head of Healthcare, ████████ that there are 3 allocated times during the day when Prisoners collect medication. During these times, there are around 70 prisoners collecting their medication. The room can be quite chaotic and loud, and prisoners can be in close contact clambering over each other. She described the hatch as overloaded. This is an ideal scenario to pass medication to one another without detection. iii. In addition, during the routine medication dispensing, there are no checks done to confirm that Prisoners have actually swallowed the medication. This can allow them to retain the medication for redistribution. iv. At the last inspection by Her Majesty’s Inspectorate of Prisons these issues were raised and attempts have been made to improve the situation. There are now Prison Officers at the Healthcare department during dispensing times, but usually only one Officer stood in the room where the medication hatch is located and another outside the room. Despite these changes, Mrs Jameson advised that the arrangements at medication dispensing times continue to be an ongoing problem that facilitates the illicit supply of prescription drugs in the Prison. She advised that the process could be made safer and more secure. Similar concerns were also raised by one of the Prison GPs ████████ ████████ v. Mrs Jameson also gave evidence that the Prison is overwhelmed with illicit drug use, particularly psychoactive substances and that the Healthcare team receive 3 emergency calls a week at HMP Guys Marsh to assist in resuscitating Prisoners from drug overdoses. 2. I have concerns with regard to the following: i. There is an ongoing problem with the use of drugs, both prescription and illicit drugs such as psychoactive substances, at HMP Guys Marsh and there have been a number of recent deaths either confirmed to be, or suspected to be, due to drug use. ii. Although the Prison are working to address this, further consideration needs to be given to restricting the supply of such drugs. I would request that to prevent a future death at HMP Guys Marsh, there is a review of the policies and procedures by both the Prison Staff and the Healthcare Staff regarding the dispensing and monitoring of the medication administered at the medication hatch to ensure compliance and reduce distribution to others. ”

    Source location

    Andrew Craig · Prevention of Future Deaths report
    Page 5 · 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

    Operate CCTV surveillance and follow the adjudication process when medication diversion is observed.

    Verbatim wording from the response

    “We are aware that medication is diverted from the Healthcare department and we have already implemented a number of factors that will help to reduce this.”

    Source location

    2018-0194-Response-by-Care-UK_Redacted
    Page 2 · response
    Published 10 July 2018

    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

    Have prison staff support healthcare staff when prisoners may not have swallowed medication or are otherwise non-compliant.

    Verbatim wording from the response

    “Having seen the response from Care UK I understand that healthcare staff will not be checking each person’s mouth to ensure that they have swallowed their medication. However, prison staff will be present to deal with any issues and will support healthcare staff when they have reason to believe that a prisoner has not swallowed medication or is being otherwise non-compliant.”

    Source location

    2018-0194-Response-by-HM-Prison-Probabtion-Service
    Page 3 · response
    Published 10 July 2018

    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

    Universal swallowing checks are not considered practical or appropriate because queues, the physical wall and confidentiality prevent reliable checks.

    Verbatim wording from the response

    “Whilst we understand the diversion of medication happens we do not think it is acceptable to ask for visual evidence each time. We do not have the ability within the medication queues to ensure prisoners show us they have swallowed their medication. We have a physical wall between medical staff and the patient and would not be able to ensure this happens. Due to confidentiality reasons we do not feel it would be appropriate for officers to check patient’s mouths either. However, healthcare staff do ask to check a patient’s mouth if we have reason to believe that a patient has diverted their medication.”

    Source location

    2018-0194-Response-by-Care-UK_Redacted
    Page 4 · response
    Published 10 July 2018

    Open published response

  2. Manchester West

    AI-generated summary

    Jorge Emanuel Mousinho Assabay E Castro · 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

    Jorge Emanuel Mousinho Assabay E Castro died at home on 16 October 2014 after being found collapsed and unresponsive. He had post-traumatic epilepsy but had not received sodium valproate after 3 July 2014, despite attending his GP practice three times without the medication issue being reviewed. The principal concerns were the lack of systems to identify uncollected prescriptions and to alert GPs to medication-adherence concerns, particularly for vulnerable patients.

    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

    Lack of systems to identify and highlight outstanding prescriptions

    Wider context from the report

    “1. During the Inquest evidence was heard that: i. Jorge had not received sodium valproate medication for administration after 3rd July 2014 and he had been diagnosed with post traumatic epilepsy in February 2014 requiring regular treatment with sodium valproate as an anti-epileptic medication. ii. Jorge had been seen by General Practitioners at the Springfield Medical Centre on three occasions after the 3rd July 2014 without any review of the fact that he had not collected prescriptions for sodium valproate and the fact that the General Practitioner had received a letter from ████████ alerting the General Practitioner to an issue in relation to his regular adherence with his anti-epileptic medication. iii. Jorge was known to be a vulnerable person, who consumed excess amounts of alcohol on a regular basis and who was being treated with Citalopram for depression prior to his injuries on the 20th June 2013 and subsequently on the 18th September 2014 prior to his death. iv. The General Practitioner’s surgery at Springfield Medical Centre does not appear to have any systems to identify and highlight a patient who has not collected prescriptions, particularly in relation to vulnerable patients who will be dependent on medication for the control of a diagnosed condition and, as in the case of Jorge, to reduce the risk of episodes of seizure. In particular the computerised records do not have a system of highlighting any outstanding prescriptions at subsequent consultations so that a General Practitioner was not alerted to the fact that Jorge had not collected his prescriptions and would not have had a supply of his anti-epileptic medication after the 3rd July 2014 at any of the appointments following the 3rd July 2014. v. The evidence raised concerns that there is a risk that future deaths will occur unless action is taken to review the above issues. 2. I request you to consider the above concerns, particularly with regard to the following: i. The procedures and systems to highlight and alert General Practitioners in relation to concerns or issues raised by a Hospital Consultant, namely in Jorge’s case by ████████ with regard to Jorge’s regular adherence with his anti-epileptic medication. ii. A review of your systems and procedures to alert General Practitioners in relation to the issue of prescriptions and the failure of a patient to collect prescriptions for prescribed medications, particularly in relation to vulnerable patients who have not collected or received their prescriptions for a period of time. iii. Training of all staff, both professional and administrative, in relation to record keeping and checks in relation to outstanding prescriptions, particularly when a vulnerable patient has not collected a prescription and has not received necessary and prescribed medications for a period of time. ”

    Source location

    Jorge Emanuel Mousinho Assabay E Castro · Prevention of Future Deaths report
    Page 4 · 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

    Amend the prescribing system to highlight overdue prescriptions after three months and prompt timely clinical follow-up.

    Verbatim wording from the response

    “time period and the practice has made the necessary amendments so that in future any staff viewing a patient’s prescriptions will be alerted sooner (from 3 months) and appropriate action can be taken to mitigate any risk to the patient. This would include immediate notification to the General Practitioner who would then liaise with the patient, carers, family and pharmacy as appropriate. The practice can then work with all necessary individuals or agencies to help support the patient with compliance of their medication.”

    Source location

    2015-0170-Response-by-Springfield-Medical-Centre
    Page 3 · response
    Published 29 April 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

    Create and regularly update a register of patients receiving weekly prescriptions, with monthly administrative checks and GP review of omissions.

    Verbatim wording from the response

    “However, even this system has its limitations, as it would only highlight the issue of overdue prescriptions when a member of the practice team is actually in the patient’s records and looking at the repeat medication screen. As a practice we have over 3000 patients on regular repeat medication. Each prescription is usually for 1 to 2 months duration. However, approximately 300 of these patients, like Mr Castro, are issued medications on a weekly basis. This system is usually for patient safety or as a compliance aid. We have thus decided to create a register of all patients who are receiving prescriptions on a weekly basis. These prescriptions are issued in 4 weekly batches and the administrative staff will be checking the prescriptions have been issued for each patient every month. Those that have not been issued will be passed to a General Practitioner for review.”

    Source location

    2015-0170-Response-by-Springfield-Medical-Centre
    Page 3 · response
    Published 29 April 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

    Notify and collaborate with local pharmacies regarding interruptions to weekly medication collection or supply, and disseminate the significant-event learning.

    Verbatim wording from the response

    “Weekly prescriptions are all sent to the patient’s nominated pharmacy. We have written to our local pharmacies and asked them to kindly inform us if there is any interruption to any of these patients’ medication collection or supply.”

    Source location

    2015-0170-Response-by-Springfield-Medical-Centre
    Page 3 · response
    Published 29 April 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

    Deliver a half-day training workshop for staff involved in repeat-prescription generation to support the revised systems and procedures.

    Verbatim wording from the response

    “3. Training of all staff in relation to prescribing As a practice we have taken this opportunity to look at our prescribing systems and the changes above do require staff training. However, we have also looked at the possibility of external facilitators who may bring further advice and expertise to the practice of effective management of repeat prescribing. We can confirm that a half-day workshop has been arranged for Thursday 25th June and we would be open to any further recommendations on this day.”

    Source location

    2015-0170-Response-by-Springfield-Medical-Centre
    Page 3 · response
    Published 29 April 2015

    Open published response
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Data last updated 7 September 2026