First reported 4 Dec 2014•Latest report 9 Dec 2025
Definition
What this concern includes
Includes failures in which clinicians or services do not clearly define, communicate, retain or act on responsibility for prescribing decisions and associated medication advice, including responsibility at interfaces between specialist recommendations, non-prescriber advice and GP prescribing.
Not included
Excludes general unsafe prescribing decisions where responsibility was clear and the deficiency is the clinical choice, dose or indication.
Excludes generic medication counselling omissions where no uncertainty or failure concerning responsibility for prescribing or medication advice is identified.
Excludes ordinary communication, training or documentation deficiencies that do not create unclear accountability for prescribing or medication advice.
Excludes medication administration, dispensing, supply, monitoring and reconciliation failures unless they directly arise from unclear prescribing or medication-advice responsibility.
Reports
6
Distinct published reports
Individual concerns
7
A report can raise multiple concerns
Date range
2014–2025
First to latest report issue date
Stated actions
17
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 Care2
NHS Central East Integrated Care Board2
Barts Health NHS Trust1
Cambridgeshire and Peterborough NHS Foundation Trust1
Maylands Health Care1
NHS England1
Norfolk and Suffolk NHS Foundation Trust1
North East London NHS Foundation Trust1
Oakwood Medical Centre1
Orchard Surgery, Melbourn1
Partnership of East London Co-operatives (PELC) Limited1
NHS trust4
Healthcare site3
Integrated care board2
Ministerial department2
Company1
Executive non-departmental public body1
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.
East London
Concerns raised1
Breakdown of communication about responsibility for penicillin prescription and dispensation
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.6
Action
Proactively contact patients with sickle cell disease annually for medication reviews, including Penicillin V prescribing and compliance.
Stated by Maylands HealthcareStated completedThe respondent said that this action was complete when they made their response on 19 December 2025.
Action
Liaise directly with secondary or tertiary specialists when responsibility for Penicillin V prescribing or dispensing requires clarification.
Stated by Maylands HealthcareStated completedThe respondent said that this action was complete when they made their response on 19 December 2025.
Action
Move all patients with sickle cell disease to electronic repeat dispensing for Penicillin antibiotics.
Stated by Maylands HealthcareStated completedThe respondent said that this action was complete when they made their response on 19 December 2025.
Action
Require the on-site pharmacist to communicate uncollected sickle cell disease prescriptions to the practice.
Stated by Maylands HealthcareStated completedThe respondent said that this action was complete when they made their response on 19 December 2025.
Action
Increase access to shared care records to improve communication between primary and secondary care.
Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 19 December 2025.
Action
Develop greater interoperability of electronic patient records, starting with structured medication information sharing.
Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 19 December 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Responsibility for addressing the prophylactic penicillin communication concern lies with other bodies.
Stated by Partnership of East London Co-operatives LtdRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Without a shared care protocol, the hospital should retain responsibility for care, monitoring and issuing the prescription.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Suffolk
Concerns raised1
Lack of a clear prescribing decision-making and coordination system for mental health 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.
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
Add prescribing responsibilities and communication instructions to standard letters sent to GPs when service users join CRHT caseloads.
Stated by Norfolk and Suffolk NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 November 2024.
Action
Remind staff to liaise directly with GPs when requesting adjustments to medications already prescribed by GPs.
Stated by Norfolk and Suffolk NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 November 2024.
Action
Undertake a joint clinical audit with primary care colleagues three months after implementing the revised CRHT wording and report results to the Trust-wide Safety Group.
Stated by Norfolk and Suffolk NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 28 November 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Commissioning NHS 111 Option 1 and out-of-hours GP services is outside the respondent’s responsibility.
Stated by Norfolk and Suffolk NHS Foundation TrustOutside remitThe respondent said that this matter was outside its role or authority.
Derby and Derbyshire
Concerns raised1
Lack of a clear policy for communicating drug alerts when a GP prescribes at the behest of a non-prescriber without seeing the patient
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.4
Action
Provide daily GP debriefs and clinical supervision for mental health workers, including medication safety, alerts, side effects and documentation.
Stated by Lister House SurgeryStated completedThe respondent said that this action was complete when they made their response on 26 September 2023.
Action
Allocate non-prescriber prescribing decisions to GP partners with protected time and require GP review, debriefing and drug-safety checks before prescribing.
Stated by Lister House SurgeryStated completedThe respondent said that this action was complete when they made their response on 26 September 2023.
Action
Expand TeamNet for all staff to circulate MHRA alerts, record review and track clinicians’ understanding.
Stated by Lister House SurgeryStated plannedThe respondent said that this action was planned when they made their response on 26 September 2023.
Action
Trial sending selected patients AccuRx messages linking to medication information leaflets, informed by clinical judgement and confidentiality considerations.
Stated by Lister House SurgeryStated in progressThe respondent said that this action was in progress when they made their response on 26 September 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The practice considers that it has taken the necessary action to address the Coroner’s concerns and does not identify a need for further work.
Stated by Lister House SurgeryNo action considered necessaryThe respondent said that no further action was needed.
Cambridgeshire and Peterborough
Concerns raised2
Failure of GPs to recognise their responsibility for prescribing and medication advice
Non-prescriber mental health staff advising GPs on medication
This report raised 4 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.
East London
Concerns raised1
Lack of clarity about responsibility for communicating medication risks
This report raised 16 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
Review and implement AABIT standard operating procedures.
Stated by North East London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 16 November 2015.
Bedfordshire and Luton
Concerns raised1
Failure of the General Practitioner to confirm the correct medication rather than relying on nursing-home staff
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
Develop and consult stakeholders on a medication-reconciliation protocol for transfers into care homes and registration with a new GP.
Stated by NHS Central East Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 4 December 2014.
Action
Share the medication-reconciliation protocol with GP commissioners and NHS England’s Area Team for consideration of contractual compliance measures.
Stated by NHS Central East Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 4 December 2014.
Action
Write an action plan to drive the medication-reconciliation work forward and monitor its progress through the Patient Safety and Quality Committee.
Stated by NHS Central East Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 4 December 2014.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Prescribing GPs are responsible for ensuring medication meets patients’ clinical needs, rather than relying on non-clinical care-home staff to identify errors.
Stated by NHS Central East Integrated Care BoardRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
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Includes failures in which clinicians or services do not clearly define, communicate, retain or act on responsibility for prescribing decisions and associated medication advice, including responsibility at interfaces between specialist recommendations, non-prescriber advice and GP prescribing.
