Recurring concern

Unreliable clinician management of medication side effects

First to latest report 12 Oct 2013 — 3 Jun 2026

Reports that mention this concern
11
Times this concern has been raised
15
Stated actions linked to this concern
10

What this concern includes

Includes failures in clinician-facing processes for identifying, enquiring about, recording, communicating, reviewing or escalating medication side effects, including unclear recording guidance and inadequate awareness of required escalation procedures.

What is not included
  • Excludes patient-facing medication counselling or warnings where the clinician-facing recognition, recording or escalation process is not deficient.
  • Excludes prescribing, dispensing, administration, monitoring or treatment failures that do not specifically concern recognising or responding to medication side effects.
  • Excludes generic clinical documentation, training or communication deficiencies unless they directly impair medication-side-effect management.
  • Excludes side effects from non-medication treatments unless the assertion explicitly concerns medication side effects.

Reports and published responses 11 reports

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

  1. Cheshire

    AI-generated summary

    Carol Ann Gibson · 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

    Carol Ann Gibson, aged 65, died at home on 8 August 2012 following an adverse reaction to nitrofurantoin, which had been prescribed despite an alert in her medical records about a previous adverse reaction. The concerns included failure to heed and appropriately investigate the alert, and possible weaknesses in the practice’s systems and staff understanding for managing patient safety alerts.

    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 check adverse-reaction alerts before prescribing

    Wider context from the report

    “1. ████████ ignored a warning alert in the medical records that his patient had suffered an adverse reaction to nitrofurantoin without checking the nature of the adverse reaction and issued a prescription for the drug regardless. 2. A letter dated 3rd November 2008 was sent by a consultant to ████████ at Castlefields Health Centre identifying that the interstitial lung disease from which 3. ████████ on commenting on alert warnings, said that most are “trivial, spurious, irrelevant or just wrong”, identified a phenomenon that he described as alert fatigue and further stated that colleagues within the practice had admitted that they “may well have done the same in my situation”. I am concerned that if ████████ comments correctly describe the attitude within his medical practice to patient safety alerts this is a matter of considerable concern and warrants investigation by you to ensure first of all that the practice has a robust system in place for posting such alerts, secondly that such alerts when posted, correctly and sufficiently identify the problem and thirdly that doctors and medical staff within the practice have full understanding and training to respond to such alerts in an appropriate manner. ”

    Source location

    Carol Ann Gibson · Prevention of Future Deaths report
    Page 1 · 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