Recurring concern

Unreliable clinician management of medication side effects

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First reported 12 Oct 2013•Latest report 3 Jun 2026

Definition

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.

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
11

Distinct published reports

Individual concerns
15

A report can raise multiple concerns

Date range
2013–2026

First to latest report issue date

Stated actions
10

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 Care3
Medicines and Healthcare products Regulatory Agency3
NHS England3
Royal College of Psychiatrists2
BNF Publications1
British Association Of Dermatologists1
Care Quality Commission1
Castlefields Health Centre1
Cwm Taf Morgannwg University Local Health Board1
Egton Medical Information Systems Limited1
Greater Manchester Health and Social Care Partnership1
Guy's Hospital1
Herefordshire and Worcestershire Health and Care NHS Trust1
NHS Greater Manchester Integrated Care Board1
Park View Group Practice1

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. 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
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Data last updated 7 September 2026