First reported 30 Jul 2013•Latest report 16 Mar 2026
Definition
What this concern includes
Includes failures of dosage verification, clarification, read-back, discussion or communication when they directly concern medication dosage safety across prescribing, dispensing, administration or transitions of care.
Not included
Excludes medication safety concerns unrelated to dosage verification or communication, such as failures to refer for non-medication care.
Excludes generic staffing, documentation or communication deficiencies that are not directly tied to medication dosage safety.
Excludes failures concerning medication choice, monitoring or adherence where dosage verification or communication is not the unsafe condition.
Reports
16
Distinct published reports
Individual concerns
20
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
26
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
Barking, Havering and Redbridge University Hospitals NHS Trust1
Boehringer Ingelheim Limited1
Brace Street Health Centre1
Brook Medical Centre1
BTCM Limited1
Care Quality Commission1
Central and North West London NHS Foundation Trust1
Department of Health and Social Care1
Doncaster Royal Infirmary1
Essex Partnership University NHS Foundation Trust1
General Pharmaceutical Council1
Godfrey Care1
Inmind Healthcare Group1
Manor Field Surgery1
NHS trust6
Healthcare site5
Executive non-departmental public body4
Multi-service care provider2
Company limited by guarantee1
Health and care professional regulator1
Health and social care service regulator1
Health professional body1
Independent healthcare provider1
Integrated care board1
Ministerial department1
Private limited company1
Social-care provider1
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.
Cumbria
Concerns raised1
Failure to ensure clear communication with GP services about ongoing drug use and doses
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Essex
Concerns raised1
Failure to scrutinise prescribed medication and medication-system information
This report raised 18 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.4
Action
Operate networks for Controlled Drugs Accountable Officers and Medication Safety Officers to receive and spread learning from medication errors.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 19 November 2025.
Action
Provide guidance and tools to NHS Trusts for learning from patient safety incidents and improving controlled-drug safety.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 19 November 2025.
Action
Remove the option to modify existing prescriptions in the electronic prescribing system, requiring cancellation or discontinuation and reordering with clinical warnings.
Stated by the Princess Alexandra Hospital NHS TrustStated completedThe respondent said that this action was complete when they made their response on 19 November 2025.
Action
Clarify morphine product names and predefine twice-daily frequency for modified-release morphine prescriptions in the electronic prescribing system.
Stated by the Princess Alexandra Hospital NHS TrustStated completedThe respondent said that this action was complete when they made their response on 19 November 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Education and training alone would not sufficiently mitigate recurrence; systems improvements and mechanisms are also required.
Stated by NHS EnglandDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
The hospital trust is responsible for providing the response and addressing the reported concerns through its governance arrangements and actions.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Essex
Concerns raised1
Failure to verify antidepressant prescription doses
This report raised 7 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
Reinforce with medical staff the need to communicate medication-dose inconsistencies clearly and promptly.
Stated by Essex Partnership University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 14 August 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The maximum licensed sertraline dose meant no dose increase was possible, so no additional prescribing action was considered necessary before the planned review.
Stated by Essex Partnership University NHS Foundation TrustNo action considered necessaryThe respondent said that no further action was needed.
West Yorkshire Eastern
Concerns raised1
Failure of hospital systems to review and safeguard medication prescribing and administration
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Actions taken following the Serious Incident Report are considered sufficient to address identified issues and prevent similar future deaths.
Stated by Inmind HealthcareExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Staffordshire and Stoke-on-Trent
Concerns raised4
Failure to refer dosage-clarification correspondence to a clinician
Failure to refer medication-change correspondence to a clinician for consideration
Failure to give the prescribing GP express instructions to amend Brivaracetam prescriptions after dosage changes
Failure to maintain a reliable written basis for Brivaracetam dosage administration
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.8
Action
Review internal policies and procedures against the coroner’s concerns and identify necessary changes.
Stated by Godfrey CareStated plannedThe respondent said that this action was planned when they made their response on 21 February 2024.
Action
Implement a local medication policy covering medication receipt, transcription, altered labels, missed doses, written prescribing confirmation and triangulation between prescribers.
Stated by Godfrey CareStated plannedThe respondent said that this action was planned when they made their response on 21 February 2024.
Action
Update staff medication competency assessments to test clarification of unclear directions, MAR-label discrepancies and verbal medication changes.
Stated by Godfrey CareStated completedThe respondent said that this action was complete when they made their response on 21 February 2024.
Action
Require GP review and triage of all neurology correspondence received by Brook Medical Centre.
Stated by Brook Medical Centre and University Hospitals of North Midlands NHS TrustStated completedThe respondent said that this action was complete when they made their response on 21 February 2024.
Action
Have a GP review and triage all neurology correspondence and clinic letters received by Brook Medical Centre.
Stated by Brook Medical Centre and University Hospitals of North Midlands NHS TrustStated completedThe respondent said that this action was complete when they made their response on 21 February 2024.
Action
Develop a standardised Medisec clinic-letter template specifying medication changes and clear prescribing actions for primary care.
Stated by Brook Medical Centre and University Hospitals of North Midlands NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 21 February 2024.
Action
Update weekly and monthly managers’ medication audits to verify written authorisation, dosage changes and timely receipt of replacement prescriptions.
Stated by Godfrey CareStated completedThe respondent said that this action was complete when they made their response on 21 February 2024.
Action
Develop a standardised clinic-letter template specifying medication changes and clear actions for prescribing GPs.
Stated by Brook Medical Centre and University Hospitals of North Midlands NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 21 February 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
A standardised clinic-letter template cannot be created immediately because implementation across the Trust requires substantial timeframes.
Stated by Brook Medical Centre and University Hospitals of North Midlands NHS TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
The delay in administering medication did not contribute to the death.
Stated by Brook Medical Centre and University Hospitals of North Midlands NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Inner South London
Concerns raised2
Failure to identify conflicting medication concentration and specify administration volume before dispensing
Failure to clearly record prescribed medication strength and administration volume
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.2
Action
Undertake further actions and discussions after receiving the paediatric medicines review’s statement on next steps.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 6 September 2023.
Action
Discuss liquid morphine safety with London ICB medication-safety representatives and provide regional oversight of action-plan implementation, including communications to GPs and community pharmacists.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 6 September 2023.
Hertfordshire
Concerns raised1
Failure to use clear and non-confusable communication and expression of numbers for medication dosages
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
Use of different units for opiate medication between pre-hospital services and hospitals
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Black Country
Concerns raised1
Failure to independently verify warfarin dosage before prescribing
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
Require Warfarin patients to present yellow books, record and verify INR results and doses, and confirm prescriptions before issuing them.
Stated by Brace Street Health CentreStated completedThe respondent said that this action was complete when they made their response on 30 October 2019.
Action
Implement a written procedure for prescribing Warfarin, checking INR results, and changing doses.
Stated by Brace Street Health CentreStated completedThe respondent said that this action was complete when they made their response on 30 October 2019.
Action
Assign the assistant practice manager to check Warfarin requests during the practice manager’s leave.
Stated by Brace Street Health CentreStated plannedThe respondent said that this action was planned when they made their response on 30 October 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing Warfarin prescribing, monitoring and auditing systems are considered robust and sufficient to prevent further recurrences.
Stated by Brace Street Health CentreExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
West Sussex
Concerns raised1
Failure to counsel medication users on the use and risks of exceeding the prescribed dose
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Prescribing clinicians and other healthcare professionals are responsible for explaining dosing, risks, and consequences of exceeding prescribed doses.
Stated by Boehringer Ingelheim LimitedRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
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Includes failures of dosage verification, clarification, read-back, discussion or communication when they directly concern medication dosage safety across prescribing, dispensing, administration or transitions of care.
