First reported 12 Oct 2013•Latest report 1 Apr 2026
Definition
What this concern includes
Includes failures of clinical records, prescribing systems or related clinical information processes to create, retain, update, display or otherwise reliably surface safety alerts concerning patients, medicines or treatment.
Not included
Excludes failures to act on a clearly received alert where the alerting system itself operated as intended.
Excludes non-clinical alert systems such as police, custody, safeguarding or transport systems unless the report directly concerns a clinical safety-alert system.
Excludes generic record-keeping or communication deficiencies that are not specifically tied to the reliability of a clinical safety alert.
Reports
53
Distinct published reports
Individual concerns
56
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
66
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 England12
Department of Health and Social Care11
Egton Medical Information Systems Limited3
Medicines and Healthcare products Regulatory Agency3
Barts Health NHS Trust2
Care Quality Commission2
Great Western Hospitals NHS Foundation Trust2
Medway NHS Foundation Trust2
NHS Wales2
Proprietary Association of Great Britain2
Royal College of General Practitioners2
Royal Cornwall Hospitals NHS Trust2
Welsh Government2
Adelaide Medical Centre, London1
Alliance Pharmaceuticals Limited1
NHS trust27
Executive non-departmental public body13
Healthcare site13
Ministerial department11
Private limited company6
Health professional body5
Medicines and medical devices regulator3
Company2
Devolved government2
Health and social care service regulator2
Health-system partnership2
Social-care provider2
Trade association2
Community interest company1
Health and care professional regulator1
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.
Gateshead and South Tyneside
Concerns raised1
Failure to red-flag significant maternal and fetal growth findings in records
This report raised 8 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.
Oxfordshire
Concerns raised1
Failure of EPR VTE alerts to appear when records remain open
This report raised 2 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.
Inner North London
Concerns raised1
Failure to record opioid sensitivity as an alert across care records
This report raised 9 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.10
Action
Introduce a transfer checklist ensuring required medical history and care information accompanies residents between homes and hospitals.
Stated by Central & Cecil Housing Trust (C&CStated completedThe respondent said that this action was complete when they made their response on 24 January 2019.
Action
Introduce an electronic care-plan system and update training for staff who review and update care plans.
Stated by Central & Cecil Housing Trust (C&CStated plannedThe respondent said that this action was planned when they made their response on 24 January 2019.
Action
Roll out enhanced refresher training on care-plan documentation, medication administration, and recording residents’ conditions and needs across C&C homes.
Stated by Central & Cecil Housing Trust (C&CStated in progressThe respondent said that this action was in progress when they made their response on 24 January 2019.
Action
Implement rigorous checks for maintaining current care-plan and medication records, delete obsolete electronic care-plan forms, and roll these controls out across C&C homes.
Stated by Central & Cecil Housing Trust (C&CStated completedThe respondent said that this action was complete when they made their response on 24 January 2019.
Action
Remind staff to record and check allergies and sensitivities on every admission and discharge, including manual updates to TTA forms and drug charts.
Stated by Royal Free HospitalStated completedThe respondent said that this action was complete when they made their response on 24 January 2019.
Action
Develop an electronic process with IT and Cerner to record allergy information at admission and transfer it to discharge documentation, including assessing backdating options.
Stated by Royal Free HospitalStated in progressThe respondent said that this action was in progress when they made their response on 24 January 2019.
Action
Introduce EPR/EPMA functionality to populate discharge documentation with allergy status and prompt staff when allergy information is missing.
Stated by Royal Free HospitalStated plannedThe respondent said that this action was planned when they made their response on 24 January 2019.
Action
Discussed appropriate coding of clinically significant opioid sensitivities in GP notes.
Stated by Adelaide Medical Centre, LondonStated completedThe respondent said that this action was complete when they made their response on 24 January 2019.
Action
Shared learning on recording opioid sensitivities with Royal Free Hospital and Compton Lodge representatives.
Stated by Adelaide Medical Centre, LondonStated completedThe respondent said that this action was complete when they made their response on 24 January 2019.
Action
Recorded the learning in an internal significant event and shared it with all practice clinicians, including the opioid-sensitivity alerting process.
Stated by Adelaide Medical Centre, LondonStated completedThe respondent said that this action was complete when they made their response on 24 January 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
Care staff cannot diagnose medication allergies or sensitivities and therefore cannot record family concerns in care plans without clinical confirmation.
Stated by Central & Cecil Housing Trust (C&CUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
GPs, treating doctors and hospitals must provide official clinical advice before medication allergies or changes can be recorded and communicated to pharmacists.
Stated by Central & Cecil Housing Trust (C&CRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Systematic alerting of opioid sensitivities between hospital and GP practice cannot be implemented until the planned new IT system is available.
Stated by Adelaide Medical Centre, LondonUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
West Yorkshire (Western)
Concerns raised1
Inconsistent fire-risk alerts and warnings across NHS prescribing systems
This report raised 5 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
Create a SystmOne alert identifying patients at risk when emollient treatment is entered in the clinical record.
Stated by Bradford District Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 October 2018.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Other recipients of the report will address concerns about healthcare warnings, prescribing systems, incident data and fire-safety training.
Stated by Bayer plcRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
London (East)
Concerns raised1
Lack of electronic record alerts to clinical staff when results are ready
This report raised 5 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.
Cornwall and Isles of Scilly
Concerns raised1
Failure of clinical alert processes to reflect applicable lithium monitoring guidelines
This report raised 2 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
Highlight lithium monitoring requirements to GPs and practices and remind them that current BNF and local CCG prescribing guidance is available.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 7 March 2018.
Manchester West
Concerns raised1
Lack of alerts for new medications subject to repeat prescription
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
Study and discuss the repeat prescribing and scanning protocols at a practice meeting.
Stated by Grasmere SurgeryStated completedThe respondent said that this action was complete when they made their response on 6 October 2017.
Action
Meet with all receptionists and nurses to address the protocols.
Stated by Grasmere SurgeryStated completedThe respondent said that this action was complete when they made their response on 6 October 2017.
Action
Arrange a follow-up meeting in three months to review how the prescribing protocol is working within the practice.
Stated by Grasmere SurgeryStated plannedThe respondent said that this action was planned when they made their response on 6 October 2017.
Mid Kent and Medway
Concerns raised1
Failure of haematology laboratory alerting for abnormal ALT and toxic paracetamol results
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.2
Action
Implement an automated paracetamol phone-trigger and ALT alert prompting laboratory staff to telephone critical results to requesting clinicians.
Stated by Medway NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 November 2017.
Action
Audit compliance with SBAR reporting and associated critical-result protocols.
Stated by Medway NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 25 November 2017.
Surrey
Concerns raised1
Failure to reliably identify and flag early repeat prescription requests for GP review
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
Configure an EMIS Web pop-up alert for early controlled-drug prescription requests, enabling staff to flag requests for GP attention.
Stated by Moat House SurgeryStated completedThe respondent said that this action was complete when they made their response on 3 December 2017.
West Yorkshire (West)
Concerns raised1
Failure to provide private community-care companies with alerts about relevant medicines and medical devices
This report raised 8 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
Continue reviewing methods for communicating important healthcare information to healthcare professionals and the public.
Stated by Medicines and Healthcare products Regulatory AgencyStated in progressThe respondent said that this action was in progress when they made their response on 21 July 2017.
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Includes failures of clinical records, prescribing systems or related clinical information processes to create, retain, update, display or otherwise reliably surface safety alerts concerning patients, medicines or treatment.
