Recurring concern

Unreliable clinical safety-alert systems

Get email alerts

Request correction

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
Individual concerns: 56
Date range: 2013–2026
Stated actions: 66

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

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

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.

15 May2014
Manchester South
Concerns raised1
1. Failure of the laboratory to flag blood-calcium levels from 3.0mmol/l
This report raised 11 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 1
1. Action
  Escalate serum calcium results above 3 mmol/L through Trust laboratory processes.
  Stated by Stockport NHS Foundation TrustStated completed
Respondent positions 2
1. Position
  NICE does not stipulate laboratory reference values or alert thresholds because this falls outside its remit.
  Stated by Department of Health and Social CareOutside remit
1. Position
  Individual NHS Trusts are responsible for reviewing their own standards for laboratory result reporting and alerts.
  Stated by Department of Health and Social CareRedirects responsibility
AI-generated summary

Gary Bradshaw · 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

Gary Bradshaw attended hospital with groin pain and kidney stones, later developed hyperparathyroidism and died during a hospital admission. The report identified concerns including delays and errors in diagnosis and testing, prescribing bendroflumethiazide before blood-test results, discharge before full investigation, inadequate escalation and fluid monitoring, and incomplete clinical records.

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 of the laboratory to flag blood-calcium levels from 3.0mmol/l
Wider context from the report
“8. The hospital laboratory only ‘flag-up’ the blood-calcium levels exceed 3.5mmol/l or more of serum calcium. The expert witness opined that this should occur at levels of 3.0mmol/l, and that this should be the National standard.(Stockport NHS Trust and The Secretary of State) ”
Source location
Gary Bradshaw · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Escalate serum calcium results above 3 mmol/L through Trust laboratory processes.

Verbatim wording from the response
“8. The hospital laboratory only “flag up” blood results if the blood calcium levels exceed 3.5mmol/L or more of serum calcium. The expert witness opined that this should occur at levels of 3.0mmol/L and that this should be a national standard The escalation of serum calcium levels above 3mmol/L was introduced into Trust processes in March 2014.”

Source location
2014-0232-Response-2
Page 3 · response
Published 15 May 2014
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
NICE does not stipulate laboratory reference values or alert thresholds because this falls outside its remit.

Verbatim wording from the response
“In response to your concerns about the reporting of blood test results, NICE do not stipulate laboratory reference values or ‘flags’ on when to alert clinicians to blood test results. As this is not something that falls within NICE’s remit, it is for individual NHS Trusts to review their own standards.”

Source location
2014-0232-Response-by-Department-of-Health
Page 2 · response
Published 15 May 2014
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Individual NHS Trusts are responsible for reviewing their own standards for laboratory result reporting and alerts.

Verbatim wording from the response
“In response to your concerns about the reporting of blood test results, NICE do not stipulate laboratory reference values or ‘flags’ on when to alert clinicians to blood test results. As this is not something that falls within NICE’s remit, it is for individual NHS Trusts to review their own standards.”

Source location
2014-0232-Response-by-Department-of-Health
Page 2 · response
Published 15 May 2014
Open published response
27 Jan2014
York City
Concerns raised1
1. Uncertainty about availability of prescription-reading software alerts for drug identity or amount errors
This report raised 6 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 2
1. Action
  Prepare and publish a Patient Safety Alert to improve medication-error reporting and learning across healthcare sectors, including community pharmacy.
  Stated by NHS EnglandStated in progress
2. Action
  Review community-pharmacy incident data and relevant research, and engage stakeholders to develop safer-practice guidance on dispensing medicines, technology and checking systems.
  Stated by NHS EnglandStated planned
Respondent positions 2
1. Position
  NHS England is responsible for commissioning pharmaceutical services and has addressed the concerns in its detailed response.
  Stated by Department of Health and Social CareRedirects responsibility
1. Position
  The regulator cannot require registered pharmacies to use automation to reduce dispensing errors.
  Stated by General Pharmaceutical CouncilUnable to act
AI-generated summary

Judith Lesley Marshall · 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

Judith Lesley Marshall was prescribed morphine sulphate 10mg twice daily, but a pharmacy dispensed 60mg capsules. She took the capsules as prescribed and was found dead on 30 September 2009; the inquest recorded bronchopneumonia and the effects of morphine, with a conclusion of accidental death. The principal concerns were pharmacy dispensing errors, the adequacy of checking and monitoring systems, and the absence of central monitoring of prescription errors.

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
Uncertainty about availability of prescription-reading software alerts for drug identity or amount errors
Wider context from the report
“(3) It is not clear whether there is any software, obtainable from the Department of Health or elsewhere, that could read prescriptions and raise an alert if the label sought to be created or if the drug sought to be dispensed is wrong in identity or amount. This would be of particular significance when a high risk drug is dispensed or when a drug is dispensed in an unusual quantity, dosage or form. ”
Source location
Judith Lesley Marshall · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Prepare and publish a Patient Safety Alert to improve medication-error reporting and learning across healthcare sectors, including community pharmacy.

Verbatim wording from the response
“b) NHS England is preparing to publish a Patient Safety Alert on March 2014 to improve reporting and learning of medication errors from all sectors including community pharmacy. This will include the establishment of a National Medication Safety Network, the identification of medication safety officers in large healthcare provider organisations including community pharmacy companies and other measures into to increase the number, quality, timeliness and learning of medication error incident reports.”

Source location
2014-0039-Response-by-NHS-England
Page 4 · response
Published 27 January 2014
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Review community-pharmacy incident data and relevant research, and engage stakeholders to develop safer-practice guidance on dispensing medicines, technology and checking systems.

Verbatim wording from the response
“Unfortunately, there is little use of bar codes in the dispensing process in community pharmacy at present. Greater use of this technology in dispensaries could improve patient safety. The Safe Medication Practice Team in NHS England, plan to undertake a review of community pharmacy incident data, together with relevant research and engage with stakeholders to prepare a Patient Safety Alert for possible publication in 2014. The proposed Alert would better describe the risks arising from dispensing medicines and safer practices to further minimise these risks, including better use of technology and checking systems. This guidance will help inform health care commissioners, providers and regulators of actions that they can take to further minimise risks arising from dispensing medicines.”

Source location
2014-0039-Response-by-NHS-England
Page 4 · response
Published 27 January 2014
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
NHS England is responsible for commissioning pharmaceutical services and has addressed the concerns in its detailed response.

Verbatim wording from the response
“As Secretary of State for Health, I am responsible for setting national priorities, monitoring the whole system’s performance and supporting the integrity of the system to protect the best interests of patients, the public and the taxpayer. Since 1 April 2013, most day to day decisions are taken by NHS England. NHS England is responsible for commissioning primary care services, including pharmaceutical services.”

Source location
2014-0039-Response-by-Department-of-Health
Page 2 · response
Published 27 January 2014
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
The regulator cannot require registered pharmacies to use automation to reduce dispensing errors.

Verbatim wording from the response
“3. There is research that shows the use of automation within a dispensing process can reduce the rate of errors. Whilst we cannot require registered pharmacies to use automation, we do ensure that the way in which we regulate does not stifle the introduction of new technology.”

Source location
2014-0039-Response-by-General-Pharmaceutical-Council
Page 2 · response
Published 27 January 2014
Open published response
12 Oct2013
Cheshire
Concerns raised2
1. Lack of a robust system for posting patient safety alerts
2. Failure of posted patient safety alerts to correctly and sufficiently identify the problem
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.
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
Lack of a robust system for posting patient safety alerts
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 2 · concerns
Open source report
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 of posted patient safety alerts to correctly and sufficiently identify the problem
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 2 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure of the laboratory to flag blood-calcium levels from 3.0mmol/l

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised1

Uncertainty about availability of prescription-reading software alerts for drug identity or amount errors

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised2

Lack of a robust system for posting patient safety alerts

Failure of posted patient safety alerts to correctly and sufficiently identify the problem

Actions described in response 1

Respondent positions 2

Actions described in response 2

Respondent positions 2