First reported 4 Sep 2013•Latest report 17 Jun 2026
Definition
What this concern includes
Includes failures in the medication-provision process that delay or prevent clinically required medication from being prescribed, processed, dispensed or administered when needed, including delayed usual medication after admission and delayed urgent therapeutic medication.
Not included
Excludes long-term medication review, medication reconciliation, dosage verification and medication administration concerns when timely provision of required medication is not the shared unsafe condition.
Excludes failures limited to medication continuity across care transitions where the issue is maintaining uninterrupted access rather than promptly initiating or providing medication when clinically needed.
Excludes medication shortages, prescribing inappropriateness or monitoring failures that do not directly cause delayed or absent provision of clinically required medication.
Excludes generic staffing, communication, documentation or electronic-system deficiencies unless they directly result in delayed or absent provision of the required medication.
Reports
32
Distinct published reports
Individual concerns
34
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
51
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.
Greater Manchester Mental Health NHS Foundation Trust3
Department of Health and Social Care2
Essex Partnership University NHS Foundation Trust2
Royal Cornwall Hospital2
Royal Free Hospital2
University Hospitals Sussex NHS Foundation Trust2
Aneurin Bevan University LHB1
Betsi Cadwaladr University LHB1
Blackpool Teaching Hospitals NHS Foundation Trust1
Coastal Homecare – Hove Branch1
Community Disability Nurse1
Droylsden Road Family Practice1
Dr Simon Chapple1
General Pharmaceutical Council1
Hc-One Limited1
NHS trust17
Healthcare site8
Type not available3
Local health board2
Ministerial department2
Domiciliary care provider1
Executive non-departmental public body1
Health and care professional regulator1
Health professional body1
Local authority service1
Medicines and medical devices regulator1
Multi-service care provider1
Private limited company1
Professional body1
Residential care home1
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.
Suffolk
Concerns raised1
Lack of direct access to required Mental Health medication for Mental Health Liaison Team Non-Medical Prescribers in Emergency Departments
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Responsibility for relevant clinical guidance, NHS service delivery and oversight sits with NHS England.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
West Sussex, Brighton and Hove
Concerns raised1
Risk of discontinued or essential seizure-control medication being incorrectly administered
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.12
Action
Update the MAR chart SOP with guidance on discontinued medicines remaining in patients’ homes and mandatory GP second checks for discrepancies.
Stated by Sussex Community NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 26 March 2026.
Action
Strengthen escalation pathways by referring complex medicines-reconciliation issues to senior clinicians and SCFT pharmacy support.
Stated by Sussex Community NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
Action
Deliver staff briefings and training aligned with the revised MAR chart SOP after approval.
Stated by Sussex Community NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 26 March 2026.
Action
Provide staff with Plexus shared-care-record access for real-time GP medication summaries.
Stated by Sussex Community NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
Action
Embed pharmacy support within the UCR and General Virtual Ward model for complex or unclear medication regimes.
Stated by Sussex Community NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
Action
Revise and implement UCR referral documentation to require receiving agencies to reconcile medicines with prescribers and pharmacies and clarify that UCR MAR charts are for SCFT staff only.
Stated by Sussex Community NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 26 March 2026.
Action
Strengthen referral-pathway expectations that medicines reconciliation is confirmed when care responsibility transfers.
Stated by Sussex Community NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
Action
Require staff to cross-check medicines against prescribing records, administration records, and referral documentation during handover.
Stated by Coastal Homecare (Hove) Ltd.Stated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
Action
Integrate GP Connect into the digital platform and current practice to verify medicines and identify recent changes.
Stated by Coastal Homecare (Hove) Ltd.Stated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
Action
Record each person’s dispensing pharmacy and require escalation to relevant healthcare professionals when medication discrepancies or uncertainties arise.
Stated by Coastal Homecare (Hove) Ltd.Stated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
Action
Require all staff to complete additional Epilepsy Awareness training.
Stated by Coastal Homecare (Hove) Ltd.Stated in progressThe respondent said that this action was in progress when they made their response on 26 March 2026.
Action
Attend Local Authority training on epilepsy awareness, seizure management, and buccal midazolam.
Stated by Coastal Homecare (Hove) Ltd.Stated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
Essex
Concerns raised1
Failure to enter and administer re-prescribed medication
This report raised 30 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
Implement electronic prescribing and medicines administration safeguards against omitted medicines during prescription-chart changes.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 February 2026.
Essex
Concerns raised1
Failure to administer prescribed medication
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.
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.
Cornwall and Isles of Scilly
Concerns raised1
Failure to ensure timely prescription of usual medication for late and unexpected admissions
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.9
Action
Establish a multidisciplinary clinical group to advise on strengthened governance for timely, accurate prescribing after unexpected day-case admissions.
Stated by Royal Cornwall Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 14 November 2025.
Action
Submit the prescribing governance action plan to the Clinical Effectiveness Group for sign-off before implementation.
Stated by Royal Cornwall Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 14 November 2025.
Action
Identify systems that alert relevant staff when day-surgery patients are unexpectedly admitted, including their location, admission reason and responsible consultant.
Stated by Royal Cornwall Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 14 November 2025.
Action
Ensure patient-data platforms triangulate accurate information about unexpected day-surgery admissions for the site-coordination office and responsible doctors.
Stated by Royal Cornwall Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 14 November 2025.
Action
Ensure a responsible consultant is identified and aware of each unexpected day-surgery admission at admission.
Stated by Royal Cornwall Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 14 November 2025.
Action
Ensure medical and nursing staff follow pharmacy prescribing policies, including medicines reconciliation focused on high-risk medicines.
Stated by Royal Cornwall Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 14 November 2025.
Action
Share the patient-safety review and PFD findings with care-group leadership and clinical-governance teams for dissemination to day-surgery services.
Stated by Royal Cornwall Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 14 November 2025.
Action
Audit postoperative prescribing for all inpatients admitted after day-case surgery against the five workstream recommendations.
Stated by Royal Cornwall Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 14 November 2025.
Action
Review learning and further work identified through the postoperative prescribing audit.
Stated by Royal Cornwall Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 14 November 2025.
Birmingham and Solihull
Concerns raised1
Failure to ensure availability and escalation of necessary prescribed medication
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
Circulate a Trust patient-safety notice reinforcing procedures for obtaining and escalating time-critical medicines, using safety huddles, meetings, newsletters, and governance channels.
Stated by University Hospitals Birmingham NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 14 August 2025.
Action
Strengthen induction and Medicines Management training on missed doses, time-critical medicines, escalation, and staff accountability for medicines administration.
Stated by University Hospitals Birmingham NHS Foundation TrustStated in progressThe respondent said that this action was in progress 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.2
Position
Fidaxomicin was available throughout admission; missed doses resulted from nursing failures to record and communicate its location, not pharmacy supply failure.
Stated by University Hospitals Birmingham NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
UHB Pharmacy could not have prevented the missed doses because they occurred outside normal hours and Fidaxomicin was available through emergency drug cupboards.
Stated by University Hospitals Birmingham NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Inner North London
Concerns raised1
Failure to ensure timely availability of Naloxone
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
Deliver two weeks of safety-huddle sessions on accessing and replenishing Naloxone, including out-of-hours arrangements.
Stated by Royal Free London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 1 April 2025.
Action
Increase ward 8 North Naloxone stock from two to three boxes and audit stocking consistency.
Stated by Royal Free London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 1 April 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Access to Naloxone on ward 8 North was not disrupted; unusually high usage caused the delay in administration.
Stated by Royal Free London NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Inner North London
Concerns raised1
Failure to administer the first antibiotic dose in the emergency department
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.3
Action
Provide mandatory induction and continuing teaching on paediatrics, deterioration, escalation, TTA medication use and individualized safety-netting.
Stated by Royal Free London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 17 March 2025.
Action
Progress plans for dedicated emergency-department pharmacy provision through the business-case approval process.
Stated by Royal Free London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 March 2025.
Action
Ensure sufficient adult TTA medication stock and assign medication-stock responsibilities in job planning.
Stated by Royal Free London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 17 March 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Earlier antibiotics were unlikely to have altered Billie’s outcome because the infection was likely viral, although earlier treatment may benefit similar patients.
Stated by Royal Free London NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
No national guidance or clear rationale supports requiring clinicians to administer the first antibiotic dose absent suspected allergy.
Stated by Royal College of Emergency MedicineDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Lancashire and Blackburn with Darwen
Concerns raised1
Restrictions preventing pharmacists from issuing equivalent medication strengths to provide the same dose
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
Explore new flexibilities allowing pharmacists, in appropriate circumstances, to supply alternative doses or formulations.
Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 13 January 2025.
Action
Conduct and publish a public consultation on proposed medication-supply flexibilities, subject to governmental clearances and Northern Ireland involvement.
Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 13 January 2025.
West Yorkshire Eastern
Concerns raised1
Failure to obtain and supply prescribed anti-epileptic medication promptly
This report raised 4 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
Inspect the pharmacy’s systems for managing out-of-stock medicines and supply issues.
Stated by General Pharmaceutical CouncilStated completedThe respondent said that this action was complete when they made their response on 9 January 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
The pharmacy’s staged process sought medication supplies, and referral to other pharmacies followed unsuccessful attempts to obtain the prescribed brand.
Stated by Midway PharmacyDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
National medication shortages prevented the pharmacy from obtaining the prescribed Tegretol medication and require a national resolution.
Stated by Midway PharmacyUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
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Includes failures in the medication-provision process that delay or prevent clinically required medication from being prescribed, processed, dispensed or administered when needed, including delayed usual medication after admission and delayed urgent therapeutic medication.
