Recurring concern

Failure to provide required medication promptly when clinically needed

First to latest report 4 Sep 2013 — 17 Jun 2026

Reports that mention this concern
32
Times this concern has been raised
34
Stated actions linked to this concern
51

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.

What is 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 and published responses 32 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Gwent

    AI-generated summary

    DESGRAE REGINA TUCKER · 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

    Desgrae Regina Tucker was admitted with abdominal pain, underwent gall bladder removal surgery, was discharged home, and died at home six days later. Concerns included inadequate recording and consideration of anti-embolic stockings and no anti-coagulant medication being prescribed on discharge.

    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 prescribe anti-coagulant medication on discharge

    Wider context from the report

    “(1) The lack of recording in the patient's notes as to whether the patient was wearing the anti-embolic stockings prescribed. (2) No consideration given as to whether the patient should be discharged home with anti-embolic stockings. (3) No anti-coagulant medication prescribed to the patient upon discharge. ”

    Source location

    DESGRAE REGINA TUCKER · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  2. Leicester City and South Leicestershire

    AI-generated summary

    Karen Lesley SUTTON · 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

    Karen Lesley Sutton, who had primary antibody deficiency disorder and had undergone a splenectomy, was readmitted on 11 October 2012 with severe sepsis and died that evening after cardiac arrest. Concerns included the Immunology team not being notified of her hospital admissions, discontinuation of her prophylactic antibiotics on discharge, and inadequate arrangements for follow-up and communication between departments.

    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 provide prophylactic antibiotic medication at discharge

    Wider context from the report

    “(1) Not withstanding her 12 year history of regular Immunology follow-up, the team were not notified of her admission to hospital , on either occasion during August and September 2012, and thus given the opportunity to have input into her care and her discharge. (2) Mrs Sutton was discharged home without prophylactic antibiotic medication (3) Mrs Sutton was left to arrange her next out patient appointment and it was fortuitous that ████████ was able to see her after the day of discharge, 4th October 2012. (4) ████████ was unaware of any Trust policy to share admissions between departments. He acknowledged this as a Learning point and although he has personally instigated a practice to encourage patients and /or their relatives to let his department know of any admissions, this is neither robust or in some circumstances practical and cannot be relied upon as a means of communication Trust-wide. ”

    Source location

    Karen Lesley SUTTON · 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

    Explore ward-based technicians’ knowledge of prophylactic antibiotics required after splenectomy.

    Verbatim wording from the response

    “In addition as a result of your second concern our Chief Pharmacist will explore the current level of knowledge of ward-based technicians on prophylactic antibiotics post splenectomy. This case will be discussed at clinical meetings on all three Trust sites to discuss systems and processes that can be implemented to ensure that drugs that must continue on discharge can be flagged and clearly communicated. Both of these actions will be concluded by the end of November 2013. This case will be discussed at the Trust’s Medicines Management Board in December 2013. In addition the junior doctors involved in the care of Mrs Sutton will be particularly reminded about the importance of fully considering pre-admission medication.”

    Source location

    2013-0223-Response-by-University-Hospitals-of-Leicester
    Page 2 · response
    Published 4 September 2013

    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

    Discuss systems and processes across all three Trust sites for flagging and communicating medicines that must continue after discharge.

    Verbatim wording from the response

    “In addition as a result of your second concern our Chief Pharmacist will explore the current level of knowledge of ward-based technicians on prophylactic antibiotics post splenectomy. This case will be discussed at clinical meetings on all three Trust sites to discuss systems and processes that can be implemented to ensure that drugs that must continue on discharge can be flagged and clearly communicated. Both of these actions will be concluded by the end of November 2013. This case will be discussed at the Trust’s Medicines Management Board in December 2013. In addition the junior doctors involved in the care of Mrs Sutton will be particularly reminded about the importance of fully considering pre-admission medication.”

    Source location

    2013-0223-Response-by-University-Hospitals-of-Leicester
    Page 2 · response
    Published 4 September 2013

    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

    Remind the junior doctors involved to fully consider patients’ pre-admission medication.

    Verbatim wording from the response

    “In addition as a result of your second concern our Chief Pharmacist will explore the current level of knowledge of ward-based technicians on prophylactic antibiotics post splenectomy. This case will be discussed at clinical meetings on all three Trust sites to discuss systems and processes that can be implemented to ensure that drugs that must continue on discharge can be flagged and clearly communicated. Both of these actions will be concluded by the end of November 2013. This case will be discussed at the Trust’s Medicines Management Board in December 2013. In addition the junior doctors involved in the care of Mrs Sutton will be particularly reminded about the importance of fully considering pre-admission medication.”

    Source location

    2013-0223-Response-by-University-Hospitals-of-Leicester
    Page 2 · response
    Published 4 September 2013

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026