Recurring concern

Unreliable communication of critical medication information to GPs

Pin Get email alerts Request correction

First reported 14 Mar 2014•Latest report 19 Mar 2026

Definition

What this concern includes

Includes failures, delays or unreliable processes for conveying critical medication information to a GP or GP surgery when the information is needed for safe prescribing, supply, monitoring or continuity of treatment.

Not included

  • Excludes generic clinical communication failures not materially concerned with medication information.
  • Excludes medication administration errors where the relevant information-exchange failure is not itself identified.
  • Excludes failures of diagnosis, treatment choice or clinical assessment that do not involve communication of medication information.
  • Excludes general electronic-record interoperability problems unless they prevent the exchange of critical medication information with GPs.
Reports
23

Distinct published reports

Individual concerns
25

A report can raise multiple concerns

Date range
2014–2026

First to latest report issue date

Stated actions
47

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.

Department of Health and Social Care6
NHS England3
Care Quality Commission2
NHS Greater Manchester Integrated Care Board2
Office of the Chief Coroner2
Pennine Care NHS Foundation Trust2
Aneurin Bevan University LHB1
Birmingham Women'S and Children'S NHS Foundation Trust1
Brindavan Care Home Limited1
Brook Medical Centre1
Bryntirion Surgery1
BTCM Limited1
Care Inspectorate Wales1
Cwm Taf Morgannwg University Local Health Board1
Edge Hill Rest 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.

  1. Powys, Bridgend and Glamorgan Valleys

    AI-generated summary

    Mrs. Mary Patricia James · 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

    Mrs. Mary Patricia James had a prosthetic heart valve requiring anticoagulation, but INR monitoring was inadequate and there was uncertainty about whether she was taking Warfarin. Concerns included failures in communication between the INR Unit, care home and GP, and that she was not admitted to hospital on 15 May 2015 despite concern about a possible ischaemic leg. The inquest concluded: “Ischaemic leg contributed to by inadequate Warfarin monitoring and dosing”.

    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

    Inadequate communication about anticoagulation monitoring and potential therapy adjustment

    Wider context from the report

    “(3) Inadequate communication between the INR Unit, the Care Home and the GP regarding this patient’s anticoagulation monitoring and the potential need for therapy adjustment; ”

    Source location

    Mrs. Mary Patricia James · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Portsmouth and South East Hampshire

    AI-generated summary

    Courtney Jordan Mills · 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

    Courtney Jordan Mills was found unresponsive in bed at home on 19 April 2013 and was pronounced deceased at hospital that morning. The concerns included repeated prescription and communication problems affecting access to Clonodine, which was reported as a medication that should not be stopped abruptly, and the potential risk to other children in similar circumstances. The inquest recorded acute bronchopneumonia in a child with sleep apnoea and cerebral palsy, with death due to natural causes.

    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 communicate and coordinate timely Clonodine supply

    Wider context from the report

    “I was told that (quote): "Courtney was on a quantity of different medication for her conditions one of which is "Clonodine". Her parents reported that they had been having problems getting the correct prescriptions for this from the GP surgery (written as tablets instead of solution, wrong dosage etc) and this caused problems. This drug cannot just be stopped as the patient suffers from withdrawal symptoms and has to be weaned off gradually. The drug was ordered in by the Pharmacist and could take 5 days to get in so the prescription was always requested in advance of when it was required. Courtney's supply was running low and a prescription was collected by mother and taken to the pharmacy. She returned a few days later she was told that the prescription had been written wrongly and had been returned to the GP and she should have been called by them. Neither parent had received a call. Mother attended the surgery and was told that the prescription could not be done until they had spoken to Courtney's consultant at SGH, ████████ and they would be called when done. No calls received. Courtney's last dose of this medication was due to be given on Thursday morning and father continued to contact the GP surgery on Wednesday but was told it was not ready, he called again on Thursday to an answering machine stating the practice was closed for a training day. He was due to go into the surgery this morning to discuss the matter with the GPs." I was also told that Clonodine could be obtained from the pharmacy at Queen Alexandra Hospital for patients under the care of a consultant - as was Courtney. There had been a history of delay in her obtaining this medication due to communication difficulties between the hospital and her GP surgery. I believe such a problem could put other children's lives at risk in similar circumstances. ”

    Source location

    Courtney Jordan Mills · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    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 medication was not prescribed by the Trust, and there was no evidence that the hospital had been approached for a supply.

    Verbatim wording from the response

    “I understand from ████████ that the Clonidine was not in fact prescribed by Portsmouth Hospitals NHS Trust and our Pharmacy Department have also confirmed that we have no evidence to suggest that Queen Alexandra Hospital were approached for a supply of the drug, although had we been approached, we would have supplied it. In past situations like these, where community pharmacists have had trouble getting hold of non-routine medicines, the patient’s family have contacted our Children’s Assessment Unit (CAU) who have arranged for it to be prescribed by a doctor here and then we have dispensed it from the QAH pharmacy. This is a situation that we are used to and we would have done this in this case. However, had CAU been asked, they may have had a problem verifying the usual dosage, in which case we would have had to contact Southampton prior to writing the prescription.”

    Source location

    2014-0224-Response-by-Portsmouth-Hospitals-NHS-Trust
    Page 1 · response
    Published 12 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

    Existing assessment-unit and pharmacy arrangements would have enabled medication supply if the hospital had been approached, so no further Trust steps were proposed.

    Verbatim wording from the response

    “I understand from ████████ that the Clonidine was not in fact prescribed by Portsmouth Hospitals NHS Trust and our Pharmacy Department have also confirmed that we have no evidence to suggest that Queen Alexandra Hospital were approached for a supply of the drug, although had we been approached, we would have supplied it. In past situations like these, where community pharmacists have had trouble getting hold of non-routine medicines, the patient’s family have contacted our Children’s Assessment Unit (CAU) who have arranged for it to be prescribed by a doctor here and then we have dispensed it from the QAH pharmacy. This is a situation that we are used to and we would have done this in this case. However, had CAU been asked, they may have had a problem verifying the usual dosage, in which case we would have had to contact Southampton prior to writing the prescription.”

    Source location

    2014-0224-Response-by-Portsmouth-Hospitals-NHS-Trust
    Page 1 · response
    Published 12 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

    If medication-continuity issues require national consideration, the Royal Pharmaceutical Society is suggested as the appropriate body to address them.

    Verbatim wording from the response

    “I am aware that maintaining correct medication when patients leave hospital is a significant problem across the NHS as it involves co-ordination between hospitals, GP practices, pharmacy and patients themselves, often with an important medication change made as a result of acute illness. While doctors clearly share responsibility for this, Pharmacists may be best placed to ensure safe processes around this. In the first instance, and if you feel that this issue needs to be considered on a national level, I would suggest that the Royal Pharmaceutical Society may be the best body to contact.”

    Source location

    2014-0224-Response-by-Portsmouth-Hospitals-NHS-Trust
    Page 2 · response
    Published 12 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

    The delay obtaining Clonidine solution was due to community supply constraints, not communication difficulties between the surgery and hospital.

    Verbatim wording from the response

    “████████ then spoke to ████████ on the telephone on 18.04.2013 regarding the Clonidine prescription. They discussed the transdermal option but ████████ felt there were medico-legal issues as it was off licence. ████████ felt that it was more appropriate that Southampton carried on supplying the medication and explained the difficulties to ████████ these being that there was a week’s delay, minimum, in sourcing Clonidine solution in the community and it was also impossible to issue it via the computer.”

    Source location

    2014-0224-Response-by-Waterside-Medical-Centre
    Page 2 · response
    Published 12 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

    Southampton Hospital should continue supplying Clonidine solution because community pharmacies could not readily obtain it.

    Verbatim wording from the response

    “████████ then spoke to ████████ on the telephone on 18.04.2013 regarding the Clonidine prescription. They discussed the transdermal option but ████████ felt there were medico-legal issues as it was off licence. ████████ felt that it was more appropriate that Southampton carried on supplying the medication and explained the difficulties to ████████ these being that there was a week’s delay, minimum, in sourcing Clonidine solution in the community and it was also impossible to issue it via the computer.”

    Source location

    2014-0224-Response-by-Waterside-Medical-Centre
    Page 2 · response
    Published 12 May 2014

    Open published response

  3. Leicester City and South Leicestershire

    AI-generated summary

    Michael Anthony Tarratt · 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

    Michael Anthony Tarratt, who had a history of poly-drug and alcohol abuse and was receiving methadone treatment, was found deceased at home from multiple drug toxicity. The concerns included a lack of contact between drug and alcohol services and his GP for 18 months, and the prescription of tramadol to an opioid-dependent patient without routine information-sharing between services.

    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 exchange prescription information between treatment services and the GP

    Wider context from the report

    “(2) Despite Evidence that the GP prescription of tramadol (for knee pain) was inappropriate for an opiate dependent patient, no contact was made with the GP surgery and it was left to the patient to tell his GP. There was no evidence to suggest that Mr Tarratt did this. Consideration should be given to routine exchange of information regarding prescriptions between services, to avoid one agency counter-acting the treatment of the other. Consideration should be given to the appropriateness of asking the patient to be responsible for this communication. ”

    Source location

    Michael Anthony Tarratt · 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

    Publish the Leicester Recovery Partnership standard operating protocol defining GP communication requirements for structured treatment and open access services.

    Verbatim wording from the response

    “The Leicester Recovery Partnership’s working draft Standard Operating Protocol (SOP) is under review and due for publication within the next few weeks. In relation to GP communication the SOP will state:”

    Source location

    2014-0115-Response-by-Leicestershire-Partnership-NHS-Trust
    Page 2 · response
    Published 14 March 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

    Upload reviewed GP letter templates with prompts for detailed updates into SystmOne.

    Verbatim wording from the response

    “I enclose a copy of the standard GP letter templates which have been reviewed and now include prompts to ensure detailed updates are sent. These are due to be uploaded as part of the configuration with SystmOne within the next 14 days. The subsequent phase of work that will be completed by June 30th 2014 at the latest will include prompts and reminders to practitioners when GP updates are due.”

    Source location

    2014-0115-Response-by-Leicestershire-Partnership-NHS-Trust
    Page 2 · response
    Published 14 March 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

    Implement SystmOne prompts and reminders to alert practitioners when GP updates are due.

    Verbatim wording from the response

    “I enclose a copy of the standard GP letter templates which have been reviewed and now include prompts to ensure detailed updates are sent. These are due to be uploaded as part of the configuration with SystmOne within the next 14 days. The subsequent phase of work that will be completed by June 30th 2014 at the latest will include prompts and reminders to practitioners when GP updates are due.”

    Source location

    2014-0115-Response-by-Leicestershire-Partnership-NHS-Trust
    Page 2 · response
    Published 14 March 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

    Audit case notes for GP correspondence within 14 days and repeat the audit every six months.

    Verbatim wording from the response

    “A case note audit is due to take place within the next 14 days and will include a review of GP correspondence. Audits will be completed every 6 months thereafter.”

    Source location

    2014-0115-Response-by-Leicestershire-Partnership-NHS-Trust
    Page 2 · response
    Published 14 March 2014

    Open published response
Back to top

Data last updated 7 September 2026