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
NHS trust13
Ministerial department6
Healthcare site5
Executive non-departmental public body4
Integrated care board3
Coronial office2
Health and social care service regulator2
Social-care provider2
Community interest company1
Company1
Company limited by guarantee1
Devolved government1
Devolved legislature1
English county council1
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.
Bedfordshire and Luton
Concerns raised1
Failure to convey information about critically depleted seizure medication to the GP
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.3
Action
Introduce a formal escalation process prioritising requests for critical medicines, including same-day clinical review and urgent clinician alerts.
Stated by Sundon Medical CentreStated in progressThe respondent said that this action was in progress when they made their response on 26 March 2026.
Action
Train reception and administrative staff to recognise critical medicines, manage split-strength requests, escalate concerns and verify communications.
Stated by Sundon Medical CentreStated in progressThe respondent said that this action was in progress when they made their response on 26 March 2026.
Action
Review implementation of the medication-safety changes and monitor compliance with urgent-medicine, dosage-wording, written-request and escalation procedures.
Stated by Sundon Medical CentreStated plannedThe respondent said that this action was planned when they made their response on 26 March 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
NHS England and delegated Integrated Care Boards commission and performance-manage general practice, including addressing persistent performance concerns.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Cheshire
Concerns raised1
Failure to notify or give choice to GPs when software alters lifelong prescriptions
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
Repeat medication does not automatically expire unless an authorised system user configures the expiry setting.
Stated by OptumDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Existing EMIS Web functionality is considered sufficient to mitigate the specific repeat-medication risk, so no further software development is required.
Stated by OptumExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Essex
Concerns raised1
Delays in communication with the GP about antidepressant prescribing
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.1
Action
Reinforce with medical staff the need to communicate medication-dose inconsistencies clearly and promptly.
Stated by Essex Partnership University NHS Foundation TrustStated plannedThe respondent said that this action was planned 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.1
Position
The maximum licensed sertraline dose meant no dose increase was possible, so no additional prescribing action was considered necessary before the planned review.
Stated by Essex Partnership University NHS Foundation TrustNo action considered necessaryThe respondent said that no further action was needed.
West Sussex, Brighton and Hove
Concerns raised1
Lack of information being made available to the GP to prevent duplicitous prescribing
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.4
Action
Roll out the shared care record to primary care during the 2025/2026 financial year.
Stated by NHS Surrey and Sussex Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 21 May 2025.
Action
Migrate to the SystmOne electronic patient record system.
Stated by Sussex Partnership NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 21 May 2025.
Action
Enable two-way, real-time information sharing with GP practices and provide sharing agreements.
Stated by Sussex Partnership NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 21 May 2025.
Action
Establish electronic prescribing, prioritising community electronic prescribing within the programme.
Stated by Sussex Partnership NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 21 May 2025.
Suffolk
Concerns raised1
Failure to require consent and notify current or regular practitioners about online prescriptions
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.
Liverpool and the Wirral
Concerns raised1
Delays in sending information about prescriptions to GP surgeries
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.8
Action
Define and test interoperable medicine standards and make them available to IT system suppliers.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 4 November 2024.
Action
Support wider Trust adoption of interoperable medicine standards through an Information Standards Notice and national digital medicines programmes.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 4 November 2024.
Action
Adopt interoperable medicine standards nationally for medication transfers at hospital admission and discharge.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 4 November 2024.
Action
Require GP IT suppliers to deliver interoperable medicine standard requirements by June 2025.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 4 November 2024.
Action
Enable supplying professionals to electronically record specified prescription-only medicines in GP records through GP Connect.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 4 November 2024.
Action
Update the medicines specification for the Transfer of Care initiative.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 4 November 2024.
Action
Work with Integrated Care Boards to support development of local shared care records presenting medication information across providers.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 4 November 2024.
Action
Use interoperable medicine standards in a local shared care record through an NHS Trust.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 4 November 2024.
Oxfordshire
Concerns raised1
Failure to inform the GP of declined attendance for medication
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.2
Action
Share qualifying mental-health reports with GPs, explain the reasons, and request follow-up and identification of social-care needs.
Stated by Oxfordshire County CouncilStated completedThe respondent said that this action was complete when they made their response on 17 July 2026.
Action
Escalate urgent concerns by contacting GPs immediately or referring cases to the Professional Support Team for evaluation and decision.
Stated by Oxfordshire County CouncilStated completedThe respondent said that this action was complete when they made their response on 17 July 2026.
Staffordshire and Stoke-on-Trent
Concerns raised1
Failure to give the prescribing GP express instructions to amend Brivaracetam prescriptions after dosage changes
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.5
Action
Review internal policies and procedures against the coroner’s concerns and identify necessary changes.
Stated by Godfrey CareStated plannedThe respondent said that this action was planned when they made their response on 21 February 2024.
Action
Implement a local medication policy covering medication receipt, transcription, altered labels, missed doses, written prescribing confirmation and triangulation between prescribers.
Stated by Godfrey CareStated plannedThe respondent said that this action was planned when they made their response on 21 February 2024.
Action
Update weekly and monthly managers’ medication audits to verify written authorisation, dosage changes and timely receipt of replacement prescriptions.
Stated by Godfrey CareStated completedThe respondent said that this action was complete when they made their response on 21 February 2024.
Action
Develop a standardised clinic-letter template specifying medication changes and clear actions for prescribing GPs.
Stated by Brook Medical Centre and University Hospitals of North Midlands NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 21 February 2024.
Action
Develop a standardised Medisec clinic-letter template specifying medication changes and clear prescribing actions for primary care.
Stated by Brook Medical Centre and University Hospitals of North Midlands NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 21 February 2024.
Inner North London
Concerns raised1
Failure to update prescribing GPs about medication non-adherence and stockpiling risks
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
Existing medication-review procedures and subsequent GP notification were considered sufficient; no additional GP communication was expected before the review.
Stated by North London NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Cornwall and Isles of Scilly
Concerns raised1
Failure to communicate medication dosage errors to patients and GPs
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing procedures did not require reporting a no-harm dosage discrepancy to the GP when no post-discharge GP action was needed.
Stated by Royal Cornwall Hospitals NHS TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
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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.
