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.
Manchester North
Concerns raised2
Lack of online pharmacy information sharing with patients’ GPs
Failure to prevent contraindicated prescribing across online and other prescribers
This report raised 8 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
NHS England has no jurisdiction over private healthcare provision, including private online prescribing services.
Stated by Department of Health and Social CareOutside remitThe respondent said that this matter was outside its role or authority.
Nottinghamshire
Concerns raised1
Delays in sending outpatient letters containing important clinical information
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Leicester City and South Leicestershire
Concerns raised1
Failure to notify the person's GP of prescribed drugs
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.5
Action
Publish guidance for pharmacist prescribers on sharing prescribing information with people’s prescribers and other care professionals.
Stated by General Pharmaceutical CouncilStated completedThe respondent said that this action was complete when they made their response on 4 November 2021.
Action
Inspect online providers’ management of medicines, prescriptions, consent, identity checks, information sharing, governance and staff safety training.
Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 4 November 2021.
Action
Publish guidance requiring providers to inform patients’ GPs about prescribed medications and assess safety when patients decline information sharing.
Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 4 November 2021.
Action
Work with healthcare regulators on digital healthcare provision.
Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 4 November 2021.
Action
Review the UK legislative position on digital healthcare and identify regulatory gaps.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 4 November 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Online consultations and prescribing without face-to-face assessment can be safe where appropriate safeguards, history-taking, GP engagement and monitoring exist.
Stated by Care Quality CommissionDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Systems for accessing and sharing prescribing and dispensing information are outside the respondent’s remit.
Stated by General Medical CouncilOutside remitThe respondent said that this matter was outside its role or authority.
Cornwall and Isles of Scilly
Concerns raised2
Failure of doctors considering opiate prescriptions to contact the registered GP
Failure of dispensing pharmacists to contact the registered GP when checking prescription appropriateness
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.5
Action
Inspect each registered online provider identified from the inquest and review their medication-prescribing management processes.
Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 22 February 2021.
Action
Submit proposals to DHSC for legislative changes addressing regulatory safety gaps in independent online primary care services.
Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 22 February 2021.
Action
Share key learning and practice points from the inquest with relevant providers and stakeholders.
Stated by Care Quality CommissionStated plannedThe respondent said that this action was planned when they made their response on 22 February 2021.
Action
Continue using enforcement powers to require improvements when online providers fail to meet regulatory requirements.
Stated by Care Quality CommissionStated in progressThe respondent said that this action was in progress when they made their response on 22 February 2021.
Action
Publish guidance setting expectations for providers to inform patients’ GPs about prescribed medicines and assess safety when information sharing is declined.
Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 22 February 2021.
Mid Kent and Medway
Concerns raised1
Failure to share and escalate delayed antibiotic treatment information
This report raised 10 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.
Manchester South
Concerns raised1
Failure of information sharing between GPs and psychiatrists about sedative and antipsychotic medication decisions
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Stoke-on-Trent and North Staffordshire
Concerns raised1
Failure to independently verify patients’ concurrent opiate replacement therapy and prescribing organisation
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
Contact the service lead and request reviews of GP-data collection, verification, and reliable information sharing with registered GPs.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 13 September 2019.
Action
Write to Staffordshire GP practices about the inquest risks, considering other agencies' opiate prescribing, and alerting the clinic when patients are registered elsewhere.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 13 September 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
NHS England is neither commissioner nor regulator of these substance misuse services and has no direct responsibility for them.
Stated by NHS EnglandOutside remitThe respondent said that this matter was outside its role or authority.
Position
The Local Authority, rather than NHS England or the Clinical Commissioning Group, commissions these substance misuse services.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Manchester South
Concerns raised1
Failure to communicate with community GPs before discharge about ongoing melatonin prescribing
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
Review the case with the practice to identify further learning.
Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 16 June 2018.
Action
Raise how medication provision at discharge was handled with Pennine Care and identify required improvements.
Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 16 June 2018.
Suffolk
Concerns raised1
Failure to reliably notify GPs of discharge medication types and quantities
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.1
Action
Plan the technical changes required to notify GPs electronically about prescribed discharge medication.
Stated by Norfolk and Suffolk NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 30 April 2024.
South Lincolnshire
Concerns raised1
Failure to communicate hospital advice, medication changes and increased INR levels to the GP in time
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
Send electronic inpatient discharge letters to the appropriate GP practice within 24 hours of discharge.
Stated by United Lincolnshire Teaching Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 5 April 2017.
Action
Issue and recirculate standards for communicating test results between secondary and primary care.
Stated by United Lincolnshire Teaching Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 5 April 2017.
Action
Circulate an organisation-wide patient safety bulletin on antibiotic-related anticoagulation interactions and timely communication.
Stated by United Lincolnshire Teaching Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 5 April 2017.
Action
Write to the lead clinicians of all three Accident and Emergency departments about the concerns and required timely communication.
Stated by United Lincolnshire Teaching Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 5 April 2017.
Action
Develop electronic Accident and Emergency documentation enabling direct electronic transmission of clinical information to patients’ GPs.
Stated by United Lincolnshire Teaching Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 5 April 2017.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Electronic A&E-to-GP communication cannot yet be implemented because competing Trust-wide electronic systems and IT upgrades constrain progress.
Stated by United Lincolnshire Teaching Hospitals NHS TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
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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.
