First reported 10 Jan 2014•Latest report 30 Jun 2025
Definition
What this concern includes
Includes failures of the end-to-end long-term medication review process, including missing or inadequate formal review arrangements, untimely reviews, reviews based on insufficient clinical knowledge, and failures to reassess continued suitability or medication risks.
Not included
Excludes review failures concerning only short-term or acute medication courses unless the report explicitly connects them to long-term medication review.
Excludes medication administration, prescribing, supply or reconciliation failures that are not part of reviewing ongoing long-term medication use.
Excludes generic staffing, training, documentation or electronic-alert failures unless they are explicitly dedicated to the long-term medication review process.
Excludes medication review concerns involving a different named clinical process, such as specialist treatment review, unless long-term medication review is the shared unsafe condition.
Reports
14
Distinct published reports
Individual concerns
17
A report can raise multiple concerns
Date range
2014–2025
First to latest report issue date
Stated actions
72
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 Care3
NHS Greater Manchester Integrated Care Board3
National Institute for Health and Care Excellence2
NHS England2
Recipient name withheld2
Bexley Medical Group1
Browning Street Surgery1
Delamere Medical Practice1
Devon Local Medical Committee1
Devon Partnership NHS Trust1
Donneybrook Medical Centre1
Fitzalan Medical Group1
Flixton Road Medical Centre1
Fremington Medical Centre1
General Medical Council1
Healthcare site11
Integrated care board6
Executive non-departmental public body4
Ministerial department3
NHS trust2
Type not available2
Domiciliary care provider1
Health and care professional regulator1
Health professional body1
Registered provider of social housing1
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.
Derby and Derbyshire
Concerns raised2
Lack of clear and consistent guidance on ECGs during annual monitoring of long-term antipsychotic medication
Failure to include ECGs in annual reviews for people prescribed antipsychotic medication long term
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
Share the report with the Clinical Knowledge Summaries publisher to support awareness of the ECG-monitoring concern.
Stated by National Institute for Health and Care ExcellenceStated completedThe respondent said that this action was complete when they made their response on 14 July 2025.
Action
Update local antipsychotic prescribing guidance to recommend ECG monitoring after dose changes and ideally annually.
Stated by NHS Derby and Derbyshire Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 14 July 2025.
Action
Review NICE’s response and implement any necessary local updates or further actions arising from changes to national ECG monitoring guidance.
Stated by NHS Derby and Derbyshire Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 14 July 2025.
Action
Share the ratified learning report and guidance updates with primary-care clinicians and relevant system networks through existing communications and governance meetings.
Stated by NHS Derby and Derbyshire Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 14 July 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
Agilio Software, the CKS publisher, is responsible for further changes and detailed information about CKS prescribing content.
Stated by National Institute for Health and Care ExcellenceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
There is insufficient evidence to justify annual ECGs for everyone prescribed long-term antipsychotics.
Stated by National Institute for Health and Care ExcellenceDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Existing SPC, NICE guidance and BNF provisions do not require continued annual ECG monitoring for risperidone.
Stated by National Institute for Health and Care ExcellenceExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Manchester South
Concerns raised2
Limited review of long-term opiate prescribing
Lack of long-term detailed planning and oversight of patients prescribed opiates
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.14
Action
Complete a comprehensive review of opioid prescribing practices.
Stated by Flixton Road Medical CentreStated completedThe respondent said that this action was complete when they made their response on 19 May 2025.
Action
Require regular structured medication reviews for high-dose opioid prescriptions, with defined intervals and GP and pharmacist oversight.
Stated by Flixton Road Medical CentreStated completedThe respondent said that this action was complete when they made their response on 19 May 2025.
Action
Complete an audit of high-risk opioid prescribing to identify improvement needs and support appropriate monitoring.
Stated by Flixton Road Medical CentreStated completedThe respondent said that this action was complete when they made their response on 19 May 2025.
Action
Conduct follow-up audits of compliance with revised opioid prescribing protocols and safety measures, reviewing results and learning at practice meetings.
Stated by Flixton Road Medical CentreStated plannedThe respondent said that this action was planned when they made their response on 19 May 2025.
Action
Work with Manchester University colleagues to investigate and implement the SMASH dashboard opioid indicator for identifying and reviewing patients after hospital discharge.
Stated by NHS Greater Manchester Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 19 May 2025.
Action
Produce and disseminate primary-care communications highlighting chronic-pain opioid risks, review expectations and available resources.
Stated by NHS Greater Manchester Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 19 May 2025.
Action
Use regular meetings with PCN clinical pharmacists to promote identification and prioritisation of opioid patients for structured medication review and signpost review resources.
Stated by NHS Greater Manchester Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 19 May 2025.
Action
Work with GP practices to increase use of the SMASH dashboard, including its opioid indicator.
Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 19 May 2025.
Action
Review patients flagged by the SMASH opioid indicator, identify primary-care review-process improvements and feed potential secondary-care improvements to the Opioid Safety Group.
Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 19 May 2025.
Action
Work with other Greater Manchester localities to produce and implement standards for primary-care review of patients discharged on opioids.
Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 19 May 2025.
Action
Provide GP practices with opioid-prescribing data, including high-dose prescribing, and signpost resources supporting patient review.
Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 19 May 2025.
Action
Increase awareness and accessibility of local services supporting opioid-patient review, including pain-clinic referral pathways and non-pharmacological pain-management support.
Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 19 May 2025.
Action
Collaborate with other localities and secondary-care pain clinics to explore multidisciplinary review of complex primary-care patients receiving high-dose opioids.
Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 19 May 2025.
Action
Revise opioid prescribing policy and introduce a prescribing protocol with escalation thresholds, rationale documentation and multidisciplinary oversight.
Stated by Flixton Road Medical CentreStated completedThe respondent said that this action was complete when they made their response on 19 May 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Resource constraints limited the practice’s ability to undertake more proactive, structured opioid reviews.
Stated by Flixton Road Medical CentreUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Structured medication reviews for opioid patients are limited by PCN clinical pharmacist capacity under the DES contract.
Stated by NHS Greater Manchester Integrated Care BoardUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Bedfordshire and Luton
Concerns raised1
Failure to review prolonged prescribing of dependency-forming drugs and formulate dosage-reduction plans
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
Risk-score opioid and gabapentinoid patients, recall them for face-to-face structured medication reviews, and provide follow-up supporting safe dose reduction.
Stated by Kirby Road SurgeryStated in progressThe respondent said that this action was in progress when they made their response on 8 January 2024.
Action
Recruit a specialist prescribing pharmacist with pain-clinic experience to conduct structured medication reviews.
Stated by Kirby Road SurgeryStated completedThe respondent said that this action was complete when they made their response on 8 January 2024.
Action
Train three in-house clinical pharmacists with the specialist pharmacist to develop their capability to conduct structured medication reviews.
Stated by Kirby Road SurgeryStated in progressThe respondent said that this action was in progress when they made their response on 8 January 2024.
Action
Update, externally review, approve and ratify the opioid and gabapentinoid prescribing policies.
Stated by Kirby Road SurgeryStated completedThe respondent said that this action was complete when they made their response on 8 January 2024.
East London
Concerns raised1
Failure to review Zopiclone use despite high-risk medication-taking behaviour
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.12
Action
Review Zopiclone prescriptions within two weeks, identify existing patients for review, provide senior clinical oversight, and audit compliance six-monthly.
Stated by North East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 15 September 2023.
Action
Train staff in the safe prescribing and management of Z-drugs and benzodiazepines through repeat sessions.
Stated by North East London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 15 September 2023.
Action
Coordinate primary and secondary care medication monitoring through an established integrated-care-system workstream and improve information sharing.
Stated by North East London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 15 September 2023.
Action
Improve team handovers by documenting patient information, care plans and professional responsibilities, including primary-care prescribing arrangements, and audit effectiveness.
Stated by North East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 15 September 2023.
Action
Increase Crisis and Home Treatment team staffing through additional pharmacist posts.
Stated by North East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 15 September 2023.
Action
Use additional pharmacy capacity to improve discharge medication reconciliation, monitor and reconcile Zopiclone prescriptions, and provide medication education during transfers.
Stated by North East London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 15 September 2023.
Action
Audit patients prescribed Zopiclone or Zolpidem to identify those requiring medication review.
Stated by PracticeStated completedThe respondent said that this action was complete when they made their response on 15 September 2023.
Action
Review identified patients’ Zopiclone or Zolpidem medication and develop reduction, cessation or safer-alternative plans.
Stated by PracticeStated in progressThe respondent said that this action was in progress when they made their response on 15 September 2023.
Action
Code completed medication plans in EMIS so healthcare professionals and administrators can follow them.
Stated by PracticeStated completedThe respondent said that this action was complete when they made their response on 15 September 2023.
Action
Conduct medication reviews every four weeks where possible, focusing on reduction according to withdrawal symptoms, risk and support.
Stated by PracticeStated plannedThe respondent said that this action was planned when they made their response on 15 September 2023.
Action
Review Zopiclone and Zolpidem prescriptions as acute rather than repeat prescriptions and limit quantities to a maximum two-week supply.
Stated by PracticeStated completedThe respondent said that this action was complete when they made their response on 15 September 2023.
Action
Apply the acute-prescription policy to new Zopiclone and Zolpidem requests.
Stated by PracticeStated plannedThe respondent said that this action was planned when they made their response on 15 September 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Prescribing and medication review decisions rest with the GP or responsible clinician, who must determine treatment with the patient.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Milton Keynes
Concerns raised1
Failure to actively identify patients taking high-risk medication combinations and rationalize or reduce their medications
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.8
Action
Audit high-dose opioid patients, arrange reviews, and consider dose reduction where appropriate.
Stated by Hilltops Medical CentreStated in progressThe respondent said that this action was in progress when they made their response on 28 February 2023.
Action
Identify and review patients prescribed opioids with gabapentinoids and benzodiazepines or Z-drugs.
Stated by Hilltops Medical CentreStated completedThe respondent said that this action was complete when they made their response on 28 February 2023.
Action
Maintain three-monthly medication reviews using recall systems, preferably face to face and with a named clinician.
Stated by Hilltops Medical CentreStated in progressThe respondent said that this action was in progress when they made their response on 28 February 2023.
Action
Use the Arden’s Opioid Initiation and Monitoring template during medication reviews.
Stated by Hilltops Medical CentreStated plannedThe respondent said that this action was planned when they made their response on 28 February 2023.
Action
Operate a national programme to reduce harm from high-dose opioids prescribed for non-cancer pain.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 28 February 2023.
Action
Support Integrated Care Systems to develop, implement, adapt and share effective improvements in chronic pain and opioid prescribing care.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 28 February 2023.
Action
Develop national resources supporting consistent repeat-prescribing processes and structured medication reviews for patients at risk from multiple medicines.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 28 February 2023.
Action
Publish a national framework to help systems improve personalised care for adults prescribed dependence- or withdrawal-associated medicines.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 28 February 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
ICBs are responsible for commissioning chronic pain and opioid-withdrawal support services for their geographically covered populations.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Manchester South
Concerns raised1
Lack of systematic review of patients receiving repeat prescriptions of multiple analgesics
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
Provide support and set expectations for clinical pharmacists working in general practice.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 20 September 2022.
Action
Use medicines-optimisation support to identify, categorise and prioritise patients receiving repeat prescriptions for multiple analgesics.
Stated by Donneybrook Medical CentreStated completedThe respondent said that this action was complete when they made their response on 20 September 2022.
Action
Review patients on the red, amber and green priority lists, including checking previous reviews and recording required follow-up dates.
Stated by Donneybrook Medical CentreStated in progressThe respondent said that this action was in progress when they made their response on 20 September 2022.
Action
Limit prescription durations according to risk category and automatically arrange GP review when prescriptions become due.
Stated by Donneybrook Medical CentreStated plannedThe respondent said that this action was planned when they made their response on 20 September 2022.
Action
Maintain a safety-netting system recording review dates and run monthly searches to identify new patients requiring inclusion.
Stated by Donneybrook Medical CentreStated completedThe respondent said that this action was complete when they made their response on 20 September 2022.
Inner South London
Concerns raised1
Insufficiently thorough review of repeat medication
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
Implement medication reviews for patients without a review for over 12 months, using EMIS searches, clinician prompts, and recall monitoring for higher-risk medicines.
Stated by Bexley Medical GroupStated in progressThe respondent said that this action was in progress when they made their response on 13 September 2019.
Manchester North
Concerns raised1
Failure to conduct a full review of all prescribed medications
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.6
Action
Provide feedback to the locum doctor about the inadequacy of the medication review.
Stated by Hopwood House Medical PracticeStated plannedThe respondent said that this action was planned when they made their response on 23 August 2019.
Action
Employ a clinical pharmacist to undertake complicated medication reviews and support practice workload.
Stated by Hopwood House Medical PracticeStated plannedThe respondent said that this action was planned when they made their response on 23 August 2019.
Action
Maintain heightened vigilance in communication, correspondence and medication reviews, particularly for sedatives, chronic pain medication, methadone and substance misuse.
Stated by Hopwood House Medical PracticeStated in progressThe respondent said that this action was in progress when they made their response on 23 August 2019.
Action
Highlight recording externally prescribed medicines in EMIS, and associated interaction alerts, to all practices through clinical-pharmacist cluster support.
Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 23 August 2019.
Action
Address identified locum GP competency issues through appropriate channels.
Stated by NHS Greater Manchester Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 23 August 2019.
Action
Change prescriber templates used to review clients across community substance misuse services.
Stated by Turning PointStated completedThe respondent said that this action was complete when they made their response on 23 August 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Clinical Pharmacists cannot reconcile every patient’s medications because current resources do not permit it; entering external prescriptions is considered safer.
Stated by NHS Greater Manchester Integrated Care BoardUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Manchester South
Concerns raised1
Medication reviews failing to provide a full overview of prescribed long-term medication
This report raised 6 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.4
Action
Educate GPs and pharmacists to review acute, repeat and recently issued medicines during medication reviews.
Stated by NHS Greater Manchester Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 23 May 2019.
Action
Require documentation of reasons and review plans when regular long-term medicines are issued acutely.
Stated by NHS Greater Manchester Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 23 May 2019.
Action
Require medication reviews to record the medicines and content reviewed, with follow-up appointments when reviews are incomplete.
Stated by NHS Greater Manchester Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 23 May 2019.
Action
Make prescribers aware that EMIS can set review dates for individual medicines.
Stated by NHS Greater Manchester Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 23 May 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The EMIS Web system distinguishes acute and repeat medicines and supports comprehensive medication reviews, so medicines need not be placed on repeat lists.
Stated by Department of Health and Social CareExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
West Sussex
Concerns raised2
Failure to conduct timely and sufficiently informed medication reviews for long-term repeat prescriptions
Inadequate recording of medication reviews and reasons for repeat prescribing
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.1
Action
Refer controlled-drug prescribing and medication-review issues for national review and a decision on whether guidance requires amendment.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 28 November 2017.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Annual medication reviews were considered unlikely to have prevented this death, which resulted primarily from the patient's decision not to seek medical advice.
Stated by NHS EnglandDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
The national prescribing team will decide whether guidance on controlled-drug prescriptions requires amendment.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
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Includes failures of the end-to-end long-term medication review process, including missing or inadequate formal review arrangements, untimely reviews, reviews based on insufficient clinical knowledge, and failures to reassess continued suitability or medication risks.
