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.
Exeter and Greater Devon
Concerns raised1
Failure to review patients receiving extended-term medication for suitability of continued long-term use
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
Remind practices through the regular electronic newsletter to review patients receiving short-acting benzodiazepines.
Stated by Devon LMCStated plannedThe respondent said that this action was planned when they made their response on 3 December 2017.
Action
Make the relevant short-acting benzodiazepine review information available on the Devon LMC website.
Stated by Devon LMCStated plannedThe respondent said that this action was planned when they made their response on 3 December 2017.
Action
Audit patients prescribed Lorazepam and all practice patients receiving it on repeat prescription.
Stated by Fremington Medical CentreStated completedThe respondent said that this action was complete when they made their response on 3 December 2017.
Action
Send personal letters asking patients with repeat benzodiazepine prescriptions to arrange targeted medication reviews.
Stated by Fremington Medical CentreStated completedThe respondent said that this action was complete when they made their response on 3 December 2017.
Action
Remind prescribing staff to discuss short-term benzodiazepine use, conduct regular reviews, and avoid adding these medicines to repeat prescriptions.
Stated by Fremington Medical CentreStated completedThe respondent said that this action was complete when they made their response on 3 December 2017.
Wiltshire and Swindon
Concerns raised1
Lack of adequate review of antidepressant medication
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.7
Action
Record written medication-review summaries alongside medication-review codes to support reliable audits and identify patients needing review.
Stated by Partners at New Court SurgeryStated plannedThe respondent said that this action was planned when they made their response on 28 September 2015.
Action
Audit patients taking SSRI antidepressants who were due medication reviews and arrange appointments by telephone or in person.
Stated by Partners at New Court SurgeryStated completedThe respondent said that this action was complete when they made their response on 28 September 2015.
Action
Notify repeat-prescription patients about medication reviews, count down repeat issues, and contact persistent non-attenders through telephone, letters, electronic messages, and pharmacists.
Stated by Partners at New Court SurgeryStated completedThe respondent said that this action was complete when they made their response on 28 September 2015.
Action
Send all patients taking SSRI antidepressants invitations to medication reviews with information about antidepressants and stopping treatment.
Stated by Partners at New Court SurgeryStated completedThe respondent said that this action was complete when they made their response on 28 September 2015.
Action
Advise patients taking SSRI antidepressants to have an annual medication review during their birthday month.
Stated by Partners at New Court SurgeryStated in progressThe respondent said that this action was in progress when they made their response on 28 September 2015.
Action
Repeat-audit SSRI antidepressant patients due medication reviews and assess identified patients individually over six months as resources permit.
Stated by Partners at New Court SurgeryStated in progressThe respondent said that this action was in progress when they made their response on 28 September 2015.
Action
Upgrade repeat prescribing to electronic prescribing and online ordering, enabling prescription messages and review requirements at the final issue.
Stated by Partners at New Court SurgeryStated completedThe respondent said that this action was complete when they made their response on 28 September 2015.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing surgery systems are considered robust and sufficient to ensure medication reviews and counselling offers for patients taking SSRI antidepressants.
Stated by Partners at New Court SurgeryExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Black Country
Concerns raised1
Failure to account for morphine buildup during long-term therapy
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
The evidence does not support excessive accumulation of morphine metabolites in this case, as would be expected from impaired renal elimination.
Stated by Medicines and Healthcare products Regulatory AgencyDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Staffordshire South
Concerns raised1
Lack of a formal medication review process for long-term medication prescribing
This report raised 4 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
Consider and initiate independent medication reviews by asking an uninvolved doctor to review complex patients’ medication when appropriate.
Stated by Browning Street SurgeryStated plannedThe respondent said that this action was planned when they made their response on 10 January 2014.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing computerised reviews, weekly prescriptions and consultations were considered sufficient to monitor and control medication access.
Stated by Browning Street SurgeryExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
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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.
