First reported 16 Apr 2014•Latest report 8 Feb 2026
Definition
What this concern includes
Includes failures of the medication-review process, including identifying when a review is required, arranging or completing the review, obtaining relevant pharmacy or clinical input, reviewing medication-related discrepancies and maintaining required review frequency where the review is needed to support safe prescribing and treatment.
Not included
Excludes medication prescribing, administration, dispensing, supply or monitoring failures where a medication review is not itself the deficient control.
Excludes generic clinical review, diagnosis or treatment-review failures that do not materially concern review of medication or medication-related decisions.
Excludes long-term medication review where the assertion is specifically bounded to a dedicated long-term-review programme and does not support the broader clinically required medication-review condition.
Excludes generic documentation, staffing, communication or electronic-alert deficiencies unless they directly cause a clinically required medication review to be missed or left incomplete.
Reports
31
Distinct published reports
Individual concerns
37
A report can raise multiple concerns
Date range
2014–2026
First to latest report issue date
Stated actions
84
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.
Betsi Cadwaladr University LHB3
Department of Health and Social Care3
NHS Greater Manchester Integrated Care Board3
Care Quality Commission2
Essex Partnership University NHS Foundation Trust2
North East London NHS Foundation Trust2
Alexander Court Care Centre1
Alvaston Medical Centre1
Ashlea Medical Practice1
Berrywood Hospital1
Bow School1
Brighton and Hove City Council1
Bromley by Bow Health Centre1
Cardiff & Vale University LHB1
Care Inspectorate Wales1
Healthcare site16
NHS trust12
Local health board5
Ministerial department4
Integrated care board3
Health and social care service regulator2
Multi-service care provider2
Type not available2
Devolved government1
Domiciliary care provider1
English unitary authority1
Executive non-departmental public body1
Health-system partnership1
Maintained school1
Nursing 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.
North Wales (East and Central)
Concerns raised1
Absence of proper medication scrutiny or review during each care home visit
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.7
Action
Conduct a formal internal investigation to identify root causes and lessons learned.
Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 27 April 2022.
Action
Disseminate the internal investigation’s lessons to all district nursing teams.
Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 27 April 2022.
Action
Conduct and document medication reviews at every local district nursing visit using a checklist countersigned by the care home.
Stated by Betsi Cadwaladr University LHBStated completedThe respondent said that this action was complete when they made their response on 27 April 2022.
Action
Survey all district nursing teams to assess compliance with consistent medication-review practice.
Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 27 April 2022.
Action
Develop or adapt district nursing standard operating procedures and checklists to assure medication reviews.
Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 27 April 2022.
Action
Discuss with the Clinical Effectiveness Team how to audit medication-review changes over the longer term.
Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 27 April 2022.
Action
Review a proposal for structured medication-review collaboration between Central Community Pharmacy and the Central Community Resource Team.
Stated by Betsi Cadwaladr University LHBStated in progressThe respondent said that this action was in progress when they made their response on 27 April 2022.
Derby and Derbyshire
Concerns raised1
Failure to undertake a medication review in response to known excessive, hoarded and erratic medication use
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
Recruit two clinical pharmacists to support patient medication reviews.
Stated by Alvaston Medical CentreStated completedThe respondent said that this action was complete when they made their response on 26 April 2022.
Action
Conduct structured, holistic medication reviews covering compliance, understanding, social history, lifestyle and medication changes.
Stated by Alvaston Medical CentreStated plannedThe respondent said that this action was planned when they made their response on 26 April 2022.
Action
Prevent high-risk scheduled drugs from forming part of repeat prescriptions wherever possible.
Stated by Alvaston Medical CentreStated completedThe respondent said that this action was complete when they made their response on 26 April 2022.
Action
Prevent prescriptions from being ordered automatically too far in advance of their due dates.
Stated by Alvaston Medical CentreStated completedThe respondent said that this action was complete when they made their response on 26 April 2022.
Action
Continue assessing medications and prescribing areas that would benefit from additional surveillance.
Stated by Alvaston Medical CentreStated in progressThe respondent said that this action was in progress when they made their response on 26 April 2022.
Manchester North
Concerns raised2
Failure to complete annual medication reviews
Failure to ask patients about over-the-counter medication during medication reviews
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.11
Action
Participate in monthly multidisciplinary meetings with mental health, social care and other providers, including network pharmacist medication reviews for people of concern.
Stated by The Uplands Medical PracticeStated completedThe respondent said that this action was complete when they made their response on 24 May 2021.
Action
Create a standardised medication-review questionnaire prompting enquiries about over-the-counter medicines and supplements at prescribing and annual reviews.
Stated by The Uplands Medical PracticeStated in progressThe respondent said that this action was in progress when they made their response on 24 May 2021.
Action
Move to a clinical IT system with integrated prescribing-safety prompts, medication-review prompts and visual reminders.
Stated by The Uplands Medical PracticeStated plannedThe respondent said that this action was planned when they made their response on 24 May 2021.
Action
Recruit three additional permanent salaried GPs.
Stated by The Uplands Medical PracticeStated plannedThe respondent said that this action was planned when they made their response on 24 May 2021.
Action
Include the medication-review questionnaire in the prescribing policy and provide medication-review training for clinical and new staff.
Stated by The Uplands Medical PracticeStated plannedThe respondent said that this action was planned when they made their response on 24 May 2021.
Action
Employ a permanent pharmacist with medication-review competency and responsibility for improving the prescribing policy and questionnaire.
Stated by The Uplands Medical PracticeStated plannedThe respondent said that this action was planned when they made their response on 24 May 2021.
Action
Recall patients with serious mental health conditions for detailed structured medication reviews, with Mental Health Lead oversight and dedicated administrative support.
Stated by The Uplands Medical PracticeStated in progressThe respondent said that this action was in progress when they made their response on 24 May 2021.
Action
Create and monthly review an electronic, traffic-light safety net to prioritise health checks and medication reviews for higher-risk mental health patients.
Stated by The Uplands Medical PracticeStated plannedThe respondent said that this action was planned when they made their response on 24 May 2021.
Action
Engage Royal College of General Practitioners practice-development support to review Practice processes and planned safety measures.
Stated by The Uplands Medical PracticeStated in progressThe respondent said that this action was in progress when they made their response on 24 May 2021.
Action
Provide local teams with advice and guidance supporting shared decision-making and appropriately timed medication reviews.
Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 24 May 2021.
Action
Share the medication-review questionnaire with partner practices and Manchester Health and Social Care Partnership for feedback and good-practice dissemination.
Stated by The Uplands Medical PracticeStated plannedThe respondent said that this action was planned when they made their response on 24 May 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
Local teams are responsible for implementing Greater Manchester medicines advice and guidance, while GMMMG provides supporting advice.
Stated by NHS Greater Manchester Integrated Care BoardRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Existing GP medication reviews and PCN Structured Medication Reviews are considered sufficient to address medication-review concerns.
Stated by Maria Caulfield MPExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
The questionnaire may not be embeddable in the current clinical system because of its limitations, until the Practice moves to a new system.
Stated by The Uplands Medical PracticeUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Manchester South
Concerns raised1
Lack of follow-up review appointments for prescribed 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.2
Action
Flag patients at risk from neuropathic medication and alcohol dependence, conduct medication reviews, and contact them about medication and alcohol consumption.
Stated by NHS Greater Manchester Integrated Care Board and Tameside Borough CouncilStated completedThe respondent said that this action was complete when they made their response on 18 May 2020.
Action
Issue an alert to all GP practices about alert notes, follow-up reviews and considering systems to identify high alcohol use during prescribing.
Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 18 May 2020.
Inner West London
Concerns raised1
Inadequate medication review systems
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Inspections ultimately found no concerns in the areas identified, so there was no basis for enforcement action.
Stated by Care Quality CommissionDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Nottinghamshire
Concerns raised1
Lack of ward-based pharmacy review
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
South Wales Central
Concerns raised1
Failure to perform suitably frequent medication reviews
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.3
Action
Employ a full-time clinical pharmacist to oversee and improve prescribing governance and patient monitoring.
Stated by West Quay Medical CentreStated completedThe respondent said that this action was complete when they made their response on 17 May 2019.
Action
Discuss the report’s medication-review and high-risk-patient learning at the monthly significant-events meeting with clinical staff.
Stated by West Quay Medical CentreStated plannedThe respondent said that this action was planned when they made their response on 17 May 2019.
Action
Raise medication-review frequency as a practice issue with the Primary, Community and Intermediate Care Clinical Board for consideration.
Stated by Cardiff & Vale University LHBStated completedThe respondent said that this action was complete when they made their response on 17 May 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Medication review for patients managed in primary care is a matter for the GP practice and Primary, Community and Intermediate Care Clinical Board.
Stated by Cardiff & Vale University LHBRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Manchester South
Concerns raised1
Lack of regular medication reviews
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.
South Wales Central
Concerns raised1
Lack of medication review for correct Rivaroxaban dosage and duration
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.
South Yorkshire (Eastern)
Concerns raised1
Lack of procedures to fully explore drug regimens and alternative pain management at annual medication reviews
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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Includes failures of the medication-review process, including identifying when a review is required, arranging or completing the review, obtaining relevant pharmacy or clinical input, reviewing medication-related discrepancies and maintaining required review frequency where the review is needed to support safe prescribing and treatment.
