Recurring concern

Failure to reliably conduct clinically required medication reviews

First to latest report 16 Apr 2014 — 8 Feb 2026

Reports that mention this concern
31
Times this concern has been raised
37
Stated actions linked to this concern
84

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.

What is 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 and published responses 31 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Norfolk

    AI-generated summary

    KATHRYN LOUISE SAWYER · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Kathryn Louise Sawyer, who had a significant history of mental health issues and was prescribed multiple medications including Methadone, was found collapsed and unresponsive at home on 14 August 2013 and died shortly after arriving at hospital. The medical cause of death was respiratory failure due to an overdose of Methadone in combination with therapeutic levels of other drugs. A principal concern was that, although her medication was reviewed in June 2013, there was no or no detailed record of the discussion and no plan for future medication, particularly any plan to decrease it.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Delays in reviewing medication

    Wider context from the report

    “(1) Mrs Sawyer registered with the Roundwell Surgery in July 2012 at which time she was known to be addicted to Chloral Betaine (she was prescribed double the dosage recommended in the BNF) and was prescribed a number of different additional medications, including Methadone (prescribed by Trust Alcohol and Drug Service); (2) She attended the Surgery with a letter from her previous GP expressing Mrs Sawyers' concerns about her medication being decreased. It was felt sensible to allow her to feel comfortable with the Surgery before consideration was given to the medication and amounts she was being prescribed. This is accepted as reasonable. (3) During the course of the next 13 months Mrs Sawyer was seen by the Practice on a regular basis when her medication was varied and/or increased. She was admitted to Hospital in November 2012 as a result of an overdose. (4) Mrs Sawyer’s mental health condition stabilised in Spring 2013 when she attended the Surgery for physical problems only. (5) Her medication was not reviewed by the Surgery until June 2013. It was then reviewed by a Locum Doctor. There is no or no detailed record of the discussion relating to her medication and no plan made between patient and the surgery with regard to future medication and in particular any plan to decrease. ”

    Source location

    KATHRYN LOUISE SAWYER · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Conduct six-monthly reviews for patients receiving long-term benzodiazepines or opiates and document the clinical plan and management discussed.

    Verbatim wording from the response

    “4. All patients on long term medication of Benzodiazepines and Opiates will have a six month medication review which will document the clinical plan/ management discussed with the patient. Action – immediate”

    Source location

    2014-0177-Response-by-Roundwell-Medical-Centre
    Page 1 · response
    Published 16 April 2014

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Design a bespoke Addictive Medication Review template to ensure reviews are documented and completed correctly.

    Verbatim wording from the response

    “6. A bespoke “Addictive Medication Review” template to be designed to ensure that all reviews are documented and completed correctly. Action – within 3 months”

    Source location

    2014-0177-Response-by-Roundwell-Medical-Centre
    Page 2 · response
    Published 16 April 2014

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Conduct a regular monthly search to identify patients receiving addictive medication who fail to attend appointments.

    Verbatim wording from the response

    “11. Concerns were noted for those patients on addictive medication who failed to attend appointments. Agreed a regular search would be completed to identify patients and relevant action to be taken. Action – regular monthly search.”

    Source location

    2014-0177-Response-by-Roundwell-Medical-Centre
    Page 2 · response
    Published 16 April 2014

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026