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.
Essex
Concerns raised1
Lack of pharmacist scrutiny of medication changes
This report raised 30 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
Discuss medication changes at multidisciplinary reviews and re-check prescriptions during those reviews.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 February 2026.
Action
Remind staff through supervision to apply professional curiosity and challenge when medication changes require clarification.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 February 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
A pharmacist’s physical ward presence may not always be possible, although remote prescription screening provides an alternative safeguard.
Stated by Essex Partnership University NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Black Country
Concerns raised1
Failure to conduct medication reviews after overdose disclosures and related concerns
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.3
Action
Amend the self-harm follow-up policy to require medication review and consideration of reducing prescription quantities where ongoing risk exists.
Stated by Your Health Partnership PCNStated plannedThe respondent said that this action was planned when they made their response on 29 October 2025.
Action
Amend the self-harm risk-assessment template to record medication review discussions, stockpiling, medication safety, prescription quantity, and medication supervision options.
Stated by Your Health Partnership PCNStated plannedThe respondent said that this action was planned when they made their response on 29 October 2025.
Action
Expand the annual proactive self-harm follow-up audit to record medication reviews and discussions about prescribed medication quantities.
Stated by Your Health Partnership PCNStated plannedThe respondent said that this action was planned when they made their response on 29 October 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
NICE Quality Standard 34 does not specifically require medication review following self-harm.
Stated by Your Health Partnership PCNDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
City of London
Concerns raised1
Failure to review medication, consider admission, or escalate care for an acutely deteriorating patient
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.
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
Conduct multiple daily multidisciplinary clinical safety huddles in the emergency department to review risks and coordinate care.
Stated by South London and Maudsley NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 20 October 2025.
Action
Operate a 24/7 Emergency Department Low Intensity Area at King’s College Hospital with capacity for six patients.
Stated by South London and Maudsley NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 20 October 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Position
Medication discontinuation was not clearly the main cause of relapse, and the presentation did not indicate medication review by liaison psychiatry.
Stated by South London and Maudsley NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Admission was not clearly beneficial for this condition, so community treatment was considered an appropriate alternative when the patient initially engaged.
Stated by South London and Maudsley NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Doctor referral was not initially indicated because the established pathway covered admission, medication changes and other clinical complexities, with senior psychiatric doctors available continuously.
Stated by South London and Maudsley NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Recovery House was unsuitable for homeless patients and therefore unavailable as an alternative to admission in this case.
Stated by South London and Maudsley NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Essex
Concerns raised1
Failure to escalate urgent medication review requests to an appropriate clinician
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.2
Position
Onward appointment processes are at each GP surgery’s discretion, rather than being determined by the Trust.
Stated by Essex Partnership University NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The Line Manager would not have prescribed medication because prescribing for this case was outside the manager’s remit.
Stated by Essex Partnership University NHS Foundation TrustOutside remitThe respondent said that this matter was outside its role or authority.
West Yorkshire Eastern
Concerns raised1
Failure of hospital systems to review and safeguard medication prescribing and administration
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Actions taken following the Serious Incident Report are considered sufficient to address identified issues and prevent similar future deaths.
Stated by Inmind HealthcareExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Surrey
Concerns raised1
Lack of yearly 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.
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
Implement and disseminate a Severe Mental Illness Annual Reviews Policy linking physical, mental-health and medication reviews, templates, coding and recall safeguards.
Stated by Ashlea Medical PracticeStated completedThe respondent said that this action was complete when they made their response on 14 May 2024.
Action
Carry out monthly checks that SMI-register searches result in completed annual reviews.
Stated by Ashlea Medical PracticeStated in progressThe respondent said that this action was in progress when they made their response on 14 May 2024.
Action
Formally audit compliance with the SMI review policy in September 2024 and re-audit or review it thereafter as required.
Stated by Ashlea Medical PracticeStated plannedThe respondent said that this action was planned when they made their response on 14 May 2024.
North West Wales
Concerns raised3
Lack of a standard medication review practice
Failure to conduct regular medication reviews when prescribing medicines that can depress the central nervous system
Failure to meet the target frequency for monthly medication reviews
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
Develop a Health Board policy defining medication-review standards and risk-priority levels for managed practices.
Stated by Betsi Cadwaladr University LHBStated in progressThe respondent said that this action was in progress when they made their response on 22 February 2024.
Action
Put practice-specific standard operating procedures in place for medication-review responsibilities and governance.
Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 22 February 2024.
Action
Risk-stratify patients lacking recent medication reviews to prioritise review according to medication-related risk.
Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 22 February 2024.
Action
Require practices to report medication-review progress against targets through regular assurance meetings.
Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 22 February 2024.
Action
Establish a managed Practice Quality and Governance Group covering North Wales services.
Stated by Betsi Cadwaladr University LHBStated completedThe respondent said that this action was complete when they made their response on 22 February 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.
Mid Kent and Medway
Concerns raised2
Absence of electronic-record alerts for required medication discrepancy reviews
Failure to review identified medication discrepancies
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.3
Action
Develop auditable electronic prescribing functionality that alerts doctors when pharmacists identify issues requiring review.
Stated by Medway NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 21 November 2022.
Action
Investigate how primary-care morphine changes were recorded, communicated and reflected in the Kent Summary of Care Record.
Stated by Medway NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 21 November 2022.
Action
Remind pharmacy staff to follow medicines recommendations through to a conscious decision to endorse or reject them.
Stated by Medway NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 21 November 2022.
East London
Concerns raised1
Lack of meaningful review of insomnia medication prescriptions
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.3
Action
Audit and clinically review all patients prescribed Zopiclone over the previous two years, including structured reviews and a second-cycle review of repeat prescriptions.
Stated by High Street SurgeryStated completedThe respondent said that this action was complete when they made their response on 23 September 2022.
Action
Implement a local Z-Drug protocol requiring structured medication reviews at defined intervals and after relevant mental-health review.
Stated by High Street SurgeryStated completedThe respondent said that this action was complete when they made their response on 23 September 2022.
Action
Hold practice staff meetings to explain the Z-Drug protocol and require repeat-prescription requests to be referred for medication review.
Stated by High Street SurgeryStated completedThe respondent said that this action was complete when they made their response on 23 September 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Review of hypnotic prescriptions is assigned to the primary prescriber, with Trust clinicians reviewing prescriptions within their treatment scope.
Stated by High Street SurgeryRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Pin
Get email alerts
Request correction
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.
