First reported 19 Sep 2013•Latest report 19 Mar 2026
Definition
What this concern includes
Includes failures of controls dedicated to the end-to-end administration of prescribed medicines, including staff competence and supervision, administration accuracy and timing, monitoring, verification of ingestion, access and stock control, documentation, and follow-up of missed or incorrect doses.
Not included
Excludes prescribing-only, medication-selection or clinical-review deficiencies where the concern is not tied to administration.
Excludes hazards involving counterfeit or unlawfully supplied medicines outside the administering organisation's medication-administration system.
Excludes generic record-keeping, staffing or training deficiencies that are not specifically dedicated to safe medication administration.
Excludes failures concerning unrelated information-sharing, assessment or care processes merely occurring in the same case.
Reports
115
Distinct published reports
Individual concerns
147
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
192
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.
Care Quality Commission7
Stockport NHS Foundation Trust7
Department of Health and Social Care6
Ministry of Justice4
NHS England4
Tameside and Glossop Integrated Care NHS Foundation Trust4
HM Prison and Probation Service3
Nursing and Midwifery Council3
University Hospitals Sussex NHS Foundation Trust3
Barking, Havering and Redbridge University Hospitals NHS Trust2
Care UK2
Hc-One Limited2
Leeds Prison2
Leeds Teaching Hospitals NHS Trust2
Manchester University NHS Foundation Trust2
NHS trust66
Healthcare site22
Ministerial department10
Health and social care service regulator7
Multi-service care provider7
Prison or young offender institution7
Private limited company7
Residential care home6
Executive non-departmental public body5
Health and care professional regulator4
Type not available4
Executive agency3
Health professional body3
Coronial office2
Domiciliary care provider2
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.
West Sussex, Brighton and Hove
Concerns raised4
Failure to prevent administration of GP-discontinued medication
Failure to transfer all prescribed medication into the electronic MAR and cross-check it at agency handover
Inaccurate or incomplete recording of medication administration
Risk of discontinued or essential seizure-control medication being incorrectly administered
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.15
Action
Complete a formal review of the MAR chart SOP for UCR and Home First services.
Stated by Sussex Community NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
Action
Update the MAR chart SOP with guidance on discontinued medicines remaining in patients’ homes and mandatory GP second checks for discrepancies.
Stated by Sussex Community NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 26 March 2026.
Action
Strengthen escalation pathways by referring complex medicines-reconciliation issues to senior clinicians and SCFT pharmacy support.
Stated by Sussex Community NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
Action
Deliver staff briefings and training aligned with the revised MAR chart SOP after approval.
Stated by Sussex Community NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 26 March 2026.
Action
Provide staff with Plexus shared-care-record access for real-time GP medication summaries.
Stated by Sussex Community NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
Action
Embed pharmacy support within the UCR and General Virtual Ward model for complex or unclear medication regimes.
Stated by Sussex Community NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
Action
Revise and implement UCR referral documentation to require receiving agencies to reconcile medicines with prescribers and pharmacies and clarify that UCR MAR charts are for SCFT staff only.
Stated by Sussex Community NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 26 March 2026.
Action
Strengthen referral-pathway expectations that medicines reconciliation is confirmed when care responsibility transfers.
Stated by Sussex Community NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
Action
Require staff to cross-check medicines against prescribing records, administration records, and referral documentation during handover.
Stated by Coastal Homecare (Hove) Ltd.Stated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
Action
Integrate GP Connect into the digital platform and current practice to verify medicines and identify recent changes.
Stated by Coastal Homecare (Hove) Ltd.Stated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
Action
Conduct a themed review of UCR medication incidents involving MAR charts and report findings through Trust governance structures.
Stated by Sussex Community NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 26 March 2026.
Action
Photograph all medicines present at assessment and onboarding for every new care package.
Stated by Coastal Homecare (Hove) Ltd.Stated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
Action
Record each person’s dispensing pharmacy and require escalation to relevant healthcare professionals when medication discrepancies or uncertainties arise.
Stated by Coastal Homecare (Hove) Ltd.Stated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
Action
Require all staff to complete additional Epilepsy Awareness training.
Stated by Coastal Homecare (Hove) Ltd.Stated in progressThe respondent said that this action was in progress when they made their response on 26 March 2026.
Action
Attend Local Authority training on epilepsy awareness, seizure management, and buccal midazolam.
Stated by Coastal Homecare (Hove) Ltd.Stated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Receiving care agencies are responsible for medicines reconciliation with prescribers and pharmacies; SCFT MAR charts are not definitive records for external providers.
Stated by Sussex Community NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Essex
Concerns raised1
Failure to enter and administer re-prescribed medication
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.1
Action
Implement electronic prescribing and medicines administration safeguards against omitted medicines during prescription-chart changes.
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.
Suffolk
Concerns raised1
Failure to adequately consider and respond to patients’ medication refusals
This report raised 7 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
Strengthen nursing escalation of repeated medication refusals and treatment-risk concerns by reviewing handovers and embedding responsibilities in local nursing guidance.
Stated by West Suffolk NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 12 February 2026.
Bedfordshire and Luton
Concerns raised1
Withdrawal of medication administration support despite known lack of insight and need for medication compliance
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.
Sunderland
Concerns raised3
Failure to supervise preceptee nurses during medication administration
Recording medication administration before dispensing occurs
Inaccurate recording of Omnicell medication quantities and stock movements
This report raised 7 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
Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 December 2025.
Action
Add medication-administration rights content to e-learning and produce a clinic and dispensing-area awareness poster.
Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 December 2025.
Action
Add controlled-drug discrepancy-reporting guidance to the Medicines Optimisation Policy.
Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 December 2025.
Action
Develop a controlled-drug stock-adjustment report and implement the agreed escalation process for unusual Omnicell balance adjustments.
Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 December 2025.
Action
Work with electronic-care-record suppliers to explore automated Omnicell stock-adjustment reporting and improve system connectivity and safety innovation.
Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 December 2025.
Essex
Concerns raised4
Failure to accurately record medication administration
Non-mandatory medicines-administration refresher training for nurses
Failure to administer MST at the prescribed frequency
Failure to administer prescribed medication
This report raised 15 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
Operate networks for Controlled Drugs Accountable Officers and Medication Safety Officers to receive and spread learning from medication errors.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 19 November 2025.
Action
Provide guidance and tools to NHS Trusts for learning from patient safety incidents and improving controlled-drug safety.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 19 November 2025.
Action
Review the training framework, including whether management training should become mandatory and whether refresher training should be tracked and monitored.
Stated by the Princess Alexandra Hospital NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 November 2025.
Action
Clarify morphine product names and predefine twice-daily frequency for modified-release morphine prescriptions in the electronic prescribing system.
Stated by the Princess Alexandra Hospital NHS TrustStated completedThe respondent said that this action was complete when they made their response on 19 November 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Education and training alone would not sufficiently mitigate recurrence; systems improvements and mechanisms are also required.
Stated by NHS EnglandDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
The hospital trust is responsible for providing the response and addressing the reported concerns through its governance arrangements and actions.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Inner West London
Concerns raised1
Failure to supervise patients taking medication
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
Deliver medication-safety training and require induction competency assessments before staff administer medicines.
Stated by St George’s, Epsom and St Helier University Hospitals and Health GroupStated completedThe respondent said that this action was complete when they made their response on 14 November 2025.
Action
Continue medication-safety audits incorporating patient feedback and report findings to ward teams.
Stated by St George’s, Epsom and St Helier University Hospitals and Health GroupStated in progressThe respondent said that this action was in progress when they made their response on 14 November 2025.
Sunderland
Concerns raised1
Failure to clarify medication changes before continued 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.
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
Introduce and disseminate a visual flow chart guiding staff through medication checks when residents return from hospital without discharge documentation.
Stated by Care UKStated completedThe respondent said that this action was complete when they made their response on 20 October 2025.
Action
Reinforce hospital-return, discharge and medication-management policies through mandatory read-and-sign confirmation and refresher training.
Stated by Care UKStated completedThe respondent said that this action was complete when they made their response on 20 October 2025.
Action
Train staff to escalate hospital-return medication queries, obtain same-day clarification and document communications, actions and handovers.
Stated by Care UKStated completedThe respondent said that this action was complete when they made their response on 20 October 2025.
Action
Discuss imminent and new hospital discharges at daily and weekly clinical meetings so required information and follow-up actions are identified.
Stated by Care UKStated plannedThe respondent said that this action was planned when they made their response on 20 October 2025.
Action
Continue working with hospital Trusted Assessors to streamline secure, prompt sharing of discharge information and support safe transitions of care.
Stated by Care UKStated in progressThe respondent said that this action was in progress when they made their response on 20 October 2025.
East Riding and Hull
Concerns raised1
Lack of clear guidance on the location and personnel authorised to administer depot antipsychotic preparations
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
Release guidance to Integrated Care Boards on intensive and assertive community mental health care, including depot medication.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 13 August 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Local ICBs determine policies and responsibilities for prescribing, administering and dispensing depot medication.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Birmingham and Solihull
Concerns raised1
Failure to ensure availability and escalation of necessary prescribed 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.2
Action
Circulate a Trust patient-safety notice reinforcing procedures for obtaining and escalating time-critical medicines, using safety huddles, meetings, newsletters, and governance channels.
Stated by University Hospitals Birmingham NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 14 August 2025.
Action
Strengthen induction and Medicines Management training on missed doses, time-critical medicines, escalation, and staff accountability for medicines administration.
Stated by University Hospitals Birmingham NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 August 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Fidaxomicin was available throughout admission; missed doses resulted from nursing failures to record and communicate its location, not pharmacy supply failure.
Stated by University Hospitals Birmingham NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
UHB Pharmacy could not have prevented the missed doses because they occurred outside normal hours and Fidaxomicin was available through emergency drug cupboards.
Stated by University Hospitals Birmingham NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
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Includes failures of controls dedicated to the end-to-end administration of prescribed medicines, including staff competence and supervision, administration accuracy and timing, monitoring, verification of ingestion, access and stock control, documentation, and follow-up of missed or incorrect doses.
