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.
What is 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.
Trends
Reports over time
Reports mentioning this concern, 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
Reports and published responses 115 reports
See individual reports that have raised this concern, and the actions taken in response
Manchester South
Concerns raised1
Delays in administering prescribed antibiotics
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Stockport NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Stockport NHS Foundation Trust
The patient did not receive Teicoplanin during this admission; oral Doxycycline followed the subsequent knee washout.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Stockport NHS Foundation Trust
Intravenous antibiotics were not indicated during the 48-hour period because the patient was clinically well and revision surgery was not planned.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Manchester South
Concerns raised1
Failure to administer prescribed long-acting insulin as scheduled
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
Stockport NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Stockport NHS Foundation Trust
Establish a specialist Task and Finish Group to oversee the interim medication-chart solution.
Stockport NHS Foundation Trust
Review the medication-chart interface problem and develop an effective interim solution through the specialist Task and Finish Group.
Wiltshire and Swindon
Concerns raised1
Failure to detect missed steroid doses
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Birmingham and Solihull
Concerns raised1
Frequent administration of Omnipaque doses exceeding manufacturer guidelines
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
University Hospitals Birmingham NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
University Hospitals Birmingham NHS Foundation Trust
Reviewed intravenous contrast administration protocols against manufacturer guidance and relevant literature.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
University Hospitals Birmingham NHS Foundation Trust
The administered contrast dose was within accepted ranges, was not an overdose, and toxicity was unlikely to have caused the death.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Birmingham and Solihull
Concerns raised1
Failure to check prisoners' mouths during general medicine administration
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
HM Prison and Probation Service
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
HM Prison and Probation Service
Observe and record medication swallowing, supplementing opioid-substitution administration with mouth checks and officer presence to address concealment concerns.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
HM Prison and Probation Service
There is no clinical requirement to check prisoners’ mouths when administering controlled or general medication.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Inner North London
Concerns raised1
Failure to administer prescribed medication
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
North London NHS Foundation Trust
Whittington Health NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.8
North London NHS Foundation Trust and Whittington Health NHS Trust
Refresh and embed the emergency-department medication protocol defining prescriber and nursing responsibilities for checking and administering prescriptions.
North London NHS Foundation Trust and Whittington Health NHS Trust
Adapt regular audit to check whether prescribed medication has been administered.
North London NHS Foundation Trust and Whittington Health NHS Trust
Strengthen handover between emergency-department and liaison teams to explicitly check prescribed, refused, outstanding and administered medications.
North London NHS Foundation Trust and Whittington Health NHS Trust
Arrange for liaison-team prescribers to receive honorary contracts enabling them to prescribe medication in the emergency department.
North London NHS Foundation Trust and Whittington Health NHS Trust
Refresh and embed the emergency-department medication protocol requiring prescribers to notify nurses and nurses to check prescribed medicines.
North London NHS Foundation Trust and Whittington Health NHS Trust
Adapt regular audit to check whether prescribed medication has been administered.
North London NHS Foundation Trust and Whittington Health NHS Trust
Strengthen handover between emergency-department and mental-health liaison teams by explicitly checking medication status and recording findings in patient records.
North London NHS Foundation Trust and Whittington Health NHS Trust
Arrange honorary contracts enabling mental-health liaison prescribers to prescribe medication in the emergency department.
Blackpool and the Fylde
Concerns raised1
Failure of care home records to document conditions, symptoms and medication purposes
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
East London
Concerns raised1
Insufficient visibility of the heparin administration poster’s direction to seek haematology advice for underweight patients
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Manchester West
Concerns raised1
Lack of continuous stock records and verification for non-controlled ward medications
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
Bolton NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.6
Bolton NHS Foundation Trust
Audit all clinical areas quarterly against safe and secure medicines-handling standards and discuss results with ward managers.
Bolton NHS Foundation Trust
Use the NHS Protect Medicines Security Ward/Department checklist to audit medicines security, collate divisional results and agree action plans.
Bolton NHS Foundation Trust
Operate one-stop dispensing to use patients’ own medicines, reduce stock-medicine use and record dispensing and stock-review information electronically.
Bolton NHS Foundation Trust
Introduce a new Wardex recording pharmacists’ clinical reviews and medicine supply.
Bolton NHS Foundation Trust
Develop and implement a pharmacy policy endorsing Wardex entries, including medicine supply and quantity details.
Bolton NHS Foundation Trust
Present Safe and Secure Handling of Medicines audit results to the Medicines Safety Group for discussion and agreement of action plans.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Bolton NHS Foundation Trust
Existing systems were considered sufficient to ensure ward medicines are stored securely and their stock can be verified.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Powys, Bridgend and Glamorgan Valleys
Concerns raised1
Lack of certainty whether Warfarin was being taken
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.