Recurring concern
Unsafe medication administration
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Request correctionFirst reported 19 Sep 2013•Latest report 19 Mar 2026
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
- Individual concerns
- 147
- Date range
- 2013–2026
- Stated actions
- 192
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
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.
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.
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Concerns raised1
Failure to provide supervised doses of a controlled drug in accordance with the prescription's specified days and doses
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 concernsEach 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
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Action
Inspect the pharmacy’s governance and methadone dispensing arrangements against the Standards for Registered Pharmacies.
Stated by General Pharmaceutical Council -
Action
Implement the Drug and Alcohol Service guidance, including checking supervised-consumption days on agreements and notifying the service of changes.
Stated by York Road Pharmacy -
Action
Ensure all pharmacy staff understand the guidance and required procedures through internal discussion and consideration.
Stated by York Road Pharmacy
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Concerns raised1
Failure to record prescribed thickeners on Medication Administration Records
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 concernsEach 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
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Action
Audit all service-user MAR sheets and continue regular audits after their return to the office.
Stated by EasyCare Ltd (trading name: EVOLVE -
Action
Use printed MAR sheets supplied by the office or pharmacies to reduce medication errors.
Stated by EasyCare Ltd (trading name: EVOLVE -
Action
Inform staff about the inquest outcome, Section 28 requirements and resulting improvements to training, communication and MAR recording.
Stated by EasyCare Ltd (trading name: EVOLVE
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Concerns raised1
Risk of administration of toxic and fatal quantities of medications to those in the care of staff
Responses linked to these concernsEach 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
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Action
Conduct a further investigation into medication storage, auditing and administration competencies at the care home.
Stated by Voyage Care -
Action
Review all residents’ care and care plans, including relevant rescue-medication administration protocols.
Stated by Voyage Care -
Action
Renew medication training for all staff at the care home.
Stated by Voyage Care
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Action
Commission an independent pharmacist to review medication policies, procedures, training content and audits.
Stated by Voyage Care -
Action
Implement an electronic Medication Administration System across the organisation.
Stated by Voyage Care
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
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Position
Existing medication storage, auditing, competency policies, procedures and staff training were considered robust and subject to audit.
Stated by Voyage Care
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Position
No evidence was found that Voyage staff misadministered medication, following rigorous medication stock counts and investigation.
Stated by Voyage Care -
Position
Further comment and decisions on steps addressing the concerns were constrained pending completion of the Police investigation.
Stated by Voyage Care
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Concerns raised1
Failure to ensure effective administration of antibiotics
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 concernsEach 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
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Action
Create a Trust safety message covering difficult access, cannula documentation, partial-dose recording and eMeds amendments.
Stated by Northumbria Healthcare NHS Foundation Trust -
Action
Create a step-by-step training video showing staff how to amend incomplete or partial doses in eMeds.
Stated by Northumbria Healthcare NHS Foundation Trust -
Action
Disseminate the safety message and videos Trustwide through multiple media, the intranet, email bulletin and digital newsletter.
Stated by Northumbria Healthcare NHS Foundation Trust
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Action
Amend MM01 to require immediate, reasoned recording of incomplete or partial medication doses.
Stated by Northumbria Healthcare NHS Foundation Trust
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Concerns raised2
Failure to accurately record medication administration
Failure to safely administer and supervise medication for delirious patients
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 concernsEach 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
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Action
Apply the Patient Safety Incident Response Framework to assess incidents, identify learning and address wider patient-safety themes.
Stated by the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation Trust -
Action
Reintroduce the Matrons’ Ward Assurance Toolkit across the Trust, including audits of safe medication storage and unattended bedside medicines.
Stated by the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation Trust
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Concerns raised1
Failure to maintain a reliable written basis for Brivaracetam dosage 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 concernsEach 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
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Action
Review internal policies and procedures against the coroner’s concerns and identify necessary changes.
Stated by Godfrey Care -
Action
Implement a local medication policy covering medication receipt, transcription, altered labels, missed doses, written prescribing confirmation and triangulation between prescribers.
Stated by Godfrey Care -
Action
Update weekly and monthly managers’ medication audits to verify written authorisation, dosage changes and timely receipt of replacement prescriptions.
Stated by Godfrey Care
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Action
Update staff medication competency assessments to test clarification of unclear directions, MAR-label discrepancies and verbal medication changes.
Stated by Godfrey Care
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
The delay in administering medication did not contribute to the death.
Stated by Brook Medical Centre and University Hospitals of North Midlands NHS Trust
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Concerns raised1
Failure to administer Naloxone to patients with an opiate misuse history when other potential reversible causes have been treated
Responses linked to these concernsEach 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
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Action
Request a review of current JRCALC guidance on naloxone use in opioid-related cardiac arrest.
Stated by London Ambulance Service NHS Trust -
Action
Provide high-concentration naloxone on specialist Trust resources for cases involving potentially potent synthetic opioids.
Stated by London Ambulance Service NHS Trust -
Action
Work with agencies regularly contacting opioid users to improve naloxone availability.
Stated by London Ambulance Service NHS Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
Established cardiac arrest and absent immediate opioid-use evidence meant naloxone was not mandated and would not have changed the outcome.
Stated by London Ambulance Service NHS Trust
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Position
For confirmed cardiac arrest, standard resuscitation with high-quality compressions and ventilation should take priority over naloxone.
Stated by London Ambulance Service NHS Trust
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Concerns raised1
Failure to administer the final inpatient dose of dalteparin
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Delays in starting stand-by oral antibiotics
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to use a single accessible system for recording chemotherapy administration
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 concernsEach 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
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Action
Progress joint procurement of a consolidated electronic patient record through external approval and a planned formal procurement exercise.
Stated by 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
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Position
Existing digital systems make chemotherapy and treatment information available to relevant staff for emergency care decisions.
Stated by Stockport NHS Foundation Trust
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Position
The planned electronic patient record will not replace iQemo because its specialist nature requires it to remain in use.
Stated by Stockport NHS Foundation Trust
Data last updated 7 September 2026