Recurring concern

Inadequate recording of medication prescribing decisions

First to latest report 21 Mar 2014 — 27 Oct 2025

Reports that mention this concern
28
Times this concern has been raised
29
Stated actions linked to this concern
29

What this concern includes

Includes deficiencies in records supporting medication prescribing, including recording the rationale for stopping a medicine, cancelling discontinued prescriptions, accurately classifying repeat and acute prescriptions, recording externally requested medicines, and clearly displaying prescription chronology or quantities.

What is not included
  • Excludes generic deficiencies in basic clinical record keeping that are not specifically tied to medication prescribing.
  • Excludes medication administration deficiencies where the prescribing record is not the unsafe control.
  • Excludes failures to monitor a named medication hazard when the record-keeping deficiency is not part of the medication prescribing process.
  • Excludes generic communication, staffing, training or investigation failures unless they directly concern the reliability of medication prescribing records.

Reports and published responses 28 reports

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

  1. Manchester West

    AI-generated summary

    Carol Buchanan · 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

    Carol Buchanan was admitted to hospital after a fall and later deteriorated following the combined prescription of Itraconazole and Simvastatin, which led to rhabdomyolysis and muscle necrosis. She died on 26 May 2017 despite treatment. Concerns included inadequate prescription record checking and documentation, failure to recognise the serious drug interaction, missed opportunities to act on relevant history, and delays in monitoring and diagnosis.

    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

    Failure to record prescriptions in relevant records in a timely effective manner

    Wider context from the report

    “3. The prescription of Itraconazole on the 27th April 2017 was not typed up into relevant records either by way of a “GP clinic letter” or by way of a timely effective prescription. ”

    Source location

    Carol Buchanan · Prevention of Future Deaths report
    Page 2 · 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

    Roll out the Electronic Patient Record and Electronic Prescribing to enable clinicians to access current prescribed medication in outpatient clinics.

    Verbatim wording from the response

    “The Trust is currently working on the roll out of the Electronic Patient Record (EPR) and Electronic Prescribing. Whilst it is not fully operational yet, it is complete clinicians working in out-patient clinics are able to access current prescribed medication.”

    Source location

    2017-0294-Response-by-Bolton-NHS-Trust
    Page 1 · response
    Published 27 November 2017

    Open published response

  2. Manchester West

    AI-generated summary

    Terence Ryan · 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

    Terence Ryan died on 14 November 2016 after a road traffic collision caused a left leg fracture and he later self-discharged from hospital without anticoagulation medication. The report identified concerns about a consultant-prescribed anticoagulant not being added to his repeat prescriptions and the absence of a hospital protocol for patients, particularly vulnerable patients, who self-discharge without necessary medication.

    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

    Failure to record externally requested new medications on repeat prescriptions

    Wider context from the report

    “i. On the 15th July 2016 a Consultant prescribed Edoxaban 60mg per day for long term anticoagulation treatment to be collected by the deceased on a weekly basis by repeat prescription issued by the General Practitioner and the Consultant sent a letter to the General Practitioner to confirm that plan of treatment. The repeat prescription for Edoxaban was not put on the deceased’s repeat prescriptions by the General Practitioner and the deceased did not receive Edoxaban for administration after the 22nd July 2016 and he would not have had a supply of Edoxaban following his self-discharge from the Hospital on the 10th November 2016. The General Practitioner gave evidence that the Surgery had undertaken a “Significant Event Analysis” as to how the Edoxaban prescription had been missed and the investigation resulted in the following recommendations within the Surgery to prevent a recurrence:- a. GP to review “active problems” on the computer system when any patient comes in, in order to ensure patient is on the appropriate treatment. b. In respect of discharge letters directing new medication – the letter will be sent on a task to a prescription clerk, who will add the new medication and issue a month’s supply. If necessary (depending on the type of medication involved) the task will include sending a request to the patient to see the GP for review in a month’s time. However, the General Practitioner confirmed that the above recommendations had not been included in any formal documented protocol and I was not satisfied that there was to be a note on a patient’s record to alert a Doctor to a new medication subject to repeat prescription, bearing in mind that the deceased had seen a General Practitioner on the 13th September 2016, the 30th September 2016 and the 14th October 2016 without the omission being checked. ”

    Source location

    Terence Ryan · Prevention of Future Deaths report
    Page 3 · 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

    Study and discuss the repeat prescribing and scanning protocols at a practice meeting.

    Verbatim wording from the response

    “I enclose copies of our Repeat Prescribing Protocol; this includes the ‘Protection on Prescribing’ including hospital letters.”

    Source location

    2017-0225-Response-by-Grasmere-Surgery
    Page 1 · response
    Published 6 October 2017

    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

    Meet with all receptionists and nurses to address the protocols.

    Verbatim wording from the response

    “I enclose copies of our Repeat Prescribing Protocol; this includes the ‘Protection on Prescribing’ including hospital letters.”

    Source location

    2017-0225-Response-by-Grasmere-Surgery
    Page 1 · response
    Published 6 October 2017

    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

    Arrange a follow-up meeting in three months to review how the prescribing protocol is working within the practice.

    Verbatim wording from the response

    “A further meeting will be arranged in three month's time to review how the Prescribing Protocol has been working within the Practice.”

    Source location

    2017-0225-Response-by-Grasmere-Surgery
    Page 1 · response
    Published 6 October 2017

    Open published response

  3. Brighton and Hove

    AI-generated summary

    Derek LEE · 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

    Derek LEE died on 5 June 2016 following an admission to Brunswick Ward. The report identified numerous concerns about his care, including medication management, incomplete assessments and documentation, falls and pressure-sore prevention, delayed referrals and treatment, nutrition, mobility, and the absence of a care co-ordinator. The inquest concluded that the death was from natural causes, and the report stated that the identified failings did not change the outcome.

    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

    Failure to record reasons for medication changes

    Wider context from the report

    “(1) Mr Lee’s medication regimen which was to be the core of the admission was barely addressed and no reasons for any changes in medication appear in his notes. ”

    Source location

    Derek LEE · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. Manchester South

    AI-generated summary

    Fred Whittaker · 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

    Fred Whittaker, who had schizophrenia and was known to abuse drugs and alcohol, attended hospital with chest pains and drowsiness after taking codeine, alcohol and methadone, but self-discharged and went home. He was found dead in his flat the following morning; the inquest concluded that he died from developing bronchopneumonia and combined codeine, methadone and alcohol toxicity. A principal concern was that Clonazepam was restarted in error after his psychiatrist had requested that it be stopped, reflecting inadequate recording and procedures for discontinued prescriptions.

    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

    Lack of recording of reasons, requests or decisions to stop prescribing a drug in clinical records

    Wider context from the report

    “An important issue in the Inquest was the continued prescription of Clonazepam by the Heaton Moor Medical Centre despite the written request on 17th August 2015, from Mr Whittaker’s treating psychiatrist, ████████ that this medication be stopped. The evidence given to me by ████████ a partner at the Heaton Moor Medical Centre, suggests that although the prescription was stopped it was started again in error. ████████ advised that, a) On receipt of ████████ request the drug was moved from the Repeat Prescription list to the Past Prescription list, without any reference in the records of the reason as to why the Clonazepam was being stopped. b) On or about the 19th August 2015 the pharmacy which administered Mr Whittaker’s medication requested a repeat prescription. c) It was likely that upon receiving that request Clonazepam was simply moved back on to the repeat prescription by one of the doctors at the Practice on being advised by an administrator of the Pharmacy’s request. This is clearly an unacceptable error. I accept that, on this occasion, this error played no part in Mr Whittaker’s demise but it is not difficult to imagine a completely different set of circumstances where such an error would give rise to a risk of death. ████████ evidence was that there were no standard directions as to how to manage this as a situation and that other practices may adopt the same simple policy of transferring the drug from one list to another. 1. That Heaton Moor Medical Centre does not have a mechanism whereby the reasons or requests or decisions that a patient is no longer to be prescribed a particular drug are recorded in the clinical records. 2. That this poor practice may not be limited to Heaton Moor Medical Centre and is replicated in many GP practices in the Northwest and indeed, nationally. ”

    Source location

    Fred Whittaker · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. Inner South London

    AI-generated summary

    Laurence Boyens · 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

    Laurence Boyens died in prison on 15 November 2012 from Methadone, Tramadol and Diazepam intoxication. The jury identified concerns about the combination and interaction of prescribed drugs, failures to monitor intoxication symptoms and blood pressure, and failures to suspend or withhold Methadone and Tramadol when signs of toxicity were present.

    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

    Failure to cancel discontinued medication prescriptions in the computerised record

    Wider context from the report

    “4. ████████ ████████ was represented at the inquest and the following evidence gave rise to concerns: • He prescribed Citalopram, Tramadol, Methadone, Diazepam and Sodium Valproate on 10th to a new patient without seeing him, although probably in possession of old medical records from previous stay in prison, but not those from his GP related to the period before detention in prison. • When he saw the patient on 13th he failed to consider the interactions between Citalopram and Tramadol and between Citalopram and Methadone, both of which the prison expert ████████ said were contraindicated, nor the summative effects of combining Methadone, Tramadol and Diazepam. • He said that he was not aware whether withdrawal can cause low BP and thought the BP was measured to see if the patient was withdrawing. • He said that he did not know whether he should stop Methadone if the BP was low. • Mr Boyens was seen by the doctor on 13th, the day after another witness found him drowsy with “pinned eyes” and a few hours before another witness found him unsteady and drowsy. He made no record of the state of the pupils, but did record him as unusually drowsy. • At that examination, according to his 2013 statement he considered the patient was drowsy due to lack of sleep; in a 2015 statement he considered use of illicit drugs and was aware of the possibility of Methadone toxicity. But he failed to stop these drugs from continuing to be administered. • At this assessment on 13th he recorded an intention to stop the Citalopram on the request of the patient, but did not take the simple steps to cancel the prescription on the computerised record and if he told a nurse about this instruction it was not recalled or noted by them, and continued to be administered. • He gave evidence that he would not administer Naloxone to a patient unless the patient was blue and unconscious and known to have taken opiates and did not know any disadvantages of doing so. ████████ gave evidence that this was not correct and that Naloxone properly administered had the potential to save lives. ”

    Source location

    Laurence Boyens · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. Manchester West

    AI-generated summary

    Daniel Joseph McCallum Keane · 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

    Daniel Keane was found dead at home after a period in which he had difficulty managing his Type 1 diabetes and was left without active support apart from his family. The cause of death was recorded as ketoacidosis. The reported concerns included a lack of leadership and coordination, no clear post-discharge care plan, ineffective multidisciplinary meetings, and uncertainty about the GP’s role, including the prescribing of citalopram and failure to respond to concerns about Daniel’s wellbeing.

    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

    Inadequate clinical record keeping

    Wider context from the report

    “████████ was called to give evidence at the Inquest. He accepted in the course of his evidence that his record keeping was inadequate. He could not say from either his records or his recollection who had arranged for diabetic medication or citalopram to be prescribed on 29th September 2010. ████████ had no recollection or contemporaneous record of a telephone conversation with a neuropsychologist called ████████ on 8th November 2010 in which she said she alerted ████████ to Daniel Keane’s situation, which she described to him and indicated it was very worrying. ████████ asked him to make an urgent referral to the district nurses as she was concerned he was not reliable in managing his insulin himself. ████████ said he could not refer to the district nurses. Despite having been put on alert in this telephone conversation ████████ took no action. At this time ████████ was in possession of various reports including a Multi-Disciplinary Team Discharge Summary dated 2nd September 2010 that concluded Daniel Keane was at extreme risk to himself and was not a safe option to live by himself without supervision. 2. An investigation of the circumstances in which citalopram was prescribed on 29th September 2010 to establish who deemed this medication necessary, what features of his presentation justified this medication and the follow up action envisaged. 3. An investigation into ████████'s lack of response to the telephone conversation with ████████ on 8th November 2010. 4. Consideration of the role of GP’s generally in relation to the management of Type 1 diabetic patients in the community. ”

    Source location

    Daniel Joseph McCallum Keane · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Concerns about the practice’s record keeping, prescribing and response should be addressed by the GMC and CQC, which can take action where warranted.

    Verbatim wording from the response

    “I consider that the first three concerns, relating to ████████ should be raised with the General Medical Council (GMC) and the Care Quality Commission (CQC). To this end, my officials contacted your office on 12 June to advise that these actions would be most appropriately addressed by the GMC and CQC. We suggested that you write to both of these organisations for their separate responses to these issues. These organisations have the power to take action where warranted.”

    Source location

    2014-0260-Response-by-Department-of-Health
    Page 2 · response
    Published 9 June 2014

    Open published response

  7. West Sussex

    AI-generated summary

    Lee Hollman · 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

    Lee Hollman, who had a long history of intermittently severe mental ill-health, died after taking an overdose of Quetiapine, Trazodone and alcohol on 28 February 2014. The report identified concerns about inaccurate and outdated medical records, the repeat-prescription system, and failure to review patients in line with relevant guidelines.

    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

    Failure to maintain accurate and up-to-date medical records

    Wider context from the report

    “1. Failure to maintain sufficiently accurate and updated medical records 2. Failure to remove Trazodone from the repeat prescription record 3. Failure to delete the ‘old’ dosage of Quetiapine from the relevant medical records ”

    Source location

    Lee Hollman · 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

    Approve a joint RCGP–Royal Pharmaceutical Society statement setting out guidelines for good working relationships between GPs and pharmacists.

    Verbatim wording from the response

    “The tragic death of Lee Hollman highlights the need for GPs and Pharmacists to work closely together.”

    Source location

    2014-0135-Response-by-Royal-College-of-General-Practitioners
    Page 3 · response
    Published 26 March 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

    Require CMHT correspondence before changing medication, record medication changes, and prompt GPs to reconcile surgery and CMHT medication lists.

    Verbatim wording from the response

    “The medication prescribing process for patients under the care of the CMHT has been revised in the following key respects:”

    Source location

    2014-0135-Response-by-Riverside-Surgery
    Page 3 · response
    Published 26 March 2014

    Open published response

  8. West Sussex

    AI-generated summary

    MRS KERRY JACOBS · 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

    Mrs Kerry Jacobs died on 8 July 2013 from a pulmonary embolism arising from a deep vein thrombosis in her right calf. Concerns included the prescription of a steroid dose outside usual ENT practice and BNF guidelines without adequate documentation or confirmation with the consultant, and the lack of a protocol requiring discussion between pharmacists and clinicians when prescriptions are queried.

    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

    Lack of recording of deliberate decisions and grounds for prescribing medication outside usual practice or BNF guidelines

    Wider context from the report

    “(1) There was nothing within Mrs Jacobs’ hospital records indicating any awareness that she had been prescribed steroid dose which was out with usual ENT practice and the BNF guidelines. Nor was the actual prescription issued confirmed with or reported to patient’s consultant. The evidence was that there is no policy or procedure within the Trust which requires a doctor who prescribes a medication outside usual practice and/or BNF guidelines to note within the patient’s clinical record that they have made the deliberate decision to do so and to record their grounds for so deciding. ”

    Source location

    MRS KERRY JACOBS · Prevention of Future Deaths report
    Page 2 · 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

    Issue a directive requiring clinicians to document the rationale for prescribing outside BNF or usual-practice guidance and record pharmacist prescription-query discussions and outcomes.

    Verbatim wording from the response

    “Response: It is correct that there is no formal Trust policy in place, however, ████████ Chief Medical Officer, has issued a directive to the Chiefs of Service in the Divisions (see attached email dated 4 June 2014) that all staff should record and specify the rationale for the decision to prescribe a medication dosage that is outside guidance within BNF, or usual practice. In addition, when a query is raised by a pharmacist regarding a patient’s prescription, an entry must be made within the patient’s medical records, noting the discussion and outcome. This directive will be disseminated to the clinical staff within each Division, at Multi Disciplinary Team (MDT) meetings each week, and departmental meetings; and will be added to the Trust’s Audit Programme for 2014/2015.”

    Source location

    2014-0133-Response-by-Surrey-Sussex-Healthcare-NHS-Trust
    Page 1 · response
    Published 21 March 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

    Disseminate the prescribing documentation directive to clinical staff through divisional MDT and departmental meetings.

    Verbatim wording from the response

    “Response: It is correct that there is no formal Trust policy in place, however, ████████ Chief Medical Officer, has issued a directive to the Chiefs of Service in the Divisions (see attached email dated 4 June 2014) that all staff should record and specify the rationale for the decision to prescribe a medication dosage that is outside guidance within BNF, or usual practice. In addition, when a query is raised by a pharmacist regarding a patient’s prescription, an entry must be made within the patient’s medical records, noting the discussion and outcome. This directive will be disseminated to the clinical staff within each Division, at Multi Disciplinary Team (MDT) meetings each week, and departmental meetings; and will be added to the Trust’s Audit Programme for 2014/2015.”

    Source location

    2014-0133-Response-by-Surrey-Sussex-Healthcare-NHS-Trust
    Page 1 · response
    Published 21 March 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

    Add compliance with the prescribing documentation directive to the Trust’s 2014/2015 audit programme.

    Verbatim wording from the response

    “Response: It is correct that there is no formal Trust policy in place, however, ████████ Chief Medical Officer, has issued a directive to the Chiefs of Service in the Divisions (see attached email dated 4 June 2014) that all staff should record and specify the rationale for the decision to prescribe a medication dosage that is outside guidance within BNF, or usual practice. In addition, when a query is raised by a pharmacist regarding a patient’s prescription, an entry must be made within the patient’s medical records, noting the discussion and outcome. This directive will be disseminated to the clinical staff within each Division, at Multi Disciplinary Team (MDT) meetings each week, and departmental meetings; and will be added to the Trust’s Audit Programme for 2014/2015.”

    Source location

    2014-0133-Response-by-Surrey-Sussex-Healthcare-NHS-Trust
    Page 1 · response
    Published 21 March 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