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. Suffolk

    AI-generated summary

    Karen Jane Winn · 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

    Karen ‘Jane’ Winn died at West Suffolk Hospital after developing bilateral pulmonary emboli and deep venous thromboses in the context of haemolytic anaemia. Although prophylactic anticoagulation was identified as necessary, it was not administered during most of her admission, and the report states that this contributed to her death. Concerns included a lack of early haematology consultant involvement, repeated manual overriding of the automated VTE assessment warnings, and inadequate electronic flagging of the anticoagulation decision.

    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 clearly flag decisions to administer prophylactic anticoagulation in the patient electronic record

    Wider context from the report

    “3. I am further concerned that if a consultant at an early review has decided that prophylactic anticoagulation medication needs to be administered (even in the situation when a INR test is still awaited) that this is not clearly flagged on the patient electronic record in the Smart Zone, to act as a prompt for clinicians taking over that patients care. ”

    Source location

    Karen Jane Winn · Prevention of Future Deaths report
    Page 2 · 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

    The suggested Smart Zone prompt cannot currently be provided because narrative care plans cannot be pulled into the system, which only flags assessment omissions.

    Verbatim wording from the response

    “The narrative aspect of a clinician’s plan cannot be ‘pulled through’ into the smart zone. However, the actions described in section 2 will ensure that an in-completed VTE assessment is recognised. Furthermore, the addition of the haemolytic anaemia prompting within the VTE assessment tool should aid ensuring that the clinicians are aware that this condition requires VTE prophylaxis consideration.”

    Source location

    2020-0213-Response-from-West-Suffolk-Hospital-REDACTED.pdf
    Page 4 · response
    Published 4 December 2020

    Open published response

  2. East London

    AI-generated summary

    Theresa Robertson · 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

    Theresa Robertson was found deceased outside 90 Greengate Street on the evening of 18 September 2019, after being captured on CCTV in the area two days earlier. The medical cause of death was recorded as Amitriptyline and Zopiclone toxicity and hypothermia. Concerns included missing records of important telephone calls and a consultation, prescriptions exceeding the surgery’s seven-day limit for high-risk patients, and the absence of assurance that other patients’ prescriptions had been audited.

    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 meaningful records of prescribing consultations and their rationale

    Wider context from the report

    “3. The Surgery could not produce a meaningful record of Dr ████████ consultation held with Ms Robertson on 30th April 2019 setting out the reasons for re-starting her 28 day prescription. ”

    Source location

    Theresa Robertson · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  3. Manchester South

    AI-generated summary

    Kaiya Sonja Campbell · 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

    Kaiya Sonja Campbell was born at Tameside General Hospital on 28 September 2019 following her mother’s extensive bleeding and early rupture of the membranes. She lived briefly and died soon after birth, with the medical cause recorded as extreme prematurity at 19 weeks and 6 days’ gestation. Concerns included gaps in records of her mother’s anticonvulsant prescriptions, failure to seek urgent neurology guidance, and the offering of a routine rather than appropriately identified high-risk consultant appointment.

    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 GP practice records of recent medication prescribing

    Wider context from the report

    “Her GP practice did not have any records of recent medication being prescribed although there was clear evidence given to the inquest of regular request for repeat prescriptions being requested and dispensed by a local pharmacy. It was not possible to establish at the inquest why this gap in records existed; ”

    Source location

    Kaiya Sonja Campbell · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. Suffolk

    AI-generated summary

    Mark Jarvis · 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

    Mark Jarvis was found apparently deceased in his cell at HMP Warren Hill on 30 December 2015 and was later pronounced dead. The inquest concluded that the death resulted from a cardiac event precipitated by ingestion of a New Psychoactive Substance, with ischaemic heart disease recorded as the medical cause of death. Concerns included difficulties with the prison prescription system, including the inability to readily verify current and previous prescriptions, and the potential misuse of medications.

    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

    Difficulty removing no-longer-needed prescriptions from the medication system

    Wider context from the report

    “1. During the course of the inquest a GP who was responsible for medical care at HMP Warren Hill gave evidence in relation to the computer system, SytmOne which was used to review and prescribed medicines to the prisoners at the time of Mark’s death. The court was told that the SystmOne online prescription ‘module’ was not clear to read or easy to understand and appeared incompatible with the prison’s own IT system. The GP described that this left them in the situation of not being sure what a patient had been previously prescribed, not being sure what repeat prescriptions were in place and that they had no way of readily understanding what had been taken by a particular patient or when they were supposed to have taken it. It was also explained that there was no direct link on the system between medications prescribed and previous diagnoses. Due to the time it took to navigate the records it was reported that some GP’s used their experience to identify a previous diagnosis from the repeat prescriptions recorded in the prescription module. The GP further described that removing a prisoner’s prescription from the system when it was no longer necessary was very difficult. One of the contributing factors the jury found to Mark’s death was directly related with poor adherence to his blood pressure medication regime on repeat prescription. Considering the difficulties GPs are facing when using the prescription module, and the testimony given by the GP in this case, it would appear there is no easy system for a doctor to verify exactly what their patient has already been prescribed and whether or not that prescription is still current. Further, in relation to the potential misuse of drugs incorrectly or over-prescribed the GP explained that some medications, such as opioids or anti depression medication (including amitriptyline and sertraline) had ‘currency’ within the prison and it was known they would be traded by some prisoners. Therefore, not being able to readily identify what a prisoner should be, or already is being prescribed at the time of any specific consultation is again clearly a cause for concern. In an interview the GP had with investigators from the Prisons and Probation Ombudsman’s Office on the 30th December 2015 (just one day after Mark’s death) the GP described the prescription module as “an absolute nightmare and we are banging our heads against a brick wall. We’re trying hard to get some changes done because we are concerned about safety” When specifically questioned at the inquest on the 3rd September 2019 the GP stated that the situation as it stood at the end of December 2015 had still not been resolved. ”

    Source location

    Mark Jarvis · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. Manchester South

    AI-generated summary

    Jacqueline Marie Elliott · 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

    Jacqueline Marie Elliott, who had a long-standing history of back pain, was found deceased at home on 9 August 2018. Post-mortem and toxicology findings identified reduced liver function and significant toxicity from a combination of drugs. Concerns included inaccurate prescription records, insufficient clinical notes and medication-review detail, prescribing of 100 tramadol tablets despite a recorded history of non-compliance and self-medication, and a lack of continuity of care.

    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 of the GP practice recording system to accurately distinguish repeat and acute prescriptions

    Wider context from the report

    “1. The GP practice computer recording system showed drugs that were clearly on repeat prescription as drugs that were acute prescriptions. As a result the inquest was told that the medication reviews carried out would not pick up on and would not review those prescriptions. The medication reviewer would not therefore have a full overview of her prescribed long term medication; ”

    Source location

    Jacqueline Marie Elliott · 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

    Educate GPs and pharmacists to review acute, repeat and recently issued medicines during medication reviews.

    Verbatim wording from the response

    “Actions agreed with the CCG and in progress”

    Source location

    2019-0016-Response-by-Trafford-CCG-and-Department-of-Health-and-Social-Care
    Page 3 · response
    Published 23 May 2019

    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 documentation of reasons and review plans when regular long-term medicines are issued acutely.

    Verbatim wording from the response

    “2. If regular long-term medications are issued as acute – document the reason for this and the plan for review so that when they are issued other prescribers are aware of the plan. Otherwise there is a danger that acute items will be issued long-term without a review, with the person issuing assuming that because it is on acute someone else will review it next time.”

    Source location

    2019-0016-Response-by-Trafford-CCG-and-Department-of-Health-and-Social-Care
    Page 3 · response
    Published 23 May 2019

    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 medication reviews to record the medicines and content reviewed, with follow-up appointments when reviews are incomplete.

    Verbatim wording from the response

    “The medication review date is primarily set to ensure that repeat medication gets reviewed at regular intervals. As previously stated this should also include a review of any medication on the acute list. A medication review may be a review of the medical notes or a review with the patient in a telephone consultation or face to face.”

    Source location

    2019-0016-Response-by-Trafford-CCG-and-Department-of-Health-and-Social-Care
    Page 5 · response
    Published 23 May 2019

    Open published response

    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

    The EMIS Web system distinguishes acute and repeat medicines and supports comprehensive medication reviews, so medicines need not be placed on repeat lists.

    Verbatim wording from the response

    “I am advised that on the matter of the GP practice computer system and the recording of prescriptions, it could be that certain medications were not added to the repeat list to avoid them being issued without review. For example, if a medication is on the acute medication list then an active decision has to be made to re-issue the prescription. This would require a doctor to look at when the medication was last issued, and to review the indication for the drug to ensure the need for it was still evident.”

    Source location

    2019-0016-Response-by-Trafford-CCG-and-Department-of-Health-and-Social-Care
    Page 8 · response
    Published 23 May 2019

    Open published response

  6. London Inner South

    AI-generated summary

    Name not published · 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

    The deceased died at St Thomas’s Hospital on 22 November 2017 from brain damage sustained after he hanged himself at home on 20 November 2017. Concerns included changes and prescribing of psychiatric and sedative medication, inadequate clinical records and review of past records, failure to make an urgent psychiatric referral, and uncertainty about the medication found after his death and what he had taken.

    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 clinical presentations, diagnoses, medication-change rationale and attendances

    Wider context from the report

    “3. On 5 October 2017 the deceased saw Dr A again. The Zolpidem was swapped to Nitrazepam, a more potent sedative, as the deceased had said that after 2 weeks he had not found the Zolpidem to be effective. Expert evidence adduced at the inquest from ████████ was to the effect that the deceased’s presentation at this point should have triggered a further inquiry into his psychiatric history. ████████ said that he would have contacted the deceased’s home GP. 4. On 19 October 2017 the deceased saw Dr A again. He said he was feeling better on the Duloxetine but was still stressed and anxious and got a few anxiety attacks. Dr A prescribed him Propranolol, Nitrazepam and Xanax. Dr A also prescribed the deceased 6 months’ worth of Duloxetine. ████████ evidence was that it was “most unusual” to prescribe such a large amount of medication (6 months’ worth of Duloxetine) during the initial period where a patient’s medication had been switched and where close monitoring was needed. He opined that the first 6 weeks of the ‘switch’ period were ones in which the patient might get worse before getting better, might get worse and might develop suicidal thoughts. ████████ said that such a volume of medication was not merited clinically and could create a risk of overdose. 5. On 8 and 9 November 2017 the deceased saw Dr B. She made no notes of his presentation or diagnosis on any occasion when she saw him which she accepted she should have done. She also did not note her rationale for changing his medication which again ████████ said should have happened. He also considered that Dr B should have examined the past records for the deceased which she accepted she had not done in full. 6. There are a series of further issues with the medication Dr B prescribed the deceased and her records of the same. The electronic patient notes reflect a prescription for Xanax but she said in evidence that the deceased had not in fact accepted this. She prescribed him Temazepam but this is a controlled drug in this country and cannot be prescribed in the usual way. She changed this to Nitrazepam but the dose was incorrect and this was refused by the pharmacy. The next day she prescribed him Lorazepam without him returning the Nitrazepam prescription to her. She made an error in the dose for Lorazepam and had to correct that. When he attended on 15 November 2017 asking for more medication she made no note of his attendance. 7. ████████ evidence was that the multiple changes to the medication regime made by Dr B were not medically indicated and that the deceased had needed an urgent psychiatric referral. He said this was the case by 8 November 2017. 8. Overall ████████ said his impression was that Dr B did not understand what she was prescribing. 9. I accepted ████████ opinion on the various issues set out above. 10. Large numbers of boxes of medication were found at the deceased’s flat after his death by the police and his family. There remains some uncertainty as to where he obtained all the medication from, and what exactly he had taken and when. ”

    Source location

    Name not published · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  7. Inner South London

    AI-generated summary

    Nigel Handscomb · 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

    Nigel Handscomb was admitted to University Hospital Lewisham after being diagnosed with pneumonia and possibly having suffered a stroke. He was not reviewed by a doctor for 48 hours, opportunities to escalate his care were missed, and he later suffered a cardiac arrest; the inquest concluded that natural causes, including aspiration pneumonia, bronchopneumonia and severe ketoacidosis, involved neglect. Concerns included incomplete and inaccurate GP records, delayed recording, and missing information about examinations, medication and swallowing difficulties.

    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 changes to medication-taking instructions

    Wider context from the report

    “During your evidence to the inquest it became clear that the notes you had made of your consultation with Mr Handscomb were incomplete and inaccurate. Although in this case I accepted that this did not cause or contribute to the death I am concerned that, if repeated, it may do so in other cases. The inquest was told that GP records will now be more readily available to hospitals and will therefore inform their decision making processes. (1) Your records were made several hours after the consultation. (2) You did not record that you had carried out a chest examination, or the result of this examination. (3) You did not record that Mr Handscomb had told you that he had not taken his lithium medication for several days. This was of particular importance in view of the possibility that his symptoms might be the result of lithium toxicity. (4) You did not record that you carried out a swallow test and that Mr Handscomb could not swallow. (5) You prescribed medication and recorded that it should be taken once a day in the morning. This was the instruction recorded on the medication packet. Your evidence was that you told Mr Handscomb to take the medication that afternoon. This was not recorded. ”

    Source location

    Nigel Handscomb · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  8. Isle of Wight

    AI-generated summary

    Cuthbert Anthony Stanley Hingert · 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

    Cuthbert Anthony Stanley Hingert was admitted to hospital with shortness of breath and possible acute coronary syndrome, during which duplicate doses of antiplatelet and anticoagulant medications were given. He later became confused, fell and sustained a subdural haematoma, skull fracture and subarachnoid haemorrhage, dying in hospital on 5 March 2017. Concerns included failures to check the medicines database, inappropriate or potentially inappropriate prescribing, delayed documentation, inadequate staff training and failure to report a medication incident according to protocol.

    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

    Delays in documenting verbal prescribing orders

    Wider context from the report

    “5. There was a 2-hour delay in writing up a verbal order with regard to a prescribing decision. ”

    Source location

    Cuthbert Anthony Stanley Hingert · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  9. Suffolk

    AI-generated summary

    Rachel Holly Edwards · 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

    Rachel Holly Edwards died on 8 May 2017 after an overdose of multiple prescription medicines, following a period of severe and unbearable pain. Concerns identified at the inquest included unclear quantities of discharge medication, inadequate communication of prescriptions to her GP, record-keeping weaknesses, and the absence of a formal patient advocate system to support her when pain-management news and treatment administration increased her hopelessness.

    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 the quantities of discharge medication issued

    Wider context from the report

    “The first concern regards the prescription of discharge medication, sharing that information with the GP and record keeping. It was known that Rachel was at risk of stockpiling medication as in the Serious Incident Requiring Investigation (SIRI) report it is noted that a request made on the 7th March 2017 by her treating doctor, for the disposal of her stocks of medication had not been actioned. Further, Rachel's care co-ordinator specifically recalled asking Rachel if she had stockpiled any medication after her discharge on the 29th March 2017, as he had identified this to be a risk. It is therefore a concern that according to Rachel's notes that on the day of her discharge she was supplied with 14 days of medication. This was described in evidence as ‘standard practice’. That said, some consideration appears to have been given to the quantity of some medication issued, as on closer inspection of the notes it was identified that specifically in relation to Tramadol Rachel had been prescribed this for only a 7-day period. However, there was no clear record within the notes if her other medication had actually been issued in 7 or 14 days amounts. Such confusion over the actual quantities of medication issued and the apparent issuing of 14 days supply of medicines to a patient who is known to have previously stockpiled medication, with a view to self-harm, is of obvious concern. Also of concern was evidence given by a senior consultant that there is no automated notification to a patient's GP of the type and amounts of prescription medicines issued to a patient upon discharge from Woodlands. Obviously, it is crucial that this information is readily available to a GP in all cases, to ensure that the over-prescription of medicines to a recently discharged patient does not occur. Evidence was heard that in order for Woodlands to notify a GP it is necessary for a staff member to e-mail the relevant practice, providing details of the prescriptions that had been made. This information would then have to be subsequently included in the patient's local record before it was available to the treating GP. Obviously, any system requiring such physical human input can be prone to failure and in the consultant's own words it was a recognised ‘point of weakness in the system’. ”

    Source location

    Rachel Holly Edwards · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  10. West Sussex

    AI-generated summary

    David Edward Jackson · 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

    David Edward Jackson, a 76-year-old man, fell at home and remained on the floor for about two weeks before he died on 17 July 2017. His death was recorded as accidental, with severe pressure sores associated with sepsis, toxaemia and rhabdomyolysis following prolonged immobility. Concerns included long-term repeat prescribing of Co-dydramol and Soneryl without regular face-to-face medical review, and unclear arrangements for prescription collection or delivery.

    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 recording of medication reviews and reasons for repeat prescribing

    Wider context from the report

    “Over the next 10 years, the records note a medication review was conducted by ████████ on 21 Oct 2008 and 2 March 2010 but on the records alone. There is one entry on the patient record for ████████ on 23 November 2015 noting only ‘medication review done’. When giving evidence, ████████ indicated that when ████████ retired in 2015 she took over Mr Jackson as a patient but she had never actually seen him. Her recollection was that she had conducted annual medication reviews by considering the patient's past history but only one is noted on the record printout. GMC good practice guidance was discussed with ████████ as follows: • Good medical practice (2013) – para 16: In providing clinical care you must prescribe drugs or treatment, including repeat prescriptions, only when you have adequate knowledge of the patient's health, and are satisfied that the drugs or treatment serve the patient's needs; and, • Prescribing and Managing Medicines (2013) – paragraphs 51; 54; 55; 56; 59 o 51: Whether you prescribe with repeats or on a oneoff basis, you must make sure that suitable arrangements are in place for monitoring, follow-up and review, taking account of the patients' needs and any risks arising from the medicines. o 54: Pharmacists can help improve safety, efficacy and adherence in medicines use, for example by advising patients about their medicines and carrying out medicines reviews. This does not relieve you of your duty to ensure that your prescribing and medicines management is appropriate… o 55: You are responsible for any prescription you sign, including repeat prescriptions for medicines initiated by colleagues, so you must make sure that any repeat prescription you sign is safe and appropriate. You should consider the benefits of prescribing with repeats to reduce the need for repeat prescribing. o 56: As with any prescription, you should agree with the patient what medicines are appropriate and how their condition will be managed, including a date for review. You should make clear why regular reviews are important and explain to the patient what they should do if they: a) suffer side effects or adverse reactions, or b) stop taking the medicines before the agreed review date (or a set number of repeats have been issued), You must make clear records of these discussions and your reasons for repeat prescribing. o 59: When you issue repeat prescriptions or prescribe with repeats, you should make sure that procedures are in place to monitor whether the medicine is still safe and necessary for the patient. You should keep a record of dispensers who hold original repeat dispensing prescriptions so that you can contact them if necessary. 1. When asked about current practice in relation to issuing prescriptions for drugs such as Soneryl or Co-dydramol ████████ acknowledged national guidance had tightened up particularly in respect of issuing prescriptions to patients for opiate based drugs. She accepted that medical thinking had moved on considerably. She was candid and accepted that in respect of Mr Jackson he had not been seen for 10 years and must have fallen through the cracks in terms of medication reviews including a period when the surgery had a shortage of doctors. This suggests a need to review: a. how and when medication reviews are carried out in the Fitzalan Medical Group; b. a potential training need for group doctors in GMC good practice; or, c. the development of a local CCG/Group policy. ”

    Source location

    David Edward Jackson · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

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