First reported 15 Jan 2015•Latest report 27 Oct 2025
Definition
What this concern includes
Includes prescribing-process controls specifically intended to identify and respond to a patient's overdose history or material overdose risk, including mandatory clinical review before issuing prescriptions, scrutiny of repeat prescriptions, use of relevant overdose information and proportionate restrictions or supervision of prescribing.
Not included
Excludes general medication-prescribing errors, medication review or quantity-control failures where no overdose history or material overdose risk is part of the asserted unsafe condition.
Excludes medication administration, dispensing, storage or supply failures occurring after a safe prescribing decision unless the prescribing safeguard itself was deficient.
Excludes generic record-keeping, communication, training or alert-system deficiencies unless they directly impair overdose-risk safeguards in medication prescribing.
Excludes treatment of an overdose and broader self-harm or suicide-risk management where no medication-prescribing control is identified.
Reports
12
Distinct published reports
Individual concerns
16
A report can raise multiple concerns
Date range
2015–2025
First to latest report issue date
Stated actions
26
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.
Department of Health and Social Care3
NHS England2
Addison House Surgery1
Ashford and St Peter'S Hospitals NHS Foundation Trust1
Axminster Medical Practice1
Bedfordshire Hospitals NHS Foundation Trust1
Daynight Pharmacy (Macklin Street)1
Devon Partnership NHS Trust1
Epsom and St Helier University Hospitals NHS Trust1
Frimley Health NHS Foundation Trust1
General Medical Council1
Hampshire and Isle of Wight Constabulary1
Heathview Medical Practice1
Macklin Street Surgery1
NHS Derby and Derbyshire Integrated Care Board1
Healthcare site5
NHS trust4
Ministerial department3
Executive non-departmental public body2
Integrated care board2
Clinical commissioning group1
Health and care professional regulator1
Police force1
Type not available1
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.
Black Country
Concerns raised2
Failure to record clinical rationale for continued repeat prescribing in light of overdose risk
Continued prescribing of repeat medications in large amounts at 28-day frequency after overdose disclosure
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.3
Action
Amend the self-harm follow-up policy to require medication review and consideration of reducing prescription quantities where ongoing risk exists.
Stated by Your Health Partnership PCNStated plannedThe respondent said that this action was planned when they made their response on 29 October 2025.
Action
Amend the self-harm risk-assessment template to record medication review discussions, stockpiling, medication safety, prescription quantity, and medication supervision options.
Stated by Your Health Partnership PCNStated plannedThe respondent said that this action was planned when they made their response on 29 October 2025.
Action
Expand the annual proactive self-harm follow-up audit to record medication reviews and discussions about prescribed medication quantities.
Stated by Your Health Partnership PCNStated plannedThe respondent said that this action was planned when they made their response on 29 October 2025.
Essex
Concerns raised1
Lack of medication review controls for repeat prescriptions to vulnerable patients with histories of addiction, self-harm, suicidal ideation or prescription medication overdose
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
Audit all registered patients coded at risk of self-harm or suicide and receiving repeat medication, complete medication and risk reviews, and restrict repeats to seven-day supplies.
Stated by Addison House & Barbara Castle SurgeryStated completedThe respondent said that this action was complete when they made their response on 29 September 2025.
Action
Update the Polypharmacy and High-Risk Prescribing Policy to require pharmacist review of relevant correspondence, seven-day high-risk medication supplies, and three-monthly or earlier reviews for high-risk patients.
Stated by Addison House & Barbara Castle SurgeryStated completedThe respondent said that this action was complete when they made their response on 29 September 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The practice disputes that no safety controls existed, stating its repeat prescribing policy already contained restrictions for inappropriate high-risk medication requests.
Stated by Addison House & Barbara Castle SurgeryDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Bedfordshire and Luton
Concerns raised1
Failure to address or adopt safeguards against unintentional paracetamol overdose in low-bodyweight adult inpatients
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.2
Action
Add EPMA prescribing prompts requiring accurate weight recording and appropriate paracetamol dosing, including liver-toxicity warnings below 50 kilograms.
Stated by Bedfordshire Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 11 April 2025.
Action
Produce and launch a Nervecentre paracetamol prescribing guide.
Stated by Bedfordshire Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 11 April 2025.
Cheshire
Concerns raised1
Inability to prescribe smaller quantities of insulin
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The MHRA is the more appropriate organisation to respond to concerns about the insulin doses currently available to patients.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Derby and Derbyshire
Concerns raised1
Lack of measures to prevent excess prescribing to patients at risk of overdose during longer bank holiday periods
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.10
Action
Review the GP practice investigation, lessons learned and identified actions, and determine required support with primary care quality and patient safety teams.
Stated by NHS Derby and Derbyshire Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 27 November 2024.
Action
Review the community pharmacy investigation, lessons learned and identified actions, and determine required support with controlled drugs and commissioning teams.
Stated by NHS Derby and Derbyshire Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 27 November 2024.
Action
Disseminate collated learning and prescribing-safety updates through pharmacy newsletters, GP messages, medicines-safety communications and prescribing-leads forums.
Stated by NHS Derby and Derbyshire Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 27 November 2024.
Action
Share learning and concerns with clinical-system providers, requesting consideration and implementation of solutions to prevent recurrence.
Stated by NHS Derby and Derbyshire Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 27 November 2024.
Action
Conduct a significant event analysis to identify safer arrangements for short-term prescriptions around bank holidays.
Stated by Macklin Street SurgeryStated completedThe respondent said that this action was complete when they made their response on 27 November 2024.
Action
Move all short-term prescription issue days to Tuesday, notify patients and pharmacies, and place alerts in patient notes.
Stated by Macklin Street SurgeryStated completedThe respondent said that this action was complete when they made their response on 27 November 2024.
Action
Implement rolling alerts notifying clinicians when patients move onto short-term prescriptions.
Stated by Macklin Street SurgeryStated in progressThe respondent said that this action was in progress when they made their response on 27 November 2024.
Action
Review short-term-prescription patients clinically and classify their risk of medication harm, with reassessment at annual medication reviews.
Stated by Macklin Street SurgeryStated in progressThe respondent said that this action was in progress when they made their response on 27 November 2024.
Action
Split high-risk patients’ prescriptions into shorter supplies when specified bank holidays fall on Tuesday.
Stated by Macklin Street SurgeryStated plannedThe respondent said that this action was planned when they made their response on 27 November 2024.
Action
Seek advice from the Integrated Care Board on using central clinical pharmacy and medicines-management expertise for high-risk patients.
Stated by Macklin Street SurgeryStated plannedThe respondent said that this action was planned when they made their response on 27 November 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5
Position
Clinical system providers are responsible for evaluating and implementing necessary updates because they control operational and developmental oversight.
Stated by NHS Derby and Derbyshire Integrated Care BoardRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Prescribing and dispensing decisions are assigned to responsible clinicians and pharmacists, who must apply clinical judgement and may delay dispensing where concerns arise.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
NHS England, through regional Controlled Drugs Accountable Officers, holds national oversight responsibility for safe controlled-drug management and use.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Risk cannot be mitigated entirely because pharmacies are not routinely open on bank holidays and patients may choose different pharmacies.
Stated by Macklin Street SurgeryUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Addressing digital reporting constraints requires action by the national system supplier and NHS Digital.
Stated by Macklin Street SurgeryRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Inner North London
Concerns raised3
Failure to maintain daily amitriptyline dispensing to mitigate overdose risk
Failure to flag the overdose risk and stop continued amitriptyline prescribing
Prescribing of amitriptyline for depression despite its increased risk of fatality in overdose
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 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
Identify eligible complex patients, add them to the Risk Management & Care Planning Register, and create corresponding care plans and EMIS alerts.
Stated by Tredegar PracticeStated plannedThe respondent said that this action was planned when they made their response on 23 May 2024.
Action
Conduct regular reviews of registered patients and the overall framework, documenting, minuting, and circulating review outcomes.
Stated by Tredegar PracticeStated plannedThe respondent said that this action was planned when they made their response on 23 May 2024.
Inner South London
Concerns raised1
Failure to limit quantities of Propranolol prescribed to people at risk of overdose
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Stoke-on-Trent and North Staffordshire
Concerns raised1
Lack of a process to prevent prescriptions being issued before full GPO review following a prescribed-medication overdose
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
Complete a significant event analysis and discuss its findings with all clinicians.
Stated by Heathview Medical PracticeStated completedThe respondent said that this action was complete when they made their response on 14 October 2022.
Action
Review the overdose policy, discuss it with clinicians, and make it accessible to staff on the shared drive.
Stated by Heathview Medical PracticeStated completedThe respondent said that this action was complete when they made their response on 14 October 2022.
Action
Teach clinical staff how to action hospital letters concerning overdoses.
Stated by Heathview Medical PracticeStated completedThe respondent said that this action was complete when they made their response on 14 October 2022.
Action
Discuss the overdose policy and significant event analysis with all practice staff at the scheduled 15 November meeting.
Stated by Heathview Medical PracticeStated plannedThe respondent said that this action was planned when they made their response on 14 October 2022.
Black Country
Concerns raised1
Failure to limit prescription quantities and avoid duplicate prescribing for patients at high risk of medication overdose
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The Trust disputes that Mrs Brady was oversupplied with medication, stating supplies were limited or not dispensed.
Stated by Sandwell and West Birmingham Hospitals NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
County Durham and Darlington
Concerns raised1
Failure to scrutinise repeat prescription requests
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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Includes prescribing-process controls specifically intended to identify and respond to a patient's overdose history or material overdose risk, including mandatory clinical review before issuing prescriptions, scrutiny of repeat prescriptions, use of relevant overdose information and proportionate restrictions or supervision of prescribing.
