First reported 5 May 2013•Latest report 25 Jun 2026
Definition
What this concern includes
Includes failures involving the clinical appropriateness of prescribing or medication selection, including inadequate assessment of indication, patient circumstances, relevant information, alternatives or dose.
Not included
Excludes failures limited to medication administration after an otherwise appropriate prescription.
Excludes generic documentation, training or communication deficiencies unless they directly result in or are explicitly tied to an unsafe prescribing decision.
Excludes dispensing, supply or monitoring failures that do not concern whether the medication prescription itself was clinically appropriate.
Reports
121
Distinct published reports
Individual concerns
151
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
246
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 Care20
NHS England16
Care Quality Commission7
NHS Greater Manchester Integrated Care Board7
General Medical Council6
National Institute for Health and Care Excellence4
Recipient name withheld4
Medicines and Healthcare products Regulatory Agency3
NHS Surrey and Sussex Integrated Care Board3
Royal College of General Practitioners3
Royal College of Physicians3
University Hospitals Birmingham NHS Foundation Trust3
Welsh Government3
BNF Publications2
Cwm Taf Morgannwg University Local Health Board2
NHS trust52
Healthcare site39
Ministerial department20
Executive non-departmental public body19
Integrated care board19
Type not available12
Health professional body8
Health and care professional regulator7
Health and social care service regulator7
Private limited company6
Local health board5
Independent healthcare provider4
Sub-organisation4
Clinical commissioning group3
Devolved government3
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.
Devon, Plymouth and Torbay
Concerns raised1
Failure to seek specialist guidance on medication appropriateness in complex mental health presentations
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Mental health services retain responsibility for prescribing and antipsychotic dose changes when a patient is under specialist care.
Stated by The Foxhayes SurgeryRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Essex
Concerns raised1
Continuation and increase of Diazepam during crisis deterioration
This report raised 18 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
Conduct a Trust-wide community benzodiazepine-prescribing audit against NICE and BNF requirements and use findings for quality improvement.
Stated by Essex Partnership University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 13 August 2026.
Action
Require short-term benzodiazepine prescribing, documented rationale, explicit review dates, and supervision-based monitoring of adherence.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 August 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Diazepam or another benzodiazepine may be continued or increased during crisis when clinically indicated, because medications may not take effect immediately.
Stated by Essex Partnership University NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Inner South London
Concerns raised1
Failure to prescribe and administer medication at the correct dose
This report raised 8 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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Inner North London
Concerns raised1
Failure to assess and record the clinical picture before and after prescribing
This report raised 11 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
Implement SYSTMOne templates requiring vital-sign and other observation recording during initial assessments and clinical reviews.
Stated by Metropolitan Police ServiceStated completedThe respondent said that this action was complete when they made their response on 24 February 2026.
Action
Audit healthcare practitioners’ clinical documentation and provide feedback, guidance, and additional training where practice or records fall below the required standard.
Stated by Metropolitan Police ServiceStated in progressThe respondent said that this action was in progress when they made their response on 24 February 2026.
Manchester North
Concerns raised3
Continuation of medicinal cannabis prescriptions obstructing appropriate psychiatric and addictions care
Failure to exhaust available treatment options before prescribing medicinal cannabis
Failure to base prescribing decisions on complete and current clinical information
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.4
Action
Required CMHT contact and explicit consent or non-objection before commencing CBMP treatment for patients receiving CMHT care.
Stated by Curaleaf ClinicStated completedThe respondent said that this action was complete when they made their response on 10 February 2026.
Action
Reviewed the approach to patients with complex psychiatric presentations and reinforced coordination with relevant external mental health services through coordinated-care arrangements.
Stated by Curaleaf ClinicStated completedThe respondent said that this action was complete when they made their response on 10 February 2026.
Action
Implemented access to the NHS National Care Records Service to obtain contemporaneous clinical information for assessments and ongoing care.
Stated by Curaleaf ClinicStated completedThe respondent said that this action was complete when they made their response on 10 February 2026.
Action
Reinforced documentation of available clinical information and review of incomplete external information through MDT and clinical governance processes.
Stated by Curaleaf ClinicStated completedThe respondent said that this action was complete when they made their response on 10 February 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
Continuing medicinal cannabis did not obstruct psychiatric or addictions care, which continued through the GP, Priory and NHS services.
Stated by Curaleaf ClinicDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Treatment options were considered exhausted because multiple medication classes and extensive non-pharmacological treatments had already been tried.
Stated by Curaleaf ClinicDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
The summary care record was less than a year old and contained information sufficient for the prescribing assessment.
Stated by Curaleaf ClinicDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Sunderland
Concerns raised1
Candesartan remaining available on repeat prescription during pregnancy
This report raised 5 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
Implement and apply an SOP covering pregnancy-related safety checks for new medicines, including stopping or replacing medicines unsafe in pregnancy.
Stated by Riverview SurgeryStated completedThe respondent said that this action was complete when they made their response on 2 February 2026.
Action
Maintain a mandatory prescribing assessment within GP specialty training that assesses prescribing for pregnancy and other special groups.
Stated by Royal College of General PractitionersStated completedThe respondent said that this action was complete when they made their response on 2 February 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Manually reviewing every repeat medication request and creating linked pregnancy alerts is impractical due to workload and lack of technical IT skills.
Stated by Riverview SurgeryUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Inner West London
Concerns raised1
Drug-selection errors associated with drop-down menu prescribing for similarly named drugs
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 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
Issue and deliver updated guidance and training on safer Cerner drug-search practices to reduce medication-selection errors.
Stated by Chelsea and Westminster Hospital NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 January 2026.
Action
Provide regular neonatal simulation training covering medication-selection error scenarios in in-situ and StiNE courses.
Stated by Chelsea and Westminster Hospital NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 January 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Oracle must determine whether mitigations can be implemented within the Cerner prescribing system to reduce drug-selection errors.
Stated by Chelsea and Westminster Hospital NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Essex
Concerns raised2
Failure to review the patient before prescribing a controlled drug
Failure to scrutinise prescribed medication and medication-system information
This report raised 17 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.4
Action
Operate networks for Controlled Drugs Accountable Officers and Medication Safety Officers to receive and spread learning from medication errors.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 19 November 2025.
Action
Provide guidance and tools to NHS Trusts for learning from patient safety incidents and improving controlled-drug safety.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 19 November 2025.
Action
Remove the option to modify existing prescriptions in the electronic prescribing system, requiring cancellation or discontinuation and reordering with clinical warnings.
Stated by the Princess Alexandra Hospital NHS TrustStated completedThe respondent said that this action was complete when they made their response on 19 November 2025.
Action
Clarify morphine product names and predefine twice-daily frequency for modified-release morphine prescriptions in the electronic prescribing system.
Stated by the Princess Alexandra Hospital NHS TrustStated completedThe respondent said that this action was complete when they made their response on 19 November 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Education and training alone would not sufficiently mitigate recurrence; systems improvements and mechanisms are also required.
Stated by NHS EnglandDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
The hospital trust is responsible for providing the response and addressing the reported concerns through its governance arrangements and actions.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Black Country
Concerns raised1
Continued prescribing of repeat medications in large amounts at 28-day frequency after overdose disclosure
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.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.
Inner South London
Concerns raised1
Failure to prevent concurrent prescriptions of paracetamol-containing drugs
This report raised 6 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.13
Action
Commission and maintain the ePRASE toolkit, including therapeutic duplication scenarios in its finalised 2025 release.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 19 December 2025.
Action
Review therapeutic-duplication scenarios as a priority for the 2026 ePRASE release.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 19 December 2025.
Action
Liaise with NHS England about preventing prescribing systems from dispensing two concurrent medicines containing paracetamol.
Stated by Medicines and Healthcare products Regulatory AgencyStated completedThe respondent said that this action was complete when they made their response on 19 December 2025.
Action
Complete a detailed review of Millennium’s duplicate-prescription and paracetamol overdose alert functionality.
Stated by Oracle Corporation UK LimitedStated completedThe respondent said that this action was complete when they made their response on 19 December 2025.
Action
Continue augmenting the content and functionality of Millennium alert notifications, including overdose-related alerts.
Stated by Oracle Corporation UK LimitedStated in progressThe respondent said that this action was in progress when they made their response on 19 December 2025.
Action
Continue working with Trust clients to inform and educate them about available alert functionality.
Stated by Oracle Corporation UK LimitedStated in progressThe respondent said that this action was in progress when they made their response on 19 December 2025.
Action
Discuss safeguards against paracetamol dosing incidents with Trust clients through quarterly meetings.
Stated by Oracle Corporation UK LimitedStated completedThe respondent said that this action was complete when they made their response on 19 December 2025.
Action
Introduce the UK Administration Alert Notification and explain its triggers, operation and implementation options to Trusts through a Special Interest Group meeting.
Stated by Oracle Corporation UK LimitedStated completedThe respondent said that this action was complete when they made their response on 19 December 2025.
Action
Present updates to the Administration Alert Notification, including patient-weight-based maximum-dose calculations, to Trust clients.
Stated by Oracle Corporation UK LimitedStated completedThe respondent said that this action was complete when they made their response on 19 December 2025.
Action
Continue reviewing and monitoring Trust-client awareness of duplicate-prescription and paracetamol overdose alert functionality.
Stated by Oracle Corporation UK LimitedStated in progressThe respondent said that this action was in progress when they made their response on 19 December 2025.
Action
Continue discussing potential software or configuration enhancements with clients, including their appropriateness and workflow impact.
Stated by Oracle Corporation UK LimitedStated in progressThe respondent said that this action was in progress when they made their response on 19 December 2025.
Action
Maintain electronic prescribing alerts preventing duplicate or excessive paracetamol prescribing and administration.
Stated by Lewisham and Greenwich NHS TrustStated completedThe respondent said that this action was complete when they made their response on 19 December 2025.
Action
Seek assurance that Epic will implement iCare paracetamol safety features when introduced across the three Trusts.
Stated by Lewisham and Greenwich NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 19 December 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5
Position
NHSE is responsible for incorporating incident learning into commissioning the ePRaSE prescribing system.
Stated by Medicines and Healthcare products Regulatory AgencyRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Building electronic prescribing alerts requires national oversight to coordinate work with secondary-care system suppliers.
Stated by Royal Pharmaceutical SocietyRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
No evidence has been identified that the software contains a defect or deficiency relevant to duplicate paracetamol prescribing.
Stated by Oracle Corporation UK LimitedDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Existing prescribing and administration alert functionality is considered appropriate and functioning as designed, so further alert-notification code development is unnecessary.
Stated by Oracle Corporation UK LimitedExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
The client decides whether to adopt particular code or configuration enhancements, taking account of clinical and commercial considerations.
Stated by Oracle Corporation UK LimitedRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
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Includes failures involving the clinical appropriateness of prescribing or medication selection, including inadequate assessment of indication, patient circumstances, relevant information, alternatives or dose.
