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.
Wiltshire and Swindon
Concerns raised1
DVT risk assessment failing to account for immobilisation when determining anti-clotting medication prescribing
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
Update the Trust policy to require VTE assessment for patients wearing a black boot with significant mobility reduction.
Stated by Great Western Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 October 2023.
Action
Relocate patient information leaflets and VTE assessment checklists to the black-boot storage area and remind Emergency Department staff to complete assessments for lower-limb casts or black boots.
Stated by Great Western Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 October 2023.
Action
Continue spot-check audits of the changes, share results at Divisional Governance meetings, and take appropriate action where required.
Stated by Great Western Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 18 October 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The current VTE risk assessment is fit for purpose and aligns with the nationally recognised Plymouth Scoring system.
Stated by Great Western Hospitals NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Norfolk
Concerns raised1
Failure of junior doctors to prescribe correctly in accordance with guidelines
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.7
Action
Review and seek approval for revised local VTE guidelines.
Stated by The TrustStated plannedThe respondent said that this action was planned when they made their response on 21 July 2023.
Action
Remove local VTE guidelines from the intranet and link to NICE guidance.
Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 21 July 2023.
Action
Consult ICS acute Trusts and the Integrated Care Board about standardising thromboprophylaxis regulation.
Stated by The TrustStated in progressThe respondent said that this action was in progress when they made their response on 21 July 2023.
Action
Reiterate accurate VTE assessment and thromboprophylaxis prescribing requirements through Trust-wide communications.
Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 21 July 2023.
Action
Review induction materials to strengthen emphasis on VTE assessment and thromboprophylaxis prescribing.
Stated by The TrustStated in progressThe respondent said that this action was in progress when they made their response on 21 July 2023.
Action
Distribute an anticoagulation booklet to junior doctors.
Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 21 July 2023.
Action
Add a consultant check box for confirming VTE assessment completion and dosage checking when Clerking Documents are next revised and reprinted.
Stated by The TrustStated plannedThe respondent said that this action was planned when they made their response on 21 July 2023.
Mid Kent and Medway
Concerns raised1
Failure to prescribe the patient's established Zoromorph medication
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
Investigate how primary-care morphine changes were recorded, communicated and reflected in the Kent Summary of Care Record.
Stated by Medway NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 21 November 2022.
Action
Remind pharmacy staff to follow medicines recommendations through to a conscious decision to endorse or reject them.
Stated by Medway NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 21 November 2022.
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.
Lincolnshire
Concerns raised1
Prescribing Rivaroxaban despite liver impairment
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.
Dorset
Concerns raised1
Failure to define safe medication amounts and dosages in these circumstances
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.2
Action
Discuss prescribing quantities and patient disengagement at a Significant Event Meeting.
Stated by Swanage Medical PracticeStated completedThe respondent said that this action was complete when they made their response on 30 September 2022.
Action
Create an electronic-record alert for drugs in the specified prescribing group, warning prescribers about dosage and alcohol-related risks.
Stated by Swanage Medical PracticeStated completedThe respondent said that this action was complete when they made their response on 30 September 2022.
Inner South London
Concerns raised1
Prescribing antibiotics without examining the patient
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
East London
Concerns raised1
Failure to limit prolonged prescribing of insomnia medication
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.4
Action
Audit and clinically review all patients prescribed Zopiclone over the previous two years, including structured reviews and a second-cycle review of repeat prescriptions.
Stated by High Street SurgeryStated completedThe respondent said that this action was complete when they made their response on 23 September 2022.
Action
Implement a local Z-Drug protocol requiring structured medication reviews at defined intervals and after relevant mental-health review.
Stated by High Street SurgeryStated completedThe respondent said that this action was complete when they made their response on 23 September 2022.
Action
Hold practice staff meetings to explain the Z-Drug protocol and require repeat-prescription requests to be referred for medication review.
Stated by High Street SurgeryStated completedThe respondent said that this action was complete when they made their response on 23 September 2022.
Action
Commence more proactive referral of patients appearing dependent on Z-Drug hypnotics to specialist mental-health services for review and advice.
Stated by High Street SurgeryStated in progressThe respondent said that this action was in progress when they made their response on 23 September 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The Trust, through its pharmacy services, is responsible for the wider Z-drug prescribing audit and safe-prescribing training package.
Stated by High Street SurgeryRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Surrey
Concerns raised1
Prescribing of Mirtazepine without sufficient mental health prescribing competence
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
Circulate NICE prescribing, treatment and patient-information guidance, CCG guidance, and Frimley ICS medicines-optimisation guidance to all clinicians.
Stated by Farnham Park Health Group and Recipient name withheldStated completedThe respondent said that this action was complete when they made their response on 19 May 2022.
Action
Audit patient use of the specified medication, present the results, and identify any required patient-safety actions.
Stated by Farnham Park Health Group and Recipient name withheldStated plannedThe respondent said that this action was planned when they made their response on 19 May 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.8
Position
Existing NICE, Clinical Knowledge Summaries, BNF, GP training and continuing professional development sufficiently support depression assessment and prescribing without a separate policy.
Stated by NHS EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
The circumstances were a specific case, not widespread poor care, and the care provided was not unsafe.
Stated by Care Quality CommissionDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
No further action is currently considered necessary because the provider’s actions are expected to protect service users from harm.
Stated by Care Quality CommissionExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Regulatory action can target registered managers or providers, but not failings attributed solely to individuals.
Stated by Care Quality CommissionOutside remitThe respondent said that this matter was outside its role or authority.
Position
Existing clinical guidance, professional standards, revalidation and training arrangements are considered sufficient to support appropriate prescribing and diagnosis.
Stated by Department of Health and Social CareExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
The concerns do not indicate that the doctor poses a patient risk or undermines public confidence in doctors.
Stated by General Medical CouncilDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
No further investigation is considered necessary, although the concerns will be shared for discussion during revalidation.
Stated by General Medical CouncilNo action considered necessaryThe respondent said that no further action was needed.
Position
The Practice concluded that the prescribed medication was appropriate because insomnia was the patient's original primary reason for contacting it.
Stated by Farnham Park Health Group and Recipient name withheldDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Manchester South
Concerns raised1
Failure to recognise and flag the most appropriate antibiotic formulation for vulnerable patients
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.5
Action
Use quarterly educational events to disseminate system changes and learning from safety events to Trafford practice staff.
Stated by NHS Greater Manchester Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 29 April 2022.
Action
Implement patient-record alerts identifying patients who may have difficulty swallowing medication.
Stated by North Trafford Group PracticeStated in progressThe respondent said that this action was in progress when they made their response on 29 April 2022.
Action
Disseminate the swallowing-medication alert learning to practice staff and discuss the process at the next clinical meeting.
Stated by North Trafford Group PracticeStated plannedThe respondent said that this action was planned when they made their response on 29 April 2022.
Action
Train workflow staff to enter swallowing-related codes and alerts when hospital correspondence identifies changes in a patient’s swallowing ability.
Stated by North Trafford Group PracticeStated plannedThe respondent said that this action was planned when they made their response on 29 April 2022.
Action
Reiterate standardised medication-requirement recording and safety-netting requirements in prescribing protocols, particularly when patients are not seen face-to-face.
Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 29 April 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Monitoring how GP practices operate their systems is outside the CCG’s responsibility.
Stated by NHS Greater Manchester Integrated Care BoardOutside remitThe respondent said that this matter was outside its role or authority.
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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.
