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.
South Wales Central
Concerns raised1
Failure to account for concomitant medications when dosing clozapine
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.5
Action
Maintain the Medicines Code and its medicines-reconciliation responsibilities for doctors, pharmacy staff and other prescribers.
Stated by Cardiff & Vale University LHBStated completedThe respondent said that this action was complete when they made their response on 17 October 2019.
Action
Provide dedicated pharmacy and specialist mental-health pharmacist support for medicines management and prescribing.
Stated by Cardiff & Vale University LHBStated completedThe respondent said that this action was complete when they made their response on 17 October 2019.
Action
Promote polypharmacy reviews through secondary-care pharmacy and primary-care medicines-management teams.
Stated by Cardiff & Vale University LHBStated completedThe respondent said that this action was complete when they made their response on 17 October 2019.
Action
Operate the Medicines Management Incentive Scheme to improve recording of medicines across care settings, including staff education and retrospective recording of complex medicines.
Stated by Cardiff & Vale University LHBStated completedThe respondent said that this action was complete when they made their response on 17 October 2019.
Action
Develop an interface between PARIS and PMS to improve information transfer and introduce medicines transcribing and electronic discharge using the Welsh Clinical Portal.
Stated by Cardiff & Vale University LHBStated in progressThe respondent said that this action was in progress when they made their response on 17 October 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Existing medicines reconciliation, pharmacist support, NICE monitoring and promoted polypharmacy reviews address medication interaction and prescribing risks.
Stated by Cardiff & Vale University LHBExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Mandated Clozapine monitoring, ZTAS reporting and primary-care record checks are considered sufficient for shared prescribing and information exchange.
Stated by Cardiff & Vale University LHBExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Central Hampshire
Concerns raised1
Lack of access to relevant psychiatric and prescribing history when prescribing Propranolol
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.3
Action
Disseminate relevant prescribing guidance extracts to support safe prescribing and patient safety.
Stated by General Medical CouncilStated completedThe respondent said that this action was complete when they made their response on 2 August 2019.
Action
Refer information about the private GPs to an Assistant Registrar to determine whether the investigation threshold is met.
Stated by General Medical CouncilStated completedThe respondent said that this action was complete when they made their response on 2 August 2019.
Action
Explore Graphnet as an integrated care record providing organisations read-only access to legal status, risks and contemporaneous care plans.
Stated by Surrey and Borders Partnership NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 2 August 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Existing GMC prescribing guidance, when followed, is considered sufficient to ensure safe practice and protect patient safety.
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
Existing prescribing guidance is considered sufficient to ensure safe prescribing and protect patient safety when followed.
Stated by General Medical CouncilExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Brighton and Hove
Concerns raised1
Failure to prevent prescribing and administration of a documented allergenic medication
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.5
Stated by University Hospitals Sussex NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 June 2019.
Action
Finalise the EPMA specification and secure funding to purchase an electronic prescribing and medicines administration package incorporating allergy safeguards.
Stated by University Hospitals Sussex NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 June 2019.
Action
Undertake medicines reconciliation for every patient as soon as possible after admission.
Stated by University Hospitals Sussex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 June 2019.
Action
Trial a single red allergy wristband system in the Acute Admissions Unit and Emergency Department, supported by compliance audits.
Stated by University Hospitals Sussex NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 June 2019.
Action
Deliver bespoke Acute Admissions Unit training on penicillin allergy risks and co-amoxiclav use.
Stated by University Hospitals Sussex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 June 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Purchase of the EPMA package cannot proceed until NHS England decides its funding allocation.
Stated by University Hospitals Sussex NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Plymouth, Torbay and South Devon
Concerns raised1
Failure to prescribe intravenous hydrocortisone when vomiting prevents oral steroid administration
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Manchester City
Concerns raised1
Prescribing antibiotics that mask Endocarditis
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.
City of London
Concerns raised1
Failure to require individualized risk-benefit justification for cyclizine prescribing in severe heart failure
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Nottinghamshire
Concerns raised1
Failure to identify incorrect warfarin prescribing
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.
London (East)
Concerns raised1
Inadequate asthma safety-netting advice and reliance on unlicensed high-dose salbutamol weaning plans
This report raised 23 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.
Manchester South
Concerns raised2
Failure to document and justify the volume of tramadol prescribed despite recorded non-compliance and self-medication
Failure to explore alternatives to repeated painkiller prescribing for persistent back pain
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.8
Action
Document follow-up plans and dosage advice whenever medication is started.
Stated by NHS Greater Manchester Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 23 May 2019.
Action
Provide GPs and non-medical prescribers with tools, information and education on safer prescribing and medication review.
Stated by NHS Greater Manchester Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 23 May 2019.
Action
Audit practices against repeat-prescribing and medication-review standards to support and maintain safety improvements.
Stated by NHS Greater Manchester Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 23 May 2019.
Action
Add patient alerts for concerns about overuse of painkillers or other medicines.
Stated by NHS Greater Manchester Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 23 May 2019.
Action
Share learning from the practice improvement plan with all Trafford practices to improve prescribing and repeat prescribing.
Stated by NHS Greater Manchester Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 23 May 2019.
Action
Provide and document advice on non-pharmacological treatments when prescribing analgesia.
Stated by NHS Greater Manchester Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 23 May 2019.
Action
Share learning on medication follow-up, dosage advice and non-pharmacological pain treatment with GPs through training and newsletters.
Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 23 May 2019.
Action
Consider running education sessions on non-pharmacological pain management and referral criteria for musculoskeletal services.
Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 23 May 2019.
Brighton and Hove
Concerns raised2
Inappropriate ADHD assessment and prescribing suggestion
Prescribing Concerta without further clinical review
This report raised 9 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
Establish a senior medical decision-making group to review ADHD assessment, diagnosis, questionnaire use and prescribing practice.
Stated by Sussex Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 12 May 2019.
Action
Complete a clinical review of ADHD prescribing within the relevant team.
Stated by Sussex Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 12 May 2019.
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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.
