Recurring concern
Unsafe medication prescribing
- Reports that mention this concern
- 121
- Times this concern has been raised
- 151
- Stated actions linked to this concern
- 246
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.
What is 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.
Trends
Reports over time
Reports mentioning this concern, 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.
Reports and published responses 121 reports
See individual reports that have raised this concern, and the actions taken in response
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Concerns raised1
Failure to issue correct Clonodine prescriptions
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
- Portsmouth Hospitals University NHS Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Portsmouth Hospitals University NHS Trust
The medication was not prescribed by the Trust, and there was no evidence that the hospital had been approached for a supply.
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Portsmouth Hospitals University NHS Trust
Existing assessment-unit and pharmacy arrangements would have enabled medication supply if the hospital had been approached, so no further Trust steps were proposed.
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Concerns raised1
Failure to avoid prescribing Diazepam for anxiety in sleep apnoea or respiratory distress
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Abbeyslade Surgery
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Abbeyslade Surgery
Check patients’ histories, previous consultations, outstanding reviews, long-term conditions and medication during consultations, arrange overdue reviews, request appropriate tests, and record advice.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Abbeyslade Surgery
Diazepam was prescribed because the known symptoms were not contraindicated; sleep apnoea was undisclosed and would have changed the prescribing decision.
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Concerns raised1
Failure to establish whether Gabapentin is contraindicated for patients with severe Type 1 diabetes
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
- Guy'S and St Thomas' NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Guy'S and St Thomas' NHS Foundation Trust
Build the drug-safety review into day-to-day clinical practice.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Guy'S and St Thomas' NHS Foundation Trust
Gabapentin should not be withheld from diabetic patients because it is licensed for painful diabetic neuropathy within specified doses.
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Concerns raised1
Failure to assess medication appropriateness in light of patients’ mental health history
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Department of Health and Social Care
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Department of Health and Social Care
Concerns about the GP’s decisions and actions should be addressed by Pennine Care NHS Trust and York House Surgery.
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Department of Health and Social Care
NHS England’s Performers Screening Group will determine whether specific action is needed regarding the GP’s clinical behaviour.
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Concerns raised1
Failure to comply with guidelines on citalopram repeat prescribing
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked responses
- Department of Health and Social Care
- Rt Hon Jeremy Hunt MP
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
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Department of Health and Social Care
Prescribing responsibility rests with the clinically responsible prescriber, while local primary care organisations must ensure adequate controls.
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Department of Health and Social Care
Further investigation of the cited prescribing guidelines depends on receiving identifying information and confirming that the matter falls within remit.
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Rt Hon Jeremy Hunt MP
National restrictions do not govern repeat citalopram prescribing; NICE guidelines are not mandatory rules restricting clinical prescribing.
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Rt Hon Jeremy Hunt MP
Prescribing and managing individual antidepressant cases remain the responsibility of the treating doctor.
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Concerns raised1
Failure to safely assess morphine prescribing alongside high-dose painkillers and alcohol dependence
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Browning Street Surgery
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Browning Street Surgery
Consider and initiate independent medication reviews by asking an uninvolved doctor to review complex patients’ medication when appropriate.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Browning Street Surgery
Morphine was considered appropriate because pain was significant, alternatives had failed, alcohol intake had reduced, and prescribing was regularly reviewed.
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Concerns raised1
Failure of junior medical staff to review clinical records and history before prescribing medication
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
- Department of Health and Social Care
- Greater Manchester Mental Health NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Greater Manchester Mental Health NHS Foundation Trust
Inform trainees about the Rapid Tranquillisation protocol through induction and clarify consultants’ supervision responsibilities for junior-doctor prescribing.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Department of Health and Social Care
Trust-level policy and procedural concerns are assigned to the NTDA and Manchester Health and Social Care Trust.
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Concerns raised1
Failure to check adverse-reaction alerts before prescribing
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to prevent prescribing penicillin-type antibiotics to patients with penicillin allergy
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to account for self-harm and suicidal tendencies when supplying unsupervised medication
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026