Recurring concern
Unsafe medication prescribing
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Request correctionFirst reported 5 May 2013•Latest report 25 Jun 2026
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
- Individual concerns
- 151
- Date range
- 2013–2026
- Stated actions
- 246
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
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.
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.
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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.
Responses linked to these concernsEach 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.2
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Position
The medication was not prescribed by the Trust, and there was no evidence that the hospital had been approached for a supply.
Stated by Portsmouth Hospitals University NHS Trust
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Position
Existing assessment-unit and pharmacy arrangements would have enabled medication supply if the hospital had been approached, so no further Trust steps were proposed.
Stated by Portsmouth Hospitals University NHS Trust
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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.
Responses linked to these concernsEach 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.1
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Action
Check patients’ histories, previous consultations, outstanding reviews, long-term conditions and medication during consultations, arrange overdue reviews, request appropriate tests, and record advice.
Stated by Abbeyslade Surgery
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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Position
Diazepam was prescribed because the known symptoms were not contraindicated; sleep apnoea was undisclosed and would have changed the prescribing decision.
Stated by Abbeyslade Surgery
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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.
Responses linked to these concernsEach 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.1
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Action
Build the drug-safety review into day-to-day clinical practice.
Stated by Guy'S and St Thomas' NHS Foundation Trust
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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Position
Gabapentin should not be withheld from diabetic patients because it is licensed for painful diabetic neuropathy within specified doses.
Stated by Guy'S and St Thomas' NHS Foundation Trust
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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.
Responses linked to these concernsEach 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.2
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Position
Concerns about the GP’s decisions and actions should be addressed by Pennine Care NHS Trust and York House Surgery.
Stated by Department of Health and Social Care
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Position
NHS England’s Performers Screening Group will determine whether specific action is needed regarding the GP’s clinical behaviour.
Stated by Department of Health and Social Care
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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.
Responses linked to these concernsEach 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.4
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Position
Prescribing responsibility rests with the clinically responsible prescriber, while local primary care organisations must ensure adequate controls.
Stated by Department of Health and Social Care
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Position
Further investigation of the cited prescribing guidelines depends on receiving identifying information and confirming that the matter falls within remit.
Stated by Department of Health and Social Care -
Position
National restrictions do not govern repeat citalopram prescribing; NICE guidelines are not mandatory rules restricting clinical prescribing.
Stated by Rt Hon Jeremy Hunt MP -
Position
Prescribing and managing individual antidepressant cases remain the responsibility of the treating doctor.
Stated by Rt Hon Jeremy Hunt MP
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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.
Responses linked to these concernsEach 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.1
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Action
Consider and initiate independent medication reviews by asking an uninvolved doctor to review complex patients’ medication when appropriate.
Stated by Browning Street Surgery
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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Position
Morphine was considered appropriate because pain was significant, alternatives had failed, alcohol intake had reduced, and prescribing was regularly reviewed.
Stated by Browning Street Surgery
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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.
Responses linked to these concernsEach 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.1
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Action
Inform trainees about the Rapid Tranquillisation protocol through induction and clarify consultants’ supervision responsibilities for junior-doctor prescribing.
Stated by Greater Manchester Mental Health NHS Foundation Trust
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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Position
Trust-level policy and procedural concerns are assigned to the NTDA and Manchester Health and Social Care Trust.
Stated by Department of Health and Social Care
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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.
Responses linked to these concernsEach statement is shown once, even when linked to more than one 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.
Responses linked to these concernsEach statement is shown once, even when linked to more than one 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.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026