Recurring concern

Unsafe medication prescribing

First to latest report 5 May 2013 — 25 Jun 2026

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.

Reports and published responses 121 reports

See individual reports that have raised this concern, and the actions taken in response

  1. North London

    AI-generated summary

    Roshen Abbas Ladak-Ebrahim · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Roshen Abbas Ladak-Ebrahim, aged 22, was found having hanged himself at home on the evening of 11 October 2012. The report raised concerns about assessing and recording immediate risk of self-harm, ensuring patients at risk were not left alone, and requiring appropriate medical consultation and follow-up when prescribing medication associated with increased self-harm risk.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to consult patients before first prescribing medication with an increased risk of self-harm

    Wider context from the report

    “Consideration to be given to guidance whereby a doctor working in the community mental health agencies is required to have a consultation with a patient before prescribing medication that carries an increased risk of self-harm when first prescribed and arranges to see the patient again to assess the effect of the medication. ”

    Source location

    Roshen Abbas Ladak-Ebrahim · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026