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 raised2
Lack of prescribing prompts to assess Barrett’s-related red flags for endoscopy
Lack of prescribing prompts to identify previously diagnosed Barrett’s patients requiring surveillance
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Secondary care should continue managing Barrett’s Oesophagus surveillance recalls; GP recalls or prompts would duplicate responsibilities and cause confusion.
Stated by Welsh GovernmentExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Inner North London
Concerns raised1
Prescribing medication despite significant mental health concerns
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.
West Sussex, Brighton and Hove
Concerns raised1
Lack of information being made available to the GP to prevent duplicitous prescribing
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
Roll out the shared care record to primary care during the 2025/2026 financial year.
Stated by NHS Surrey and Sussex Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 21 May 2025.
Action
Migrate to the SystmOne electronic patient record system.
Stated by Sussex Partnership NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 21 May 2025.
Action
Enable two-way, real-time information sharing with GP practices and provide sharing agreements.
Stated by Sussex Partnership NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 21 May 2025.
Action
Establish electronic prescribing, prioritising community electronic prescribing within the programme.
Stated by Sussex Partnership NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 21 May 2025.
Bedfordshire and Luton
Concerns raised1
Failure to ensure accurate patient weights are entered before paracetamol 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.
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
Action
Add EPMA prescribing prompts requiring accurate weight recording and appropriate paracetamol dosing, including liver-toxicity warnings below 50 kilograms.
Stated by Bedfordshire Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 11 April 2025.
Devon, Plymouth and Torbay
Concerns raised1
Failure to prescribe oral antibiotics at discharge despite microbiology advice
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.1
Action
Appoint two permanent ENT consultants and provide daily named-consultant ward rounds with senior review of discharges and ongoing treatment plans.
Stated by Royal Devon University Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 July 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Named consultant ward rounds and discharge-plan reviews are considered sufficient to provide senior oversight of ongoing treatment at discharge.
Stated by Royal Devon University Healthcare NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Hampshire, Portsmouth and Southampton
Concerns raised1
Lack of prescriber understanding of the interaction between ivabradine, amitriptyline and paroxetine
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
Prescribers are responsible for understanding medicine interactions and applying appropriate caution or monitoring rather than relying solely on software alerts.
Stated by Royal College of PhysiciansRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
BNF publishers, rather than NICE, are best placed to address concerns about drug interactions.
Stated by National Institute for Health and Care ExcellenceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
NICE cannot comment on drug-interaction concerns because BNF content responsibility remains with its publishers.
Stated by National Institute for Health and Care ExcellenceUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Suffolk
Concerns raised1
Failure to assess suicidal behaviour or thoughts in online consultations
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
If an appropriate organisation requires a standardised suicidal-behaviour question, the GPhC would monitor its inclusion through inspections.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Suffolk
Concerns raised2
Lack of clinical knowledge about microdosing hallucinogenic mushrooms and its relevance to Lorazepam prescribing
Failure to make an appropriate medication-concordance assessment when patients use alternative medication because PRN medication is ineffective
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.1
Action
Continue monitoring developments concerning benzodiazepine prescribing and emerging evidence for implementation in accordance with future NICE or regulatory guidance.
Stated by Norfolk and Suffolk NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 28 November 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Extremely limited evidence and absent specific guidance constrain development of advice on Lorazepam use alongside microdosed hallucinogenic mushrooms.
Stated by Norfolk and Suffolk NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Existing NICE guidance is considered to address concerns about which medicines should and should not be prescribed in different circumstances.
Stated by Department of Health and Social CareExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Derby and Derbyshire
Concerns raised1
Lack of measures to prevent excess prescribing to patients at risk of overdose during longer bank holiday periods
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.10
Action
Review the GP practice investigation, lessons learned and identified actions, and determine required support with primary care quality and patient safety teams.
Stated by NHS Derby and Derbyshire Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 27 November 2024.
Action
Review the community pharmacy investigation, lessons learned and identified actions, and determine required support with controlled drugs and commissioning teams.
Stated by NHS Derby and Derbyshire Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 27 November 2024.
Action
Disseminate collated learning and prescribing-safety updates through pharmacy newsletters, GP messages, medicines-safety communications and prescribing-leads forums.
Stated by NHS Derby and Derbyshire Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 27 November 2024.
Action
Share learning and concerns with clinical-system providers, requesting consideration and implementation of solutions to prevent recurrence.
Stated by NHS Derby and Derbyshire Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 27 November 2024.
Action
Conduct a significant event analysis to identify safer arrangements for short-term prescriptions around bank holidays.
Stated by Macklin Street SurgeryStated completedThe respondent said that this action was complete when they made their response on 27 November 2024.
Action
Move all short-term prescription issue days to Tuesday, notify patients and pharmacies, and place alerts in patient notes.
Stated by Macklin Street SurgeryStated completedThe respondent said that this action was complete when they made their response on 27 November 2024.
Action
Implement rolling alerts notifying clinicians when patients move onto short-term prescriptions.
Stated by Macklin Street SurgeryStated in progressThe respondent said that this action was in progress when they made their response on 27 November 2024.
Action
Review short-term-prescription patients clinically and classify their risk of medication harm, with reassessment at annual medication reviews.
Stated by Macklin Street SurgeryStated in progressThe respondent said that this action was in progress when they made their response on 27 November 2024.
Action
Split high-risk patients’ prescriptions into shorter supplies when specified bank holidays fall on Tuesday.
Stated by Macklin Street SurgeryStated plannedThe respondent said that this action was planned when they made their response on 27 November 2024.
Action
Seek advice from the Integrated Care Board on using central clinical pharmacy and medicines-management expertise for high-risk patients.
Stated by Macklin Street SurgeryStated plannedThe respondent said that this action was planned when they made their response on 27 November 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5
Position
Clinical system providers are responsible for evaluating and implementing necessary updates because they control operational and developmental oversight.
Stated by NHS Derby and Derbyshire Integrated Care BoardRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Prescribing and dispensing decisions are assigned to responsible clinicians and pharmacists, who must apply clinical judgement and may delay dispensing where concerns arise.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
NHS England, through regional Controlled Drugs Accountable Officers, holds national oversight responsibility for safe controlled-drug management and use.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Risk cannot be mitigated entirely because pharmacies are not routinely open on bank holidays and patients may choose different pharmacies.
Stated by Macklin Street SurgeryUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Addressing digital reporting constraints requires action by the national system supplier and NHS Digital.
Stated by Macklin Street SurgeryRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
North Wales (East and Central)
Concerns raised1
Failure to access and consider full medical records and risk assessments when prescribing medication changes
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
Establish a prescribing safety process requiring access to patient notes, communication of falls risk, and escalation or assessment when safe prescribing is uncertain.
Stated by Betsi Cadwaladr University LHBStated in progressThe respondent said that this action was in progress when they made their response on 27 December 2024.
Action
Progress development of integrated electronic health records through business cases, Welsh Government-supported mental health work, and collaboration with early implementers and other Welsh organisations.
Stated by Betsi Cadwaladr University LHBStated in progressThe respondent said that this action was in progress when they made their response on 27 December 2024.
Action
Roll out the electronic Prescribing and Medication Administration System across most acute and community specialties, including staff training and access to medication information.
Stated by Betsi Cadwaladr University LHBStated in progressThe respondent said that this action was in progress when they made their response on 27 December 2024.
Pin
Get email alerts
Request correction
Includes failures involving the clinical appropriateness of prescribing or medication selection, including inadequate assessment of indication, patient circumstances, relevant information, alternatives or dose.
