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.
Manchester South
Concerns raised1
Failure to consider the risks of prescribing opioids to patients with former opioid addiction
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.
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
Deliver opioid-prescribing masterclass training to Stockport GPs and clinicians.
Stated by NHS Greater Manchester Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 16 October 2024.
Action
Create, disseminate and use a seven-minute briefing based on learning from the Regulation 28 report.
Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 16 October 2024.
Action
Publish and maintain continuing professional development updates on opioid use disorder, medicine dependence, withdrawal symptoms and opioid reduction.
Stated by Royal College of General PractitionersStated completedThe respondent said that this action was complete when they made their response on 16 October 2024.
Action
Develop, launch and widely circulate a repeat-prescribing toolkit supporting safer, collaborative prescribing processes and addressing opioid-prescribing safety concerns.
Stated by Royal College of General PractitionersStated completedThe respondent said that this action was complete when they made their response on 16 October 2024.
West Yorkshire Eastern
Concerns raised1
Failure of hospital systems to review and safeguard medication prescribing and administration
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Actions taken following the Serious Incident Report are considered sufficient to address identified issues and prevent similar future deaths.
Stated by Inmind HealthcareExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Cambridgeshire and Peterborough
Concerns raised1
Inconsistent units in local anaesthetic prescribing
This report raised 7 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.
Surrey
Concerns raised1
Failure to ensure aripiprazole monotherapy is effective for prophylaxis against both bipolar polarities
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
Discuss long-term bipolar disorder treatment across both polarities with NICE topic experts.
Stated by National Institute for Health and Care ExcellenceStated plannedThe respondent said that this action was planned when they made their response on 1 August 2024.
Action
Review new evidence that could affect NICE’s long-term bipolar disorder treatment recommendations.
Stated by National Institute for Health and Care ExcellenceStated plannedThe respondent said that this action was planned when they made their response on 1 August 2024.
Action
Monitor emerging bipolar-disorder management information and consider adding appropriate detail in a future BNF update.
Stated by BNF PublicationsStated in progressThe respondent said that this action was in progress when they made their response on 1 August 2024.
Action
Update the bipolar disorder topic to discuss guideline differences and incorporate the NICE guideline in greater detail.
Stated by BMJ Publishing Group Limited (BMJ GroupStated completedThe respondent said that this action was complete when they made their response on 1 August 2024.
Action
Continue reviewing and updating the bipolar disorder topic with subject matter experts and incorporating new evidence as appropriate.
Stated by BMJ Publishing Group Limited (BMJ GroupStated in progressThe respondent said that this action was in progress when they made their response on 1 August 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Position
The content of the BNF and BMJ Best Practice is outside NICE’s responsibility, so NICE cannot comment on it.
Stated by National Institute for Health and Care ExcellenceOutside remitThe respondent said that this matter was outside its role or authority.
Position
The BNF and BMJ Best Practice publishers are best placed to respond to concerns about their content.
Stated by National Institute for Health and Care ExcellenceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The BNF guidance was not misleading because it did not recommend aripiprazole for prophylaxis of bipolar depression and advised specialist input.
Stated by BNF PublicationsDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Selection and management of bipolar treatment remain the treating clinicians’ responsibility because they know the patient’s full clinical context.
Stated by BMJ Publishing Group Limited (BMJ GroupRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Leicester City and South Leicestershire
Concerns raised1
Failure of doctors to obtain all relevant patient information before prescribing warfarin
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.
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
Continue developing the electronic patient record to make patients’ available clinical information accessible in one system.
Stated by University Hospitals of Leicester NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 28 June 2024.
Action
Deploy electronic clinical notation in the emergency department.
Stated by University Hospitals of Leicester NHS TrustStated completedThe respondent said that this action was complete when they made their response on 28 June 2024.
Action
Incorporate warfarin prescribing into the digital system to provide clinicians with more patient information.
Stated by University Hospitals of Leicester NHS TrustStated completedThe respondent said that this action was complete when they made their response on 28 June 2024.
Action
Embed a digital reminder requiring MDT colleagues to record pertinent clinical information and patient-condition changes in digital warfarin dosage requests.
Stated by University Hospitals of Leicester NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 28 June 2024.
Inner North London
Concerns raised3
Prescribing of amitriptyline above the maximum suggested dose for a patient known to be dependent on it
Failure to flag the overdose risk and stop continued amitriptyline prescribing
Prescribing of amitriptyline for depression despite its increased risk of fatality in overdose
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.2
Action
Identify eligible complex patients, add them to the Risk Management & Care Planning Register, and create corresponding care plans and EMIS alerts.
Stated by Tredegar PracticeStated plannedThe respondent said that this action was planned when they made their response on 23 May 2024.
Action
Conduct regular reviews of registered patients and the overall framework, documenting, minuting, and circulating review outcomes.
Stated by Tredegar PracticeStated plannedThe respondent said that this action was planned when they made their response on 23 May 2024.
Inner South London
Concerns raised1
Failure to limit quantities of Propranolol prescribed to people at risk of overdose
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.
Inner West London
Concerns raised3
Insufficient specialist expertise in prescribing drug treatments for withdrawal
Failure to withhold or reduce methadone when patients show signs of sedation
Failure to account for reduced opiate tolerance and synergistic agents when prescribing methadone
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
Require acute withdrawal prescribers to complete recognised specialist substance-misuse training to at least RCGP part-one level.
Stated by Oxleas NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 6 March 2024.
Action
Employ a full-time substance-misuse practitioner to oversee five-day reviews, quality assurance, audit, supervision and team development.
Stated by Oxleas NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 6 March 2024.
Action
Update the national service specification using learning from the case to strengthen prescribing and supply of sedating medicines.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 6 March 2024.
Action
Revise and disseminate the withdrawal-treatment policy, including sedation safeguards, tolerance assessment, urine screening and clinical review requirements.
Stated by Oxleas NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 6 March 2024.
Action
Discuss the case in a prescriber reflective-practice forum, focusing on individual history, clinical signs, investigations and cautious methadone dosing.
Stated by Oxleas NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 6 March 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
Existing competency requirements are considered sufficient; prescribing need not be restricted to substance misuse practitioners.
Stated by NHS EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Employers, rather than NHS England, are responsible for ensuring clinicians’ competencies and training compliance.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
National guidance already addresses reduced opioid tolerance and reducing or withholding methadone when sedation is present.
Stated by NHS EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Bedfordshire and Luton
Concerns raised1
Failure to review prolonged prescribing of dependency-forming drugs and formulate dosage-reduction plans
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
Risk-score opioid and gabapentinoid patients, recall them for face-to-face structured medication reviews, and provide follow-up supporting safe dose reduction.
Stated by Kirby Road SurgeryStated in progressThe respondent said that this action was in progress when they made their response on 8 January 2024.
Action
Recruit a specialist prescribing pharmacist with pain-clinic experience to conduct structured medication reviews.
Stated by Kirby Road SurgeryStated completedThe respondent said that this action was complete when they made their response on 8 January 2024.
Action
Train three in-house clinical pharmacists with the specialist pharmacist to develop their capability to conduct structured medication reviews.
Stated by Kirby Road SurgeryStated in progressThe respondent said that this action was in progress when they made their response on 8 January 2024.
Action
Update, externally review, approve and ratify the opioid and gabapentinoid prescribing policies.
Stated by Kirby Road SurgeryStated completedThe respondent said that this action was complete when they made their response on 8 January 2024.
Teesside and Hartlepool
Concerns raised1
Incorrect prescribing of prophylactic antibiotics after urology surgery
This report raised 11 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
Complete an antimicrobial-guidance compliance audit and share its findings with the relevant clinical collaborative.
Stated by South Tees Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 25 January 2024.
Action
Update the Adult Antimicrobial Policy with links to the MicroGuide Antibiotic Prescribing Guidelines app.
Stated by South Tees Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 25 January 2024.
Action
Create electronic drug order sets for standardised first- and second-line surgical prophylactic antibiotic prescribing.
Stated by South Tees Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 25 January 2024.
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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.
