Recurring concern
Unreliable clinical management of medication overdose and toxicity
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Request correctionFirst reported 7 Aug 2014•Latest report 17 Nov 2025
What this concern includes
Includes failures in the dedicated clinical response to suspected or identified medication overdose, therapeutic excess or medication-related toxicity, including recognising excess exposure, assessing harm, arranging medical review, monitoring for toxicity, escalating treatment and coordinating specialist or emergency care.
Not included
- Excludes routine prescribing, dosage selection, dispensing or administration failures where no medication overdose, therapeutic excess or toxicity is identified.
- Excludes prevention of overdose through prescription-quantity or medication-security controls when no failure in the clinical response after excess exposure is asserted.
- Excludes toxicity risks from a named medication or drug combination when the assertion concerns only prescribing guidance or prevention and not clinical management after suspected or identified excess exposure.
- Excludes failures in treatment after medication toxicity has been reliably assessed and an appropriate response has been initiated.
- Reports
- 7
- Individual concerns
- 7
- Date range
- 2014–2025
- Stated actions
- 8
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 consider or plan alternative pain management during opioid overdose treatment
This report raised 18 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
Share opioid reversal guidance through palliative-care educational events and hold collaborative opioid-learning events with the integrated care system.
Stated by the Princess Alexandra Hospital NHS 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
The hospital trust is responsible for providing the response and addressing the reported concerns through its governance arrangements and actions.
Stated by NHS England
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Concerns raised1
Lack of a robust process for managing therapeutic excess and potential toxicity
This report raised 6 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
Develop and provide staff with a clinical guideline for managing paracetamol overdose and therapeutic excess.
Stated by Lewisham and Greenwich NHS 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
Statutory labelling, prescribing information and ongoing safety monitoring address risks associated with paracetamol overdose.
Stated by Medicines and Healthcare products Regulatory Agency
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Concerns raised1
Lack of GP awareness of the consequences of excess propranolol ingestion at relatively small doses
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
Produce and provide a five-minute learning resource alerting GPs to propranolol toxicity risks and prescribing considerations.
Stated by Royal College of General Practitioners
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Concerns raised1
Failure to arrange medical assessment after disclosed excess oramorph ingestion
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.4
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Action
Review and revise medication policies, procedures and working practices to prevent recurrence of medication-related incidents.
Stated by Cherish Homecare Limited -
Action
Implement a medication-overdose procedure requiring staff to seek medical assistance regardless of service-user or next-of-kin agreement.
Stated by Cherish Homecare Limited -
Action
Disseminate the medical-assistance procedure to office staff through meetings and to care staff through refresher training and direct notifications.
Stated by Cherish Homecare Limited
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Action
Introduce the medication-overdose policy and medical-assistance procedures to new staff through induction.
Stated by Cherish Homecare Limited
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Concerns raised1
Failure to administer naloxone in suspected opiate overdose
This report raised 13 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 distinguish clozapine overdose signs from unresolved schizophrenia symptoms
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 assess and address ongoing excessive use of illicit amitriptyline
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.
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
Instruct clinical staff to discuss known self-harm methods, monitor related practices and medication risks, and set preventive care-plan actions.
Stated by North London NHS Foundation Trust
Data last updated 7 September 2026