Recurring concern
Unreliable dissemination of safety alerts to relevant recipients
- Reports that mention this concern
- 5
- Times this concern has been raised
- 5
- Stated actions linked to this concern
- 7
What this concern includes
Includes failures in arrangements for identifying recipients, circulating, transmitting, receiving or confirming receipt of safety alerts about medicines, medical devices or comparable patient-safety risks, including national distribution routes and dissemination to pharmacies, private care providers, inspectors and other responsible functions.
What is not included
- Excludes failures to act on or implement an alert after it has been reliably received; those concern downstream alert response or safety-action implementation.
- Excludes generic communication, policy dissemination or organisational-learning deficiencies where no safety-alert dissemination process is identified.
- Excludes the substantive content, accuracy or clinical adequacy of an alert unless the deficiency directly prevents reliable dissemination of the alert.
- Excludes ordinary clinical record alerts, system-generated warnings and patient-specific flags where the concern is the operation of that separate alerting system rather than dissemination of safety alerts to relevant organisations or functions.
Trends
Reports over time
Reports mentioning this concern, 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.
Reports and published responses 5 reports
See individual reports that have raised this concern, and the actions taken in response
-
Concerns raised1
Lack of an effective national procedure for circulating Patient Alerts to pharmacies
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Department of Health and Social Care
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Department of Health and Social Care
NHSEI is responsible for systems oversight of controlled-drug management and use, including the alert system’s operation.
-
Concerns raised1
Failure to sustain and nationally reinforce the button-battery safety alert
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Failure to provide private community-care companies with alerts about relevant medicines and medical devices
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Medicines and Healthcare products Regulatory Agency
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
-
Medicines and Healthcare products Regulatory Agency
Continue reviewing methods for communicating important healthcare information to healthcare professionals and the public.
-
Concerns raised1
Failure to alert the wider medical community to potential cardiovascular problems with intravenous Buscopan
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Medicines and Healthcare products Regulatory Agency
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
-
Medicines and Healthcare products Regulatory Agency
Revise the Buscopan Ampoules Summary of Product Characteristics to strengthen warnings about serious adverse reactions in patients with cardiac disease.
-
Medicines and Healthcare products Regulatory Agency
Communicate the revised Buscopan safety recommendations to healthcare professionals through the MHRA Drug Safety Update newsletter.
-
Medicines and Healthcare products Regulatory Agency
Analyse reported UK deaths suspected to involve Buscopan Ampoules and review the current product information to determine necessary regulatory action.
-
Medicines and Healthcare products Regulatory Agency
Request the Buscopan Ampoules licence holder to revise product information to clarify cardiac risks and recommend monitoring and readily available emergency equipment and trained personnel.
-
Concerns raised1
Failure to ensure that CQC inspectors are properly aware of relevant Department of Health alerts
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
- Care Quality Commission
- Department of Health and Social Care
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
-
Care Quality Commission
Undertake a detailed review to ensure Regulation 28 reports and other information systematically feed into intelligence monitoring, inspection and registration processes.
-
Department of Health and Social Care
Discussed the report with the CQC and considered how to ensure Safety Alerts reach appropriate teams.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
-
Care Quality Commission
Primary responsibility for managing patient safety and implementing safety alerts rests with health and social care providers.
-
Department of Health and Social Care
Providers, rather than the Department or CQC, are responsible for managing patient safety, actioning alerts, and selecting suitable window restrictors.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026