Recurring concern
Unreliable implementation of medication changes
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Request correctionFirst reported 13 Dec 2008•Latest report 8 Feb 2026
What this concern includes
Includes failures of controls specifically dedicated to implementing a medication change, including communicating and acknowledging the change, updating prescriptions or administration records, coordinating implementation between specialist and primary or community care, and arranging required monitoring or follow-up.
Not included
- Excludes medication prescribing, administration, supply or monitoring failures where no medication change is involved.
- Excludes generic communication, documentation, staffing or coordination deficiencies unless they directly impair implementation of a medication change.
- Excludes failures concerning medication reconciliation or dosage verification when the reported unsafe condition is not implementation of a medication change.
- Excludes clinical decisions about whether to change medication when the implementation process itself is not deficient.
- Reports
- 22
- Individual concerns
- 24
- Date range
- 2008–2026
- Stated actions
- 35
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 raised2
Lack of pharmacist scrutiny of medication changes
Failure to enter and administer re-prescribed medication
This report raised 29 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.3
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Action
Discuss medication changes at multidisciplinary reviews and re-check prescriptions during those reviews.
Stated by Essex Partnership University NHS Foundation Trust -
Action
Remind staff through supervision to apply professional curiosity and challenge when medication changes require clarification.
Stated by Essex Partnership University NHS Foundation Trust -
Action
Implement electronic prescribing and medicines administration safeguards against omitted medicines during prescription-chart changes.
Stated by Essex Partnership University NHS Foundation 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
A pharmacist’s physical ward presence may not always be possible, although remote prescription screening provides an alternative safeguard.
Stated by Essex Partnership University NHS Foundation Trust
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Concerns raised1
Failure to communicate medication changes between private and NHS psychiatric providers
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 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 communicate medication changes between private and NHS psychiatric providers
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 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 clarify medication changes before continued 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 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.5
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Action
Introduce and disseminate a visual flow chart guiding staff through medication checks when residents return from hospital without discharge documentation.
Stated by Care UK -
Action
Reinforce hospital-return, discharge and medication-management policies through mandatory read-and-sign confirmation and refresher training.
Stated by Care UK -
Action
Train staff to escalate hospital-return medication queries, obtain same-day clarification and document communications, actions and handovers.
Stated by Care UK
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Action
Discuss imminent and new hospital discharges at daily and weekly clinical meetings so required information and follow-up actions are identified.
Stated by Care UK -
Action
Continue working with hospital Trusted Assessors to streamline secure, prompt sharing of discharge information and support safe transitions of care.
Stated by Care UK
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Concerns raised1
Lack of consistent guidance for cross-titration of psychiatric medication
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 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
Provide clinicians and patients with cross-titration safety advice through publications and relevant prescribing guidance.
Stated by Royal College of Psychiatrists
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Concerns raised1
Provision of medication tapering instructions based on incorrect doses
This report raised 14 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
Conduct a GIRFT review visit to Mid and South Essex NHS Foundation Trust’s neurology department.
Stated by NHS England
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
The consultant had time to establish Chloe’s dose because it was documented and clinic capacity was available before the appointment.
Stated by Mid and South Essex NHS Foundation Trust
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Position
Many concerns about Chloe’s care fall within the NHS Foundation Trust’s remit rather than NHS England’s national programme or policy remit.
Stated by NHS England
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Concerns raised1
Failure to refer medication-change correspondence to a clinician for consideration
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.5
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Action
Review internal policies and procedures against the coroner’s concerns and identify necessary changes.
Stated by Godfrey Care -
Action
Implement a local medication policy covering medication receipt, transcription, altered labels, missed doses, written prescribing confirmation and triangulation between prescribers.
Stated by Godfrey Care -
Action
Require GP review and triage of all neurology correspondence received by Brook Medical Centre.
Stated by Brook Medical Centre and University Hospitals of North Midlands NHS Trust
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Action
Develop a standardised Medisec clinic-letter template specifying medication changes and clear prescribing actions for primary care.
Stated by Brook Medical Centre and University Hospitals of North Midlands NHS Trust -
Action
Have a GP review and triage all neurology correspondence and clinic letters received by Brook Medical Centre.
Stated by Brook Medical Centre and University Hospitals of North Midlands 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
A standardised clinic-letter template cannot be created immediately because implementation across the Trust requires substantial timeframes.
Stated by Brook Medical Centre and University Hospitals of North Midlands NHS Trust
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Concerns raised1
Failure to safely effect medication changes
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 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.3
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Action
Establish a specialist Pharmacy Clozapine Team to support assay follow-up, staff training and clozapine prescribing practice.
Stated by Birmingham and Solihull Mental Health NHS Foundation Trust -
Action
Provide electronic prescribing guidance and communicate procedures for implementing clozapine dose changes.
Stated by Birmingham and Solihull Mental Health NHS Foundation Trust -
Action
Implement significant changes to clozapine processes and procedures following the August 2020 report.
Stated by Birmingham and Solihull Mental Health NHS Foundation Trust
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Concerns raised1
Failure to implement Amiodarone dose down-titration
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Failure to communicate inpatient medication changes to carers of patients with cognitive impairment
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.2
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Action
Refresh training across all wards on discharge medication review, communication with relatives or carers, and recording and actioning blister-pack requirements.
Stated by University Hospitals Birmingham NHS Foundation Trust -
Action
Reinforce communication with relatives and carers of cognitively impaired patients through medical staff communication and departmental clinical governance meetings.
Stated by University Hospitals Birmingham NHS Foundation 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
Existing processes are considered sufficient to ensure medication changes are appropriately discussed with patients, relatives or carers at discharge.
Stated by University Hospitals Birmingham NHS Foundation Trust
Data last updated 7 September 2026