First reported 13 Dec 2008•Latest report 8 Feb 2026
Definition
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
Distinct published reports
Individual concerns
24
A report can raise multiple concerns
Date range
2008–2026
First to latest report issue date
Stated actions
35
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.
NHS England3
Department of Health and Social Care2
NHS Northamptonshire Integrated Care Board2
Northamptonshire Healthcare NHS Foundation Trust2
Belmarsh Prison1
Birmingham and Solihull Mental Health NHS Foundation Trust1
Brook Medical Centre1
Brunswick Ward at Lindridge1
Care UK1
Carewatch (Mid Bucks)1
Central and North West London NHS Foundation Trust1
Cwm Taf Morgannwg University Local Health Board1
Dorset Healthcare University NHS Foundation Trust1
East London NHS Foundation Trust1
Essex Partnership University NHS Foundation Trust1
NHS trust15
Executive non-departmental public body3
Integrated care board3
Healthcare site2
Ministerial department2
Prison or young offender institution2
Social-care provider2
Domiciliary care provider1
Health and care professional regulator1
Local health board1
Multi-service care provider1
Private limited company1
Professional body1
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.
Suffolk
Concerns raised1
Difficulty removing no-longer-needed prescriptions from the medication system
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
London (East)
Concerns raised1
Failure to communicate changed asthma medication to primary care
This report raised 23 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.
Dorset
Concerns raised1
Lack of a policy for communicating medication regime changes and supervision to GPs or other treating practitioners
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.
London (East)
Concerns raised1
Inability of GPs to implement rapid and accurate specialist-directed medication changes
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.
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
Email medication changes to GPs within 24 working hours.
Stated by North East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 16 June 2018.
Action
Require doctors to include their telephone number on medication-change notifications sent to GPs.
Stated by North East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 16 June 2018.
Action
Compile and redistribute NELFT consultant psychiatrists’ telephone numbers to Redbridge GPs so they can contact prescribing clinicians.
Stated by North East London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 16 June 2018.
Action
Continue joint NELFT–Fullwell Cross meetings to agree the process for referrals, prescribing during medication changes and communication, including reconvening to resolve prescribing responsibilities.
Stated by North East London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 16 June 2018.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5
Position
NELFT cannot undertake prescribing because prescribers lack an overview of patients’ full medication and may miss interactions or contraindications.
Stated by North East London NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
NELFT cannot undertake prescribing because it lacks arrangements with community pharmacists to ensure frail patients receive medication.
Stated by North East London NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
NELFT cannot use FP10 prescribing for many Older Adult Mental Health Team patients who lack capacity.
Stated by North East London NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
NELFT cannot facilitate compliance aids through local pharmacists, so medication for patients using them must be organised by GPs.
Stated by North East London NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
NELFT cannot undertake FP10 prescribing for many patients in care or sheltered accommodation because those settings will not accept such prescriptions.
Stated by North East London NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Inner North London
Concerns raised1
Failure to update drug cards to reflect increased prescriptions
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.
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
Implement a central referrals inbox for communicating hospital discharge plans to CMHT staff, with daily administrative review and senior oversight.
Stated by East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 September 2017.
Action
Require Senior Practitioners to allocate and monitor discharge-plan actions, using duty workers when care coordinators are unavailable.
Stated by East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 September 2017.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Implemented CMHT systems are considered sufficient to address concerns about monitoring care coordinators.
Stated by East London NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Staffordshire South
Concerns raised1
Failure to monitor medication after changes during admission
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Brighton and Hove
Concerns raised1
Failure to discuss medication changes
This report raised 25 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.
West Yorkshire Eastern
Concerns raised1
Failure to discontinue prescribed medication when requested by hospital clinicians
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Norfolk
Concerns raised2
Failure to communicate medication changes and monitoring requirements to involved carers and family
Failure to provide timely and continuous monitoring following medication changes
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.4
Action
Share medication-change monitoring concerns with Pharmacy, Triangle of Care leads and clinical teams for learning to be cascaded.
Stated by Norfolk and Suffolk NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 6 August 2015.
Action
Provide Pharmacy support for medication information to service users and families, including a medicines information helpline.
Stated by Norfolk and Suffolk NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 6 August 2015.
Action
Monitor patient surveys, incident reports and complaints for failures to communicate treatment changes, taking remedial action where required.
Stated by Norfolk and Suffolk NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 6 August 2015.
Action
Raise medication-change monitoring directly with clinical staff through internal communications and clinical forums.
Stated by Norfolk and Suffolk NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 6 August 2015.
Inner South London
Concerns raised1
Failure to cancel discontinued medication prescriptions in the computerised record
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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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.
