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.
What is 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.
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.
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
Reports and published responses 22 reports
See individual reports that have raised this concern, and the actions taken in response
West London
Concerns raised1
Failure to communicate medication changes between the GP practice and responsible clinician
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked responses
Central and North West London NHS Foundation Trust
NHS Hillingdon Clinical Commissioning Group
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
NHS Hillingdon Clinical Commissioning Group
Review processes for recording medications across different healthcare sectors.
NHS Hillingdon Clinical Commissioning Group
Review processes for communicating medication information between healthcare sectors, including medication changes and treatment follow-up.
NHS Hillingdon Clinical Commissioning Group
Discuss with CNWL and Hillingdon Hospitals pharmacy leads the possibility of developing a standard cross-sector medication letter or form.
NHS Hillingdon Clinical Commissioning Group
Have practice pharmacists review and improve medicines-reconciliation processes in GP practices.
Central and North West London NHS Foundation Trust
Circulate an anonymised Clinical Risk Alert highlighting communication lessons from the case to staff across the organisation.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Central and North West London NHS Foundation Trust
The CCG should respond to concerns about inadequate communication by the GP with the Trust clinician.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Central and North West London NHS Foundation Trust
The Trust considered its communication systems effective in this case and did not identify a need to change them.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Buckinghamshire
Concerns raised1
Failure to ensure individual carers read and acknowledge patient medication changes
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.