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.
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.
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.5
Action
Review processes for recording medications across different healthcare sectors.
Stated by NHS Hillingdon Clinical Commissioning GroupStated plannedThe respondent said that this action was planned when they made their response on 22 April 2014.
Action
Review processes for communicating medication information between healthcare sectors, including medication changes and treatment follow-up.
Stated by NHS Hillingdon Clinical Commissioning GroupStated plannedThe respondent said that this action was planned when they made their response on 22 April 2014.
Action
Discuss with CNWL and Hillingdon Hospitals pharmacy leads the possibility of developing a standard cross-sector medication letter or form.
Stated by NHS Hillingdon Clinical Commissioning GroupStated plannedThe respondent said that this action was planned when they made their response on 22 April 2014.
Action
Have practice pharmacists review and improve medicines-reconciliation processes in GP practices.
Stated by NHS Hillingdon Clinical Commissioning GroupStated plannedThe respondent said that this action was planned when they made their response on 22 April 2014.
Action
Circulate an anonymised Clinical Risk Alert highlighting communication lessons from the case to staff across the organisation.
Stated by Central and North West London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 22 April 2014.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
The CCG should respond to concerns about inadequate communication by the GP with the Trust clinician.
Stated by Central and North West London NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The Trust considered its communication systems effective in this case and did not identify a need to change them.
Stated by Central and North West London NHS Foundation TrustExisting 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.
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.
