First reported 21 Mar 2014•Latest report 21 Apr 2026
Definition
What this concern includes
Includes failures in doctor-to-doctor prescribing coordination, including communication arrangements, transfer or receipt of specialist prescribing advice, confirmation of advice, and implementation of prescribing decisions between doctors where these can cause medication to be continued, changed or prescribed unsafely.
Not included
Excludes prescribing errors confined to one doctor's clinical judgement where no doctor-to-doctor coordination failure is identified.
Excludes general clinical communication, handover or information-sharing deficiencies that are not specifically related to prescribing.
Excludes medication administration, dispensing, supply or monitoring failures occurring after prescribing coordination has operated reliably.
Excludes failures involving patient-facing medication advice where no doctor-to-doctor prescribing interface is involved.
Reports
24
Distinct published reports
Individual concerns
26
A report can raise multiple concerns
Date range
2014–2026
First to latest report issue date
Stated actions
37
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.
Department of Health and Social Care5
NHS England5
NHS Greater Manchester Integrated Care Board3
Barts Health NHS Trust2
North East London NHS Foundation Trust2
Brook Medical Centre1
BTCM Limited1
Care Inspectorate Wales1
Care Quality Commission1
Central and North West London NHS Foundation Trust1
Droylsden Road Family Practice1
Edge Hill Rest Home1
Eltham Palace Surgery1
Essex Partnership University NHS Foundation Trust1
Godfrey Care1
NHS trust14
Healthcare site7
Executive non-departmental public body5
Integrated care board5
Ministerial department5
Social-care provider2
Clinical commissioning group1
Company1
Company limited by guarantee1
Devolved government1
Health and social care service regulator1
Health professional committee1
Health-system partnership1
Local health board1
Residential care home1
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.
Gateshead and South Tyneside
Concerns raised1
Failure of secondary-care specialists to issue required prescriptions at diagnosis
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.1
Action
Develop the Red Tape Challenge to improve primary-secondary care communication, interface working, prescribing, records access, interoperability, and process standardisation.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 19 June 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
The concern that specialists cannot prescribe required medicines at diagnosis is based on a misunderstanding; registered secondary-care specialists may prescribe them.
Stated by NHS EnglandDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Implementation of measures improving primary-secondary care communication and prescribing is driven by integrated care boards, with national oversight.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
East Sussex
Concerns raised1
Failure to coordinate ADHD prescribing between private providers and NHS GPs
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
Highlight duplicate-prescription, medication-confusion, continuity-of-care and treatment-change communication risks to ADHD specialists and primary-care prescribers through ongoing programme work.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 10 March 2026.
Action
Publish non-mandatory ADHD assessment and treatment guide prices and commissioning guidance setting expectations for assessment, data quality, governance, shared care and follow-up.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 10 March 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The private ADHD provider considered its existing systems sufficient to ensure continuity of care and safer prescribing, requiring no process changes.
Stated by NHS EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
East London
Concerns raised1
Breakdown of communication about responsibility for penicillin prescription and dispensation
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.6
Action
Proactively contact patients with sickle cell disease annually for medication reviews, including Penicillin V prescribing and compliance.
Stated by Maylands HealthcareStated completedThe respondent said that this action was complete when they made their response on 19 December 2025.
Action
Liaise directly with secondary or tertiary specialists when responsibility for Penicillin V prescribing or dispensing requires clarification.
Stated by Maylands HealthcareStated completedThe respondent said that this action was complete when they made their response on 19 December 2025.
Action
Move all patients with sickle cell disease to electronic repeat dispensing for Penicillin antibiotics.
Stated by Maylands HealthcareStated completedThe respondent said that this action was complete when they made their response on 19 December 2025.
Action
Require the on-site pharmacist to communicate uncollected sickle cell disease prescriptions to the practice.
Stated by Maylands HealthcareStated completedThe respondent said that this action was complete when they made their response on 19 December 2025.
Action
Increase access to shared care records to improve communication between primary and secondary care.
Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 19 December 2025.
Action
Develop greater interoperability of electronic patient records, starting with structured medication information sharing.
Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 19 December 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Responsibility for addressing the prophylactic penicillin communication concern lies with other bodies.
Stated by Partnership of East London Co-operatives LtdRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Without a shared care protocol, the hospital should retain responsibility for care, monitoring and issuing the prescription.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Essex
Concerns raised1
Delays in communication with the GP about antidepressant prescribing
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 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.1
Action
Reinforce with medical staff the need to communicate medication-dose inconsistencies clearly and promptly.
Stated by Essex Partnership University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 14 August 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The maximum licensed sertraline dose meant no dose increase was possible, so no additional prescribing action was considered necessary before the planned review.
Stated by Essex Partnership University NHS Foundation TrustNo action considered necessaryThe respondent said that no further action was needed.
Suffolk
Concerns raised1
Lack of a clear prescribing decision-making and coordination system for mental health medication
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.
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
Action
Add prescribing responsibilities and communication instructions to standard letters sent to GPs when service users join CRHT caseloads.
Stated by Norfolk and Suffolk NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 November 2024.
Action
Remind staff to liaise directly with GPs when requesting adjustments to medications already prescribed by GPs.
Stated by Norfolk and Suffolk NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 November 2024.
Action
Undertake a joint clinical audit with primary care colleagues three months after implementing the revised CRHT wording and report results to the Trust-wide Safety Group.
Stated by Norfolk and Suffolk NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 28 November 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Commissioning NHS 111 Option 1 and out-of-hours GP services is outside the respondent’s responsibility.
Stated by Norfolk and Suffolk NHS Foundation TrustOutside remitThe respondent said that this matter was outside its role or authority.
Staffordshire and Stoke-on-Trent
Concerns raised2
Failure to refer medication-change correspondence to a clinician for consideration
Failure to give the prescribing GP express instructions to amend Brivaracetam prescriptions after dosage 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.7
Action
Review internal policies and procedures against the coroner’s concerns and identify necessary changes.
Stated by Godfrey CareStated plannedThe respondent said that this action was planned when they made their response on 21 February 2024.
Action
Implement a local medication policy covering medication receipt, transcription, altered labels, missed doses, written prescribing confirmation and triangulation between prescribers.
Stated by Godfrey CareStated plannedThe respondent said that this action was planned when they made their response on 21 February 2024.
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 TrustStated completedThe respondent said that this action was complete when they made their response on 21 February 2024.
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 TrustStated in progressThe respondent said that this action was in progress when they made their response on 21 February 2024.
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 TrustStated completedThe respondent said that this action was complete when they made their response on 21 February 2024.
Action
Update weekly and monthly managers’ medication audits to verify written authorisation, dosage changes and timely receipt of replacement prescriptions.
Stated by Godfrey CareStated completedThe respondent said that this action was complete when they made their response on 21 February 2024.
Action
Develop a standardised clinic-letter template specifying medication changes and clear actions for prescribing GPs.
Stated by Brook Medical Centre and University Hospitals of North Midlands NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 21 February 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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 TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Lincolnshire
Concerns raised1
Failure to prevent duplicate medication prescriptions between hospital and GP
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The Trust’s 14-day discharge-supply policy and associated arrangements remain appropriate despite accepted overlapping prescriptions.
Stated by United Lincolnshire Teaching Hospitals NHS TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Cambridgeshire and Peterborough
Concerns raised1
Lack of clarity over responsibility for monitoring GP antibiotic prescribing requested by a hospital
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.
Manchester City
Concerns raised1
Lack of escalation and contact process with secondary care when requested medication is not prescribed or contact fails
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The GP practice is to provide the response concerning medication prescribing, correspondence handling, pharmacy communication and escalation processes.
Stated by Greater Manchester Mental Health NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Manchester South
Concerns raised1
Failure of psychiatrists to comply with the shared care protocol when requesting GP initiation of Lithium prescriptions
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
Communicate the shared-care communication failure to general-practice colleagues and require similar problems to be escalated to the CCG.
Stated by Greater Manchester Medicines Management Group and NHS Greater Manchester Integrated Care Board and Pennine Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 May 2020.
Action
Review all Greater Manchester Shared Care Protocols using risk-based prioritisation, agreed review timescales, COVID-related practice changes and relevant stakeholder learning.
Stated by Greater Manchester Medicines Management Group and NHS Greater Manchester Integrated Care Board and Pennine Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 18 May 2020.
Action
Develop recommendations for a unified Greater Manchester process for implementing Shared Care Protocols, including clearly documented local arrangements where the standard is not adopted.
Stated by Greater Manchester Medicines Management Group and NHS Greater Manchester Integrated Care Board and Pennine Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 18 May 2020.
Action
Provide assurance that Greater Manchester Shared Care Protocol implementation standards are followed, including assurance where local processes deviate.
Stated by Greater Manchester Medicines Management Group and NHS Greater Manchester Integrated Care Board and Pennine Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 18 May 2020.
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Includes failures in doctor-to-doctor prescribing coordination, including communication arrangements, transfer or receipt of specialist prescribing advice, confirmation of advice, and implementation of prescribing decisions between doctors where these can cause medication to be continued, changed or prescribed unsafely.
