Recurring concern

Unreliable doctor-to-doctor coordination of prescribing

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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

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.

  1. East London

    AI-generated summary

    EMMA LOUISE BRAY · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Emma Louise Bray had a history of problems with mood and was assessed by mental health services in January 2015 after her mood deteriorated. Her family reported worsening symptoms, hopelessness, suicidal research and concerns about her medication, but several planned referrals, follow-up actions and communication of information did not occur. She hanged herself on 25 February 2015. Concerns included incomplete medication and treatment histories, failures in follow-up and referral, inadequate response to family information, failures to record emails, unclear medication-risk communication, and wider deficiencies in service guidance and monitoring.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of clarity about responsibility for communicating medication risks

    Wider context from the report

    “During the evidence I was told that a number of things had not happened that ought to have done: (a) A proper medication history was not taken on assessment (b) EB’s treatment and medication history were not obtained from either public or private sector providers. (c) Had EB’s history been obtained she should have been referred to a psychiatrist following assessment, to be seen and assessed within 14 days. (d) ████████ felt that there was an underestimate of the level and complexity of EB’s condition. (e) EB remained with the Intake team for the whole period of her contact with the service. This appears to have occurred because of a failure to make a referral rather than because of any positive decision to retain her within the team. (f) EB should have been referred to an appropriate service, probably initially the BIT. This would have provided her with better support and regular monitoring. (g) Even within the IT there was a failure to follow EB up. Telephone contact should have been made with her by seven days after the initial assessment. (h) There should have been regular contact with EB thereafter, initiated by IT. (i) Important information was provided by EB’s family about the changes in her presentation, most notably on 19 January, 22 January and then from 19 February 2015 onwards. Nothing happened in response to these reports. The information should have been placed before the Intake Team MDT to discuss her care. (j) Had the information been provided EB should have been seen by the team and, in response to the information of 19 February 2015 at the latest, had a psychiatric assessment. (k) The emails sent by EB’s family were not placed on her notes; accordingly other members of staff looking at her care were not aware of the family’s concerns. (l) Risks associated with the drug Sertraline do not appear to have been communicated to EB and her family. Were the drug was recommended by a psychiatrist who had not seen or assessed EB it was unclear where responsibility for advising about risk lay. On a systemic level, the following issues are of concern: (a) Absence of guidelines about what information must be obtained on assessment, including the medication history. (b) Absence of guidance about where that information should be obtained from: the patient / primary sources. (c) A lack of clarity amongst staff about when to retain patients under the IT and when to refer out of it intake to other services. (d) Lack of clarity about who should be the person between patients and the IT. (e) Lack of guidance about what to do when patients are not engaging directly with the IT but there is reason for concern about them. (f) A lack of monitoring / auditing of the passage of patients through the service to see whether cases are being managed and progressed as they ought to be. (g) An absence of guidelines giving staff timescales within which referrals should take place. (h) A lack of appreciation of the need to create a plan with timescales for further treatment / referral to take place. (i) A lack of clear information about the circumstances in which it is appropriate for a psychiatrist to make recommendations about the medication without a full medical history. (j) A lack of clear information about the circumstances in which it is appropriate for a psychiatrist to make recommendations about the medication without seeing the patient in person. (k) A lack of clarity about whose responsibility it is to communicate risks about medication to the individual when the medication is recommended by the WFAAT psychiatrist but prescribed by the GP. This was particularly the case with the Sertraline prescribed to EB, which apparently does have specific associated risks that must be warned of. (l) The lack of apparent process or procedure to ensure that emails sent to staff directly are placed on an individual’s notes. (m) Any proper understanding by staff of risk assessment in the context of self-harm. The risk assessment tool in use appeared very basic and not one that provided any real assistance to staff. ”

    Source location

    EMMA LOUISE BRAY · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review and implement AABIT standard operating procedures.

    Verbatim wording from the response

    “The plan has five broad objectives within which your specific concerns have been addressed. These are:”

    Source location

    2015-0438-Response-by-NELFT-NHS-Trust
    Page 1 · response
    Published 16 November 2015

    Open published response

  2. Inner South London

    AI-generated summary

    Philip Allen · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Philip Allen, who had vascular dementia, was transferred from The Oaks Care Centre to QEH in September 2012 following a deterioration in his condition and died there. The concern was that Quetiapine continued to be prescribed as a repeat prescription after specialist advice to discontinue it, because the surgery’s system did not prevent this; the inquest evidence was that the further prescriptions did not contribute to his death.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to follow specialist prescribing advice

    Wider context from the report

    “████████ as Mr Allen’s GP, sought specialist advice from ████████. Not only was this advice not followed but the Quetiapine, which ████████ had stopped, continued to be prescribed as a repeat prescription on several occasions. The evidence at the inquest was that the further prescriptions of Quetiapine did not contribute to the death. However, I am concerned that the system at Eltham Palace Surgery did not prevent the repeat prescription. ████████ was unable to say if changes have been made since this incident. ”

    Source location

    Philip Allen · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Carry out quarterly medication reviews through the CCG Prescribing Advisor.

    Verbatim wording from the response

    “As a practice we have made several changes to our policy in dealing with the care of clients at the Oaks Nursing Home:-”

    Source location

    2014-0466-Response-by-Eltham-Palace-Surgery
    Page 2 · response
    Published 27 October 2014

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Carry out twice-yearly medication reviews using the practice computer records and electronic prescribing system.

    Verbatim wording from the response

    “As a practice we have made several changes to our policy in dealing with the care of clients at the Oaks Nursing Home:-”

    Source location

    2014-0466-Response-by-Eltham-Palace-Surgery
    Page 2 · response
    Published 27 October 2014

    Open published response

  3. South Yorkshire (Western)

    AI-generated summary

    Denise Sharon Parramore · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Denise Sharon Parramore, who had a lengthy history of mental ill health and previous self-harm, died from respiratory depression after taking Tramadol in excess of the prescribed level in combination with other medication. The concerns were that psychiatric services were unaware of the Tramadol prescription and that primary and secondary care should have open two-way communication and access to each other's documentation.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure of two-way communication about prescribing between primary and secondary care

    Wider context from the report

    “(1) The Psychiatric Services, and in particular her Consultant Psychiatrist, was not aware, prior to Denise Parramore's death, of her being prescribed Tramadol by her General Practitioner. Concerns would have been raised, and action likely taken, if she had been aware. The Consultant Psychiatrist was not informed either by Mrs Parramore herself, nor the General Practitioner of the prescribing of the Tramadol. My concern is that there should be open, and constant two-way communication between those in primary care and secondary care such as in these circumstances. ”

    Source location

    Denise Sharon Parramore · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. West Sussex

    AI-generated summary

    MRS KERRY JACOBS · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Mrs Kerry Jacobs died on 8 July 2013 from a pulmonary embolism arising from a deep vein thrombosis in her right calf. Concerns included the prescription of a steroid dose outside usual ENT practice and BNF guidelines without adequate documentation or confirmation with the consultant, and the lack of a protocol requiring discussion between pharmacists and clinicians when prescriptions are queried.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to confirm or report actual prescriptions to the patient’s consultant

    Wider context from the report

    “(1) There was nothing within Mrs Jacobs’ hospital records indicating any awareness that she had been prescribed steroid dose which was out with usual ENT practice and the BNF guidelines. Nor was the actual prescription issued confirmed with or reported to patient’s consultant. The evidence was that there is no policy or procedure within the Trust which requires a doctor who prescribes a medication outside usual practice and/or BNF guidelines to note within the patient’s clinical record that they have made the deliberate decision to do so and to record their grounds for so deciding. ”

    Source location

    MRS KERRY JACOBS · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026