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.
Inner North London
Concerns raised2
Unclear prescribing advice for concurrent pain-relieving medications
Failure to seek clarification of unclear prescribing advice
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.
Manchester South
Concerns raised1
Failure to refer prescription amendments to the secondary care doctor for medication not started in primary care
This report raised 4 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.
Manchester South
Concerns raised1
Failure to verify mental health service advice before prescribing Diazepam
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.
Manchester South
Concerns raised1
Failure of information sharing between GPs and psychiatrists about sedative and antipsychotic medication decisions
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.
Inner West London
Concerns raised1
Lack of doctor-to-doctor communication for prescribing
This report raised 4 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.
West Yorkshire Eastern
Concerns raised1
Failure to follow senior clinician anticoagulant-duration advice
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.1
Action
Record post-discharge Tinzaparin instructions on electronic drug charts and transfer them automatically to electronic discharge advice notes for eligible patients.
Stated by Leeds Teaching Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 26 September 2018.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
The Trust determined that Tinzaparin was correctly prescribed under NICE guidance, and a longer course could not be shown to have prevented death.
Stated by Leeds Teaching Hospitals NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Comprehensively reviewing the entire medical record before electronic discharge prescribing is considered impractical for junior doctors.
Stated by Leeds Teaching Hospitals NHS TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
London (East)
Concerns raised1
Failure of GP prescribing to follow psychiatric team direction
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.
Cornwall and Isles of Scilly
Concerns raised1
Failure to review and act on specialist medication advice
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.
South Wales Central
Concerns raised1
Reliance of GP prescribing on receipt of hospital scan-result notification
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.5
Action
Implement a streamlined DVT pathway directing suspected cases to radiology, initiating primary treatment before ultrasound, and ensuring positive and negative results receive appropriate follow-up.
Stated by Hywel Dda University LHBStated completedThe respondent said that this action was complete when they made their response on 2 December 2017.
Action
Record all suspected DVT referrals and follow up 48 hours later to confirm receipt of results.
Stated by RHAYADER GROUP PRACTICEStated completedThe respondent said that this action was complete when they made their response on 2 December 2017.
Action
Review how inspections assess timely information transfer between services, using policy, medicines and clinical expertise.
Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 2 December 2017.
Action
Revise and improve the wording of the Key Lines of Enquiry on information sharing during transfers between services.
Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 2 December 2017.
Action
Have inspectors use two specific information-sharing questions when reviewing practice safety from November 2017.
Stated by Care Quality CommissionStated plannedThe respondent said that this action was planned when they made their response on 2 December 2017.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Welsh Clinical Portal access was considered sufficient for the GP to review the patient's A&E attendance outcome despite the discharge summary issue.
Stated by Hywel Dda University LHBExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
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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.
