First reported 8 Apr 2014•Latest report 19 Mar 2026
Definition
What this concern includes
Includes failures to review, arrange, coordinate or maintain continuous access to medication explicitly identified as vital, essential or required for ongoing treatment, including the anchor's patient-deregistration process and comparable medication-provision failures in other care transitions.
Not included
Excludes continuity-of-care concerns that do not materially concern medication provision.
Excludes generic staffing, documentation or communication failures unless they directly cause or leave unresolved an interruption in vital medication continuity.
Excludes medication prescribing, monitoring or administration deficiencies where continuity of access is not the unsafe condition.
Excludes shortages or interruptions involving medication not identified as essential or required for ongoing treatment.
Reports
4
Distinct published reports
Individual concerns
4
A report can raise multiple concerns
Date range
2014–2026
First to latest report issue date
Stated actions
14
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.
Chelsfield Surgery1
Daughter of the deceased1
Department of Health and Social Care1
Ministry of Justice1
NHS England1
Oakside Surgery1
Sundon Medical Centre1
Wife of the deceased1
Healthcare site3
Ministerial department2
Executive non-departmental public body1
Type not available1
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.
Bedfordshire and Luton
Concerns raised1
Difficulties obtaining sufficient quantities of epilepsy medication for continuous access
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.5
Action
Work with the pharmacy sector to improve awareness of emergency supply provisions and patients’ access to emergency medicines.
Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 26 March 2026.
Action
Consider repeat dispensing, batch prescribing, or one-off reserve prescriptions for suitable patients at risk of running out of critical medication.
Stated by Sundon Medical CentreStated plannedThe respondent said that this action was planned when they made their response on 26 March 2026.
Action
Inform epilepsy patients about the Charlie Card emergency-supply self-advocacy tool.
Stated by Sundon Medical CentreStatus unclearThe respondent did not make the status of this action clear when they made their response on 26 March 2026.
Action
Provide clear patient information about prescription processing and pharmacy dispensing times through the website and reception.
Stated by Sundon Medical CentreStated plannedThe respondent said that this action was planned when they made their response on 26 March 2026.
Action
Clearly communicate the urgent status of critical-medication prescriptions to pharmacies to support prompt dispensing.
Stated by Sundon Medical CentreStated plannedThe respondent said that this action was planned when they made their response on 26 March 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing regulations and NHS pharmacy terms require community pharmacies to dispense NHS medicines with reasonable promptness and notify patients of delays.
Stated by Department of Health and Social CareExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
East Sussex
Concerns raised1
Failure to review medication continuity when deregistering patients
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.9
Action
Hold a Significant Event Analysis meeting to examine the deduction and agree learning points.
Stated by Chelsfield SurgeryStated completedThe respondent said that this action was complete when they made their response on 29 July 2024.
Action
Update the Repeat Prescribing Policy to require adequate medication supply for removed patients until they register elsewhere.
Stated by Chelsfield SurgeryStated completedThe respondent said that this action was complete when they made their response on 29 July 2024.
Action
Provide removed patients with a final-prescription letter explaining the need to register elsewhere for medication continuity.
Stated by Chelsfield SurgeryStated plannedThe respondent said that this action was planned when they made their response on 29 July 2024.
Action
Continue prescribing for removed patients with safeguarding concerns until registration elsewhere is confirmed, with any stopping decision made by a senior clinician and documented.
Stated by Chelsfield SurgeryStated in progressThe respondent said that this action was in progress when they made their response on 29 July 2024.
Action
Circulate updated policies and SEA learning points to all non-clinical staff by email.
Stated by Chelsfield SurgeryStated completedThe respondent said that this action was complete when they made their response on 29 July 2024.
Action
Hold a practice meeting for non-clinical staff to disseminate SEA conclusions and explain updated deduction procedures.
Stated by Chelsfield SurgeryStated plannedThe respondent said that this action was planned when they made their response on 29 July 2024.
Action
Audit deductions from the previous three years to identify affected patients and additional learning points.
Stated by Chelsfield SurgeryStated in progressThe respondent said that this action was in progress when they made their response on 29 July 2024.
Action
Conduct monthly audits of future deductions and feed findings into weekly safeguarding meetings.
Stated by Chelsfield SurgeryStated plannedThe respondent said that this action was planned when they made their response on 29 July 2024.
Action
Review deductions involving safeguarding concerns in weekly safeguarding meetings and check that clinical needs and medication access are met.
Stated by Chelsfield SurgeryStated plannedThe respondent said that this action was planned when they made their response on 29 July 2024.
Suffolk
Concerns raised1
Failure to arrange medication for periods when detainees are out of prison care
This report raised 6 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.
Plymouth, Torbay and South Devon
Concerns raised1
Failure to ensure continuity of required anticoagulation medication
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.
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Includes failures to review, arrange, coordinate or maintain continuous access to medication explicitly identified as vital, essential or required for ongoing treatment, including the anchor's patient-deregistration process and comparable medication-provision failures in other care transitions.
