Recurring concern
Failure to provide timely clinical follow-up after medication prescribing
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Request correctionFirst reported 14 Aug 2013•Latest report 6 Jan 2026
What this concern includes
Includes timely clinical review after prescribing, assessment of treatment response, adherence or collection monitoring, and escalation when follow-up identifies concern.
Not included
- Unsafe prescribing, dispensing or administration where no follow-up deficiency is identified
- Generic appointment failures unrelated to prescribed medication
- Medication-specific toxicity or blood-level monitoring governed by a narrower dedicated control
- Reports
- 21
- Individual concerns
- 23
- Date range
- 2013–2026
- Stated actions
- 35
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
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.
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.
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Concerns raised1
Failure to check with the GP whether medication compliance was being maintained
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 concernsEach 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
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Action
Train relevant clinical staff to use the NHS Summary Care Record and routinely verify prescription issues and collection when adherence is significant to risk management.
Stated by East London NHS Foundation Trust -
Action
Implement enhanced monitoring and documented risk-management plans when service users with capacity decline medication, including documented consideration of family involvement.
Stated by East London NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
Weekly MDT review, risk-register oversight, escalation and documented accountability are considered sufficient; no further action is required.
Stated by East London NHS Foundation Trust
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Position
Routine Summary Care Record checks, enhanced monitoring and escalation processes are considered sufficient; no further action is required.
Stated by East London NHS Foundation Trust
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Concerns raised1
Failure to conduct medication reviews after overdose disclosures and related concerns
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 concernsEach 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
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Action
Amend the self-harm follow-up policy to require medication review and consideration of reducing prescription quantities where ongoing risk exists.
Stated by Your Health Partnership PCN -
Action
Amend the self-harm risk-assessment template to record medication review discussions, stockpiling, medication safety, prescription quantity, and medication supervision options.
Stated by Your Health Partnership PCN -
Action
Expand the annual proactive self-harm follow-up audit to record medication reviews and discussions about prescribed medication quantities.
Stated by Your Health Partnership PCN
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
NICE Quality Standard 34 does not specifically require medication review following self-harm.
Stated by Your Health Partnership PCN
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Concerns raised1
Failure to identify and escalate unrequested antipsychotic medication
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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
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Action
Train Mental Health Practitioners to locate current and historical prescriptions in SystmOne.
Stated by Essex Partnership University NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
Concerns about care before 6 June 2023 do not relate to the respondent, so it has identified no action concerning them.
Stated by Mid and South Essex NHS Foundation Trust
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Position
The Line Manager would not have prescribed medication because prescribing for this case was outside the manager’s remit.
Stated by Essex Partnership University NHS Foundation Trust
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Concerns raised1
Lack of HRT reviews following initial prescription
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 concernsEach 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
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Action
Introduce and disseminate a written HRT Prescribing Policy requiring timely and ongoing reviews supported by templates and standardised Accurx questionnaires.
Stated by Ashlea Medical Practice -
Action
Audit compliance with the HRT prescribing policy in September 2024, including questionnaire use, review timeliness, templates and coding.
Stated by Ashlea Medical Practice
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Concerns raised1
Failure to conduct regular medication reviews when prescribing medicines that can depress the central nervous system
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 concernsEach 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
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Action
Risk-stratify patients lacking recent medication reviews to prioritise review according to medication-related risk.
Stated by Betsi Cadwaladr University LHB -
Action
Develop a Health Board policy defining medication-review standards and risk-priority levels for managed practices.
Stated by Betsi Cadwaladr University LHB
-
Concerns raised1
Lack of a direct pharmacy-to-provider means for reporting stopped methadone collection
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 concernsEach 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
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Action
Communicate accurate contact information, including telephone numbers and secure email addresses, to all Community Pharmacies.
Stated by Waythrough
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Concerns raised1
Failure of the electronic patient system to flag uncollected or undispensed medication for early identification of non-compliance
Responses linked to these concernsEach 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
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Action
Investigate HJIS reporting functions to identify a mechanism for detecting non-collection of in-possession medicines.
Stated by NHS England -
Action
Write to Health and Justice regional teams and request commissioners remind prison healthcare staff to monitor uncollected in-possession medicines using available HJIS and local processes.
Stated by NHS England
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
An automated medication non-compliance flag would not improve safety because it would be seen only when a clinician opens the patient record.
Stated by NHS England
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Concerns raised1
Lack of GP resources for proactively checking collection of prescribed medication
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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.2
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Position
Proactive monitoring of whether patients collected prescribed medicines cannot be undertaken because pharmacies do not record collection and no such facility exists.
Stated by Birmingham and Solihull Integrated Care System
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Position
The Trust will not respond to concerns about GPs proactively checking medication collection, leaving the matter to others.
Stated by Birmingham and Solihull Mental Health NHS Foundation Trust
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Concerns raised1
Lack of a procedure for regular monitoring of medication prescribing, collection and response
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 concernsEach 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
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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 Trust
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Concerns raised1
Failure to notify relevant professionals of doubt about medication compliance
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 concernsEach 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
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Action
Review care-note wording for medication non-adherence and hoarding incidents.
Stated by PENTRE LODGE CARE HOME LIMITED
Data last updated 7 September 2026