First reported 29 Apr 2015•Latest report 11 Mar 2025
Definition
What this concern includes
Includes dedicated processes for identifying, recording, monitoring and escalating prescribed medication doses that patients do not take, including self-administered medication not taken at dispensing and medication refusal or omission procedures where the failure can leave treatment interruption or associated risk unmanaged.
Not included
Excludes general medication prescribing, dispensing, administration or supply failures where an omitted or refused dose is not the material concern.
Excludes medication-adherence problems that are not linked to a failure to detect, monitor or respond to doses not taken.
Excludes failures to manage medication effects, toxicity or treatment response after medication has been taken reliably.
Excludes generic staffing, communication, documentation or training deficiencies unless they directly impair management of medication doses not taken.
Reports
12
Distinct published reports
Individual concerns
12
A report can raise multiple concerns
Date range
2015–2025
First to latest report issue date
Stated actions
22
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.
NHS England4
HM Prison and Probation Service2
Barts Health NHS Trust1
Care Quality Commission1
Care UK1
Crystal Care1
Department of Health and Social Care1
Essex Partnership University NHS Foundation Trust1
Greater Manchester Health and Social Care Partnership1
Guys Marsh Prison1
Lancashire Teaching Hospitals NHS Foundation Trust1
Mid and South Essex NHS Foundation Trust1
Practice Plus Group1
Royal Stoke University Hospital1
Sapphire House1
NHS trust5
Executive non-departmental public body4
Executive agency2
Healthcare site2
Health and social care service regulator1
Health-system partnership1
Independent healthcare provider1
Ministerial department1
Multi-service care provider1
Prison or young offender institution1
Residential care home1
Social-care provider1
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.
Staffordshire and Stoke-on-Trent
Concerns raised1
Failure to maintain an audit trail for omitted medication doses
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.
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
Implement electronic prescribing and medicines administration across both Trust sites to record medication omissions, reasons and decision-makers.
Stated by University Hospitals of North Midlands NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 11 March 2025.
Action
Require staff to document reasons for drug omissions in patient records through a circulated Patient Safety Learning Alert.
Stated by University Hospitals of North Midlands NHS TrustStated completedThe respondent said that this action was complete when they made their response on 11 March 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Electronic prescribing systems and existing nursing record requirements address accountability and escalation risks for omitted medication doses.
Stated by NHS EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Further NHS England comment on the reported concerns is not possible based on the information provided.
Stated by NHS EnglandUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Essex
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 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
Train Mental Health Practitioners to locate current and historical prescriptions in SystmOne.
Stated by Essex Partnership University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 18 February 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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 TrustOutside remitThe respondent said that this matter was outside its role or authority.
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 TrustOutside remitThe respondent said that this matter was outside its role or authority.
East Sussex
Concerns raised1
Lack of a mechanism to report medication non-compliance to Security
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.1
Action
Use confidential intelligence reports to notify Security when patients may be stockpiling medication.
Stated by Practice Plus Group Health And Rehabilitation Services LimitedStated completedThe respondent said that this action was complete when they made their response on 19 January 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing information-sharing protocols and weekly meetings are considered appropriate for communication and management of complex safety concerns.
Stated by HM Prison and Probation ServiceExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Manchester South
Concerns raised1
Lack of a clear escalation process for omitted critical medicines
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 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
Lancashire Teaching Hospitals NHS Foundation Trust is the appropriate organisation to respond to concerns one to seven.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Cheshire
Concerns raised1
Failure of the electronic patient system to flag uncollected or undispensed medication for early identification of non-compliance
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
Investigate HJIS reporting functions to identify a mechanism for detecting non-collection of in-possession medicines.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 14 March 2024.
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 EnglandStated plannedThe respondent said that this action was planned when they made their response on 14 March 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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 EnglandDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
West Sussex, Brighton and Hove
Concerns raised1
Lack of guidance for monitoring self-administered medications not taken at dispensing
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 considers there is no ongoing patient-safety risk concerning medication administration.
Stated by University Hospitals Sussex NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Manchester South
Concerns raised1
Failure to ensure administration and escalation of missed antibiotic doses
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.
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
Audit omitted medication doses through pharmacy, ward quality-assurance and accreditation processes, reporting results and sharing learning for improvement.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 21 July 2023.
Action
Issue a staff poster explaining how to prevent medication omissions and obtain unavailable medicines.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 21 July 2023.
Action
Redesign the medication kardex to highlight time-critical medicines and streamline ward medication-ordering and emergency supply arrangements.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 21 July 2023.
Action
Provide each ward with an allocated pharmacist and pharmacy technician to review treatment sheets daily and support timely medication ordering.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 21 July 2023.
Action
Provide medication-omission induction and refresher training, with medication-management assessment for nurses new to the Trust.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 21 July 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
The concerns fall under the Trust’s remit rather than NHS England’s functions.
Stated by NHS EnglandOutside remitThe respondent said that this matter was outside its role or authority.
Position
The Trust is the appropriate organisation to respond, with the Greater Manchester Integrated Care Board responsible for commissioning.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
East London
Concerns raised1
Lack of electronic alerts escalating non-administration of prescribed anticoagulation medication to the medical team
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
Update Millennium training so multidisciplinary teams understand and use visual flags to prevent omission of critical medications.
Stated by Barts Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 18 July 2023.
Manchester South
Concerns raised1
Lack of a defined escalation process for refusal of medication and fluids
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.
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
Undertake an unannounced targeted inspection of Lisburne Court covering the concerns raised in the prevention of future death report.
Stated by Care Quality CommissionStated plannedThe respondent said that this action was planned when they made their response on 29 April 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Existing arrangements requiring contact with the GP provide the escalation route when care-home patients refuse medication or fluids.
Stated by NHS Greater Manchester Integrated Care BoardExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
When patients refuse prescribed medication or fluids, their GP should decide the appropriate next steps.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Norfolk
Concerns raised1
Failure to maintain a consistent and accessible medication-refusal procedure across Homes
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.3
Action
Amend the company-wide medication policy to require condition-specific escalation after the first refusal and define emergency responses and generic-medication escalation.
Stated by Crystal Care Norfolk LtdStated completedThe respondent said that this action was complete when they made their response on 23 August 2019.
Action
Introduce medication-refusal quick-reference reminders attached to medication administration records across all homes.
Stated by Crystal Care Norfolk LtdStated completedThe respondent said that this action was complete when they made their response on 23 August 2019.
Action
Create a transfer and unfamiliar-staff checklist requiring policy familiarisation, signatures, allocated reading time and a named mentor.
Stated by Crystal Care Norfolk LtdStated completedThe respondent said that this action was complete when they made their response on 23 August 2019.
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Includes dedicated processes for identifying, recording, monitoring and escalating prescribed medication doses that patients do not take, including self-administered medication not taken at dispensing and medication refusal or omission procedures where the failure can leave treatment interruption or associated risk unmanaged.
