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Data updated 7 September 2026
Concerns 111
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Unsafe medication administration
115 reports 146 recipients
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Failure to identify clinically significant medication risks
54 reports 83 recipients
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Failure to secure and control medication
30 reports 55 recipients
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Unreliable medication dosage verification and communication
16 reports 23 recipients
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Incomplete medication safety guidance for prescribers
14 reports 29 recipients
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Unreliable medication management in care homes
11 reports 16 recipients
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Failure to ensure patients receive the correct prescribed medication at hospital discharge
13 reports 16 recipients
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Inadequate recording of medication prescribing decisions
28 reports 36 recipients
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Unreliable electronic medication-system controls for safe prescribing and administration
6 reports 13 recipients
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Inadequate safety warnings on medication packaging
5 reports 16 recipients
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Inadequate safeguards for medication-safety software overrides
2 reports 5 recipients
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Failure to provide timely clinical follow-up after medication prescribing
21 reports 29 recipients
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Failure to reassess safety risks during significant mental-health medication changes
3 reports 3 recipients
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Unreliable safety monitoring and guidance for clozapine treatment
17 reports 25 recipients
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Failure to apply overdose-risk safeguards to medication prescribing
12 reports 24 recipients
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Inadequate safeguards against misuse of medicines with abuse potential
14 reports 16 recipients
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Inadequate review of long-term medication use
14 reports 28 recipients
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Failure to reliably learn from medication incidents and implement safeguards
5 reports 10 recipients
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Unreliable communication of critical medication information to GPs
23 reports 41 recipients
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Unreliable medication reconciliation across care transitions
18 reports 34 recipients
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Unsafe medication prescribing
121 reports 177 recipients
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Failure to communicate clinically significant medication risks to patients
19 reports 34 recipients
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Unsafe prescribing for patients consuming excessive alcohol
4 reports 6 recipients
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Unreliable packaging and identification of dispensed medication
4 reports 13 recipients
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Unsafe medication management during hospital-to-care-home transitions
2 reports 3 recipients
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Unreliable safeguarding response to medication maladministration
3 reports 3 recipients
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Failure to prevent duplicate or discontinued medication prescriptions
10 reports 19 recipients
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Unsafe disposal of medication
6 reports 8 recipients
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Unreliable medication storage and access controls
2 reports 5 recipients
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Medication quantity controls failing to prevent unsafe access to excessive amounts
29 reports 42 recipients
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Failure to recognise medication-related pulmonary toxicity
3 reports 8 recipients
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Inadequate communication of opioid toxicity risks
4 reports 12 recipients
Reports 1,410
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Peter COLE · Prevention of Future Deaths report
Related indexed information (1) That repeat medication is not being adequately monitored, leading to many (often older and/or mentally infirm) patients building-up dangerous quantities of prescribed medication. (2) That the inadequate supervision of prescribed (repeat) medication is so widespread that the co... On 19/09/2019 I commenced an investigation into the death of.
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Juanita Boate Nti · Prevention of Future Deaths report
Related indexed information Failure of GP and pharmacist to communicate when prescription instructions are unclear or conflicting Failure to clearly record prescribed medication strength and administration volume Failure to identify conflicting medication concentration and specify administration volume before dispensing Failure t... Discuss liquid morphine safety with London.
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Mark Alan Smith · Prevention of Future Deaths report
Related indexed information It was conceded, accordingly, that there was - and remained - no policy or procedure in place to mitigate the clear risk involved in GPs prescribing unnecessarily excessive quantities of (potentially dangerous) prescription medication (at inappropriate frequency) to a clearly vulnerable cohort of patients, and therefore no policy or procedure is.
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Margaret Joy Daly · Prevention of Future Deaths report
Related indexed information On the 14th of June 2024 I commenced an investigation into the death of Margaret Joy Daly (DOB 23.10.32 DOD 10.6.24). Establish a prescribing safety process requiring access to patient notes, communication of falls risk, and escalation or assessment when safe prescribing is uncertain. Maintain a dedicated multidisciplinary... Roll out the.
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Judith Lesley Marshall · Prevention of Future Deaths report
Related indexed information (1) The Pharmacy’s Errors Book shows a number of drug errors (including higher or lower dose tablets and three wrong drugs) over a number of years. Establish a National Medication Safety Network and identify medication safety officers in large healthcare provider organisations, including community pharmacy companies. ...ghlight prescribing-error.
Recipients 50
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Medicines and Healthcare products Regulatory Agency
Medicines and medical devices regulator
79 reports Latest 1 Apr 2026
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UK Fatal Anaphylaxis Registry
1 report Latest 6 Apr 2023
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National Confidential Inquiry into Suicide and Safety in Mental Health
University research centre
1 report Latest 18 Mar 2022
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Greater Manchester Medicines Management Group
Health professional committee
2 reports Latest 20 Feb 2026
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Individual (care of Medical Protection Society)
1 report Latest 9 May 2018
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Hindley Health Centre Pharmacy
1 report Latest 17 Nov 2017
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UCB Pharma
1 report Latest 29 Apr 2014
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Mayday Healthcare plc
1 report Latest 17 Feb 2015
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Midway Pharmacy
1 report Latest 31 Dec 2024
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Adams Pharmacy
1 report Latest 27 Mar 2017