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Patient Safety Learning

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  1. Patient Safety Learning
    Paramedics and A&E doctors often miss signs of sepsis and two of the four ways health professionals screen for the killer condition do not work, a new study claims.
    Doctors, NHS bosses and health charities have been concerned for years that too many cases of sepsis go undiagnosed, leaving people badly damaged or dead, because sepsis is so hard to detect.
    Unless a patient is diagnosed quickly, their body’s immune system goes into overdrive in response to an infection and then attacks vital tissues and organs. If left untreated, sepsis can cause shock, organ failure and death.
    Research from Germany, presented at this week’s European Emergency Medicine Congress in Barcelona, claims to have uncovered significant flaws in two of the four screening tools that health workers use worldwide to identify cases of the life-threatening illness.
    The four systems are NEWS2 (National Early Warning Score), qSOFA (quick Sequential Organ Failure Assessment), MEWS (Modified Early Warning Score) and SIRS (Systemic Inflammatory Response Syndrome).
    The researchers analysed records of the care given to 221,429 patients in Germany who were treated by emergency health workers outside hospital settings in 2016.
    “Only one of four screening tools had a reasonably accurate prediction rate for sepsis – NEWS2. It was able to correctly predict 72.2% of all sepsis cases and correctly identified 81.4% of negative, non-septic cases,” they concluded.
    NHS England stressed that it already deploys NEWS2, which emerged as the best system.
    An NHS spokesperson said: “This study shows the NHS actually is using the best screening tool available for detecting sepsis – NEWS2 – and as professional guidance for doctors in England sets out, it is essential that any patient’s wishes to seek a second opinion are respected.”
    Read full story
    Source: Guardian, 20 September 2023
  2. Patient Safety Learning
    The NHS has declared 22 ‘critical incidents’ due to disruption caused by industrial action since December, including having to transfer critical care patients, according to the Department for Health and Social Care.
    Critical care and gynaecology patients have had to be moved to other hospitals due to staffing shortages, urgent cancer surgery and chemotherapy appointments have had to be rescheduled and urgent surgery on trauma patients “could not go ahead” during critical incidents declared in periods of strike action since December, the Department of Health and Social Care said.
    There have been strikes by both doctors and Agenda for Change staff over pay during 2023, and Wednesday sees junior doctors and medical consultants strike on the same day for the first time.
    The DHSC has not previously revealed critical incidents caused by strikes, nor details of them. Trusts typically have different triggers for declaring critical incidents, but they indicate severe strain on services, and it is not unusual for them to happen during high winter pressures. 
    Read full story (paywalled)
    Source: HSJ, 20 September 2023
  3. Patient Safety Learning
    Patients with Parkinson’s disease are being put at risk when they have spells in hospital due to a lack of timely medication, according to a new report.
    Some 58% of people with Parkinson’s disease who were admitted to hospital in England last year said that they did not receive their medication on time during their stay.
    Parkinson’s UK said that medication for people with the condition is “time critical” and a delay of 30 minutes can mean the difference between functioning well and being unable to move, walk, talk or swallow.
    The charity also conducted freedom of information requests on English hospitals and found that one in four (26%) NHS trusts do not have policies that allow people with Parkinson’s to take their own medication in hospitals.
    Only half (52%) require staff responsible for prescribing and administering medication to have training on time critical medication, the charity found.
    Parkinson’s UK has called for a number of measures to be put in place to make sure patients in hospital can get access to medications when needed including: ensuring there are medication self-administration policies for patients where it is safe to do so; more training for staff and better use of e-prescribing to keep on track of medication timings.
    Read full story
    Source: The Independent, 19 September 2023
  4. Patient Safety Learning
    The death of a mentally ill teenager who died after drinking an excessive amount of water was preventable, an investigation has found.
    The 18-year-old, known at Mr D, was being detained under the Mental Health Act at the time of his death.
    An inquiry by the Mental Welfare Commission said he had previously been treated for drinking too much water.
    It found several areas where a different course of action could have prevented his death.
    The teenager was admitted out-of-hours to an adult mental health service (AMHS) inpatient unit in a health board neighbouring his own on 5 December 2018 as there were no local beds available.
    This move was described in the report as a "high-risk action".
    On the evening of 7 December he suffered a seizure after drinking too much water and was transferred to intensive care. He died three days later from the consequences of water intoxication.
    Suzanne McGuinness, executive director (social work) at the Mental Welfare Commission, said: "This was a tragic death of a young man while he was being cared for in hospital.
    "We found that a more assertive approach to the treatment of Mr D's psychotic illness in the two years before his death was warranted. The risks associated with psychotic illness were not coherently managed."
    Read full story
    Source: BBC News, 21 September 2023
  5. Patient Safety Learning
    A mental health provider has apologised after telling a whistleblower he was being declined treatment due to an employment tribunal he had brought against a neighbouring trust.
    Andrew Wardley was among a group of staff who raised concerns over a major research project at The Christie, a prominent cancer trust in Greater Manchester.
    Dr Wardley, a leading oncologist, has claimed he was sidelined and effectively bullied out after raising legitimate concerns. He has brought an employment tribunal against the specialist trust.
    The ongoing case has caused him severe stress and anxiety, prompting him to seek psychological treatment with South West Yorkshire Partnership Foundation Trust, which runs services near his home in Huddersfield.
    He told HSJ an initial phone conversation with trust staff had been positive and ended with an agreement he would benefit from treatment with the Improving Access to Psychological Therapies team.
    But he subsequently received a letter from the trust, which said: “Given the ongoing litigation IAPT would not be in a position to offer any therapy".
    Read full story (paywalled)
    Source: HSJ, 20 September 2023
  6. Patient Safety Learning
    NHS England’s national mental health director admitted she was ‘concerned’ that 20% of mental health nurse roles were unfilled and about the impact this could have on a nationwide push to improve safety and tackle closed cultures.
    Claire Murdoch was speaking to HSJ a year on from a series of high-profile documentaries exposing abuse and poor care at mental health trusts. In their wake, Ms Murdoch urged providers to urgently review safeguarding, while a separate three-year quality programme was also launched to look at closed cultures and improve safety.
    Now in the middle of that programme, Ms Murdoch stressed that stability in staffing is “vital” to developing safe and therapeutic care, but that many services across the country are struggling with significant nursing vacancies. 
    She said: “The bit that absolutely we need to acknowledge [around changing cultures] is there are some significant workforce and staffing challenges, which I’m concerned about, with a 20%t vacancy of qualified registered mental health nurses nationally.
    “There are new support roles, psychology assistant roles, physician associates – there are all sorts coming into being in inpatient care, but a lot of services are still struggling with staffing".
    Read full story (paywalled)
    Source: HSJ, 21 September 2023
  7. Patient Safety Learning
    The US Food and Drug Administration (FDA) has sent warning letters to pharmacy chains Walgreens and CVS accusing them of illegally marketing eye care products.
    The FDA’s warning letters said the products in question, which were falsely labelled as potential treatments for conditions like glaucoma, cataracts, and pink eye, should be modified if the companies and manufacturers that make and distribute them want to avoid legal action.
    “The FDA is committed to ensuring the medicines Americans take are safe, effective and of high quality,” Jill Furman, Director of the Office of Compliance at the FDA’s Center for Drug Evaluation and Research, said in a statement. “When we identify illegally marketed, unapproved drugs and lapses in drug quality that pose potential risks, the FDA works to notify the companies involved of the violations.”
    Ms Furman wrote in the letter sent to Walgreens: “Your ‘Walgreens Allergy Eye Drops,’ ‘Walgreens Stye Eye Drops,’ and ‘Walgreens Pink Eye Drops’ products are especially concerning from a public health perspective. Ophthalmic drug products, which are intended for administration into the eyes … pose a greater risk of harm to users because the route of administration for these products bypasses some of the body’s natural defences.”
    Read full story
    Source: The Independent, 21 September 2023
  8. Patient Safety Learning
    The family of a young trans woman who is believed to have taken her own life have said she was “failed by those tasked with her care”, as the coroner investigating her death described services for transgender people as “underfunded and insufficiently resourced”.
    Alice Litman had been waiting to receive gender-affirming healthcare for more than three years when she died in Brighton at the age of 20 in May 2022.
    Ahead of an inquest which began in Hove on Monday, her mother, Dr Caroline Litman, described Alice’s death as “preventable with access to the right support”.
    Adjourning the inquest on Wednesday to give a narrative conclusion in two weeks’ time, the coroner Sarah Clarke told the court: “It seems to me that all of these services are underfunded and insufficiently resourced for the level of need that the society we live in now presents".
    Describing the trans healthcare system as “not fit for purpose”, Alice's family, who are being supported by the Good Law Project, added: “We are grateful that the coroner has agreed that the conditions of Alice’s death warrant a report to prevent future deaths.”
    Read full story
    Source: The Guardian, 20 September 2023
  9. Patient Safety Learning
    Hospital bosses fear that further strikes by doctors will push the NHS “close to breaking point” as it struggles to cope with its winter crisis in the months ahead.
    NHS leaders are concerned that medics’ plans to continue their campaign of stoppages until February will make it even harder for the service to manage what is always its toughest period.
    Four days of strikes this week in England have included the first-ever 24-hour joint strike over pay on Wednesday by consultants and junior doctors. This latest series of stoppages – two days by consultants and three days by junior doctors – has forced hospitals to reschedule many thousands of outpatient appointments and non-urgent operations because of the lack of staff.
    “Winter pressures, respiratory illness and rising Covid again mean that the next six months will be exceptionally difficult. Winter always is,” said one hospital trust chief executive, who asked not to be named.
    “The NHS is effective at absorbing pressure but the industrial action may, at times, take us close to breaking point and often patient harm and the impact on NHS staff is not fully recognised,” he said.
    Read full story
    Source: The Guardian, 20 September 2023
  10. Patient Safety Learning
    Certain spina bifida-related surgeries remain suspended at Children's Health Ireland at Temple Street (CHI) for almost a year amid serious allegations that unlicensed devices made with non-medical parts have been implanted in child patients. In two cases where these devices were used, the implants had to be removed from patients after causing significant harm, while the efficacy of a third is yet to be determined.
    One senior member at the hospital has raised concerns about the number of repeat operations required on young spina bifida patients and associated rates of reinfection, with disquiet in the hospital eventually leading to first an internal review of operations in October 2022 and later an external probe by US clinicians.
    In June this year there were 287 children on waiting lists in Ireland for life-changing spinal surgery. Despite a commitment first given by then health minister Simon Harris in 2017 that no child would be on the waiting list for more than four months, there are still more than 120 children waiting more than a year for scoliosis surgery, according to the Ombudsman for Children.
    CHI has declined to comment on allegations that one of its surgeons has used the unlicensed, failed implants, as well as its decision to cease operations on spina bifida patients.
    Patient advocate Amanda Santry, who took part in the external review on behalf of Spina Bifida & Hydrocephalus Paediatric Advocacy, has said she has been denied access to the review findings and has also called for a “full investigation” into the allegations of the use of non-medical parts.
    Read full story
    Source: The Ditch, 15 September 2023
  11. Patient Safety Learning
    The BMA’s GP Committee (GPC) has demanded an investigation into the Government and NHS England’s ‘mismanagement’ of this year’s vaccination programmes.
    A motion was passed at the GPC England meeting today which called for a review of the ‘circumstances which led to muddled and mismanaged communications’ and for reflection on how to ‘prevent a repeat occurrence’.
    Last month, there was confusion over the start date for the adult flu and Covid vaccination programmes, which usually start in September.
    NHS England said the programmes would start in October this year – a move which the BMA said would cause ‘serious disruption’.
    But the Government then announced that vaccination will begin on 11 September, in what the BMA has called a ‘u-turn’, following the identification of a new Covid variant.
    GPs were asked to vaccinate ‘as many people as possible’ by the end of October.
    The GPC has said today that these ‘conflicting instructions’ led to confusion among GPs while also impacting on patient safety.
    Read full story
    Source: Pulse, 21 September 2023
  12. Patient Safety Learning
    People living with long Covid after being admitted to hospital are more likely to show some damage to major organs, according to a new study.
    MRI scans revealed patients were three times more likely to have some abnormalities in multiple organs such as the lungs, brain and kidneys.
    Researchers believe there is a link with the severity of the illness.
    It is hoped the UK study will help in the development of more effective treatments for Long Covid.
    The study, published in Lancet Respiratory Medicine, looked at 259 patients who fell so ill with the virus that they were admitted to hospital.
    Five months after they were discharged, MRI scans of their major organs showed some significant differences when compared to a group of 52 people who had never had Covid.
    The biggest impact was seen on the lungs, where the scans were 14 times more likely to show abnormalities.
    MRI scans were also three times more likely to show some abnormalities in the brain - and twice as likely in the kidneys - among people who had had severe Covid.
    Dr Betty Raman, from the University of Oxford and one of the lead investigators on the study, says it is clear that those living with long Covid symptoms are more likely to have experienced some organ damage.
    She said: "The patient's age, how severely ill they were with Covid, as well as if they had other illnesses at the same time, were all significant factors in whether or not we found damage to these important organs in the body."
    Read full story
    Source: BBC News, 23 September 2023
  13. Patient Safety Learning
    A trust chief executive has warned of a ‘really significant increase’ in patient anxiety and frustration created by the ongoing doctors’ strikes. 
    Lance McCarthy, the chief executive officer of Princess Alexandra Hospital Trust, made the comments during the most recent four-day junior doctors’ strike, which also coincided with two days of consultant strike action.
    The trust leader told Hertfordshire and West Essex integrated care board on Friday: “We shouldn’t underestimate the impact industrial action is having.”
    Mr McCarthy said this impact was not just confined to strike days but also affected the run-up and aftermath of each bout of industrial action. He said every series of strike days caused service disruption for at least another 72 hours. 
    He said: “We are seeing increasing frustration [from] our colleagues around it, because we are constantly duplicating work, cancelling patients, rebooking the same patients, etc.
    “We are [also] quite understandably starting to see in the last two months a really significant increase in anxiety and concern and frustration from our patients, who took it quite well the first couple of rounds but are understandably really frustrated. It is having a really significant impact.”
    In a further statement to HSJ, Mr McCarthy reiterated comments that trust staff had noticed an increase in anxiety, concern and frustration among both patients and colleagues in recent months. 
    Read full story (paywalled)
    Source: HSJ, 25 September 2023
  14. Patient Safety Learning
    A coroner has warned that a private hospital is relying on NHS ambulances to transport patients despite “being fully aware” of the pressures on the ambulance service and resulting delays.
    The warning came at the end of an inquest into a patient who died after a 14-hour wait for an ambulance to transfer him from the private Spire hospital in Norwich to the NHS-run Norfolk and Norwich university hospital a few minutes’ drive away. The last two years have seen a succession of inquests relating to ambulance delays. But in the latest case Jacqueline Lake, senior coroner for Norfolk, expressed concerns over Spire hospital’s use of NHS ambulances when complications and emergencies mean its patients need NHS care.
    “Spire Norwich hospital does not deal with multi-disciplinary and emergency treatment at its hospital and transfers patients requiring such treatment to local acute trusts, usually the Norfolk and Norwich university hospital,” Lake wrote in a prevention of future deaths (PFD) report. “Spire Norwich hospital continues to rely on EEAST [East of England Ambulance Service NHS Trust] to transport such patients to the acute hospital, being fully aware of the demands placed on the EEAST generally and the delays which occur as a result.”
    Research suggests that nearly 600 patients were urgently transferred from private healthcare to NHS emergency care in the year to June 2021 across the UK – around one in a thousand private healthcare patients. But previous analysis by the Centre for Health and the Public Interest (CHPI) thinktank found that some private hospitals were transferring more than one in every 250 of their inpatients to NHS hospitals.
    ‘“Transferring unwell patients from a private hospital to an NHS hospital is a known patient safety risk which all patients treated in the private sector face – including the increased numbers of NHS patients who are now being treated in private hospitals because of government policy,” said David Rowland, director of the CHPI. “And despite numerous tragedies and despite the fact that politicians and regulators are fully aware of this risk, nothing has been done to address it.”
    Read full story
    Source: The Guardian, 23 September 2023
  15. Patient Safety Learning
    A hospital trust failed to send out 24,000 letters from senior doctors to patients and their GPs after they became lost in a new computer system, the BBC has learned.
    Newcastle Hospitals warned the problem, dating back to 2018, is significant.
    The BBC has been told the problems occurred when letters requiring sign-off from a senior doctor were placed into a folder few staff knew existed.
    The healthcare regulator has sought urgent assurances over patient safety.
    Most of the letters explain what should happen when patients are discharged from hospital. But a significant number of the unsent letters are written by specialist clinics spelling out care that is needed for patients. It means that some crucial tests and results may have been missed by patients.
    Staff have been told to record any resulting incidents of patient harm and ensure these are addressed.
    Following a routine inspection by the regulator - the Care Quality Commission (CQC) - in the summer, staff at the trust raised concerns about delays in sending out correspondence.
    A subsequent review of the trust's consultants revealed that most had unsent letters in their electronic records.
    Read full story
    Source: BBC News, 26 September 2023
  16. Patient Safety Learning
    Thousands of people with asthma and other lung problems are going undiagnosed because most GPs in England do not offer tests for them, according to a new report.
    The failure to diagnose and start treating people with breathing problems threatens to create “a deluge of hospital admissions this winter” when the NHS is under intense pressure.
    Sarah Woolnough, the chief executive of charity Asthma and Lung UK, said: “The abysmal lack of testing and patchy basic care is causing avoidable harm to people with lung conditions and the NHS.”
    The report, which the Charity Commissioned from consultants PricewaterhouseCoopers, found that most GP surgeries in England do not provide basic lung function tests.
    Patients’ inability to access a test to check if they have asthma or chronic obstructive pulmonary disease (COPD) represents a “crisis in care” that could lead to many being hospitalised this winter “as respiratory viruses take hold and people struggle to heat their homes”, Asthma and Lung UK added.
    Read full story
    Source: The Guardian, 26 September 2023
  17. Patient Safety Learning
    Police forces in parts of the UK have stopped answering urgent calls related to mental health even before alternative support is available to people, under a policy designed to free up officers’ time, MPs were told last week.
    The move means many vulnerable people are being left without help in areas where the necessary services and arrangements with other agencies are not yet in place, warned Sarah Hughes, chief executive of the mental health charity Mind.
    Giving evidence to the House of Commons health select committee on Tuesday 19 September, Hughes said, “We know of local Mind and local trust partners who are already experiencing people having no response because the police are saying they no longer respond to mental health calls.”
    The policy, Right Care, Right Person, which was developed by Humberside Police over nearly three years, is being rolled out in England and Wales from the end of October at varying speeds. Backed by the government and police representative bodies, it aims to ensure that patients in a mental health crisis are treated by the most appropriate agency, rather than have police act as default responder, when they may not be best suited to help.
    But the Royal College of Psychiatrists is among the organisations to have raised concerns over the levels of preparation and resourcing for the policy and the absence of evaluation of clinical outcomes or benefits and harms to the population.
    Read full story (paywalled)
    Source: BMJ, 25 September 2023
  18. Patient Safety Learning
    MSPs are set to vote on a new law to establish a patient safety commissioner.
    The bill to create an "independent public advocate" for patients will go through its final stage on Wednesday.
    Public Health Minister Jenny Minto has said the commissioner would be able to challenge the healthcare system and ensure patient voices were heard.
    The Scottish government has been told the new watchdog must have the power to prevent future scandals.
    In 2020, former UK Health Minister Baroness Julia Cumberlege published a review into the safety of medicines and medical devices like Primodos, transvaginal mesh and the epilepsy drug sodium valproate.
    She told the House of Lords: "Warnings ignored. Patients' concerns ignored. A system that seemed unwilling or unable to listen let alone respond, unwilling or unable to stop the harm."
    Her findings led to the recommendation for a patient safety commissioner.
    Speaking ahead of the vote on the Patient Safety Commissioner for Scotland Bill, Ms Minto said the watchdog would listen to patients' views.
    "I think it's a really important role for us to have in Scotland," she said.
    "There's been a number of inquiries or situations where the patient's voice really needs to be listened to and that's what a patient safety commissioner will do."
    Read full story
    Source: BBC News, 27 September 2023
  19. Patient Safety Learning
    Health experts are calling for a “feminist approach” to cancer to eliminate inequalities, as research reveals 800,000 women worldwide are dying needlessly every year because they are denied optimal care.
    Cancer is one of the biggest killers of women and ranks in their top three causes of premature deaths in almost every country on every continent.
    But gender inequality and discrimination are reducing women’s opportunities to avoid cancer risks and impeding their ability to get a timely diagnosis and quality care, according to a new Lancet Commission on women, power and cancer.
    The largest report of its kind, which studied women and cancer in 185 countries, found unequal power dynamics across society globally were having “resounding negative impacts” on how women experience cancer prevention and treatment.
    Gender inequalities are also hindering women’s professional advancement as leaders in cancer research, practice and policymaking, which in turn perpetuates the lack of women-centred cancer prevention and care, the report adds.
    It is calling for a new feminist agenda for cancer care to eliminate gender inequality.
    Read full story
    Source: The Guardian, 26 September 2023
     
  20. Patient Safety Learning
    More than half of staff at a hospital trust that has been under fire for its "toxic culture" have said they felt bullied or harassed.
    The findings come from an independent review commissioned by University Hospitals Birmingham (UHB) NHS Trust.
    It has been at the centre of NHS scrutiny after a culture of fear was uncovered in a BBC Newsnight investigation.
    UHB has apologised for "unacceptable behaviours". It added it was committed to changing the working environment.
    Of 2,884 respondents to a staff survey, 53% said they had felt bullied or harassed at work, while only 16% believed their concerns would be taken up by their employer.
    Many said they were fearful to complain "as they believed it could worsen the situation," the review team found.
    Read full story
    Source: BBC News, 27 September 2023
  21. Patient Safety Learning
    Millions of people wrongly believe they are allergic to penicillin, which could mean they take longer to recover after an infection, pharmacists say.
    About four million people in the UK have the drug allergy on their medical record - but when tested, 90% of them are not allergic, research suggests.
    The Royal Pharmaceutical Society says many people confuse antibiotic side-effects with an allergic reaction.
    Common allergic symptoms include itchy skin, a raised rash and swelling. Nausea, breathlessness, coughing, diarrhoea and a runny nose are some of the others.
    But antibiotics, which treat bacterial infections, can themselves cause nausea or diarrhoea and the underlying infection can also lead to a rash.
    And this means people often mistakenly believe they are allergic to penicillin, which is in many good, common antibiotics.
    These are used to treat chest, skin and urinary tract infections - but if people are labelled allergic, they are given second-choice antibiotics, which can be less effective.
    Read full story
    Source: BBC News, 28 September 2023
  22. Patient Safety Learning
    Women have faced delays in giving birth due to the ongoing strikes, a major trust’s chief executive has said.
    Matthew Hopkins, who joined Mid and South Essex Foundation Trust last month, told a board meeting on Thursday that industrial action was having a “significant and growing” impact on patients.
    He added that this extended beyond delays to outpatient appointments and elective operations, saying: “It is also delaying mums giving birth, because we are seeing delays now in being able to conduct our elective Caesarian sections.”
    Mr Hopkins said the impact was also “really significant” on staff, with those covering for colleagues “very, very tired”.
    “It is important we give a very clear message to the two sides of the argument – government and the [British Medical Association] – that we need a light at the end of the tunnel, and staff need a light at the end of the tunnel.
    “Going into winter, with this continuing disruption for our patients and our staff, is in my view unacceptable.”
    Read full story (paywalled)
    Source: HSJ, 28 September 2023
  23. Patient Safety Learning
    The NHS has to train two GPs to produce one full-time family doctor because so many have started to work part-time, new research reveals.
    The finding helps explain why GP surgeries are still struggling to give patients appointments as quickly as they would like, despite growing numbers of doctors training to become a GP.
    The disclosure is contained in a report by the Nuffield Trust health thinktank that lays bare the large number of nurses, midwives and doctors who quit during their training or early in their careers.
    “These high dropout rates are in nobody’s interest,” said Dr Billy Palmer, a senior fellow at the thinktank and co-author of the report. “They’re wasteful for the taxpayer, often distressing for the students and staff who leave, stressful for the staff left behind, and ultimately erode the NHS’s ability to deliver safe and high-quality care.”
    Read full story
    Source: The Guardian, 28 September 2023
  24. Patient Safety Learning
    Prescribers should not start any new patients on some ADHD medicines because of a national shortage, the Department for Health and Social Care has warned.
    GPs are also being asked to identify and contact all patients currently prescribed the medicines to ensure they have supplies to last.
    A national patient safety alert said there were ‘supply disruptions’ of various strengths of methylphenidate, lisdexamfetamine and guanfacine.
    It follows a previous alert about shortages of atomoxetine capsules in August which is set to resolve next month, DHSC said.
    The shortages are due to a combination of manufacturing issues and an increased global demand, the alert explained.
    With the latest issues expected to continue to December for some medicines, new patients should not be started on the products affected by shortages until the supply issue resolves, the guidance sent to healthcare professionals said.
    Where patients do not have enough to last until the re-supply date – which differs depending on the medicine in question – GPs are being asked to contact pharmacies to find out about stocks and reach out to the patient’s specialist team for advice if a product cannot be sourced.
    Read full story
    Source: Pulse, 28 September 2023
  25. Patient Safety Learning
    An NHS hospital trust in Nottingham failed to send more than 400,000 digital letters and documents to GPs and patients, BBC News can reveal.
    A former employee has told of "a lack of responsibility" over a new computer system.
    Patient body Healthwatch said it was "deeply concerned" by the scale of the incident and the impact on care.
    The trust says a full investigation took place in 2017 and found no significant harm to patients.
    But it has now said it will carry out a review of that investigation and take any further action needed.
    The healthcare regulator the Care Quality Commission (CQC) said it was not aware of the incident and would be following up with the trust.
    This is the second major incident in England involving unsent NHS letters uncovered by the BBC recently.
    Read full story
    Source: BBC News, 30 September 2023

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