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Found 1,130 results
  1. News Article
    An Independent Patients' Commissioner is set to be appointed to act as champion for people who have been harmed by medicines or medical devices. Baroness Cumberlege, who recommended the new role in a landmark report earlier this year, announced that the government had budged on the issue after initial resistance. She welcomed the move saying: "Had there been a patient safety commissioner before now, much of the suffering we have witnessed could have been avoided." But she added "the risk still remains" and further urgent action is needed to protect patients from potentially harmful drugs." At an online meeting of parliamentarians, the baroness described the testimony of a victim of the medical device vaginal mesh, which has left some patients in chronic pain. The woman had told her review team: "This device took everything from me. My health, my life, my job, my dignity, my marriage, my freedom." Reflecting on this the baroness added: "The scale of suffering we witnessed means nothing short of profound change is necessary. Not necessary in a couple or three years, but necessary now." Read full story Source: Sky News, 16 December 2020
  2. News Article
    A community trust was told to urgently review prescribing of stimulant medications for children after concern that some were posted to families but never arrived. Bridgewater Community Healthcare Foundation Trust was told that sending prescriptions through the post may be a potentially unsafe practice by the Royal College of Paediatrics and Child Health. The warning came in a report from the college after it was invited by the trust to review its community paediatrics service The trust was urged to work with primary care and clinical commissioning groups to establish shared care for children who needed these medications. Stimulant medicines are often used for children with attention deficit hyperactivity disorder. The review also found there was a “a very significant risk for patient care” with letters, reports and prescriptions being delayed or going missing due to “recurrent issues” with the post in the building used by the team covering St Helen’s. It highlighted issues with the safeguarding procedures at the trust, with each locality team having its own processes and handling a small number of cases, and called for urgent work to streamline services. Read full story (paywalled) Source: HSJ, 11 November 2020
  3. News Article
    The Medicines and Healthcare products Regulatory Agency (MHRA) has received its one millionth Yellow Card. The Yellow Card scheme is the UK’s system for reporting suspected side effects to medicines and adverse events with medical devices. This major milestone coincides with the launch of the 5th annual #MedSafetyWeek (2-8 November), which highlights the value of the Yellow Card scheme to the nation’s health, and the importance of reporting suspected side effects from medicines. The MHRA has seen an increased rate of Yellow Card reports and would like to continue to encourage more reporting this #MedSafetyWeek. MedSafetyWeek is a global campaign, with over 70 countries participating, worldwide. This year, the theme is ‘every report counts’. The MHRA will be calling upon patients and carers, as well as healthcare professionals and their organisations to report suspected side effects from medicines. Reporting helps to identify new side effects, as well as unexpected and serious safety problems. It also adds to existing information about known effects. By reporting, patients and the public can help the safe use of medicines for everyone. Read press release Source: GOV.UK, 2 November 2020
  4. News Article
    The National Pharmacy Association (NPA) has asked community pharmacies to report all patient safety incidents despite growing work pressure due to a persisting virus pandemic. Since March, there has been a significant decrease in the number of patient safety incidents being reported, the NPA said in its medication safety update for the second quarter of 2020. Overall, there was a 44.5% decrease in the number of incidents reported during the second quarter of the year, compared to the first quarter of 2020. There was a 40.6% decrease in the number of patient safety incidents when compared to the same quarter in 2019. “This is a significant reduction in number of incidents being reported. This may be due to the increased workload and pressure on pharmacy teams due to COVID-19 pandemic, whereby pharmacy teams may not be prioritising reporting of patient safety incidents, or due to other, as yet unknown, reasons,” NPA said in its update. NPA advises community pharmacists to ensure that they report the actual degree of harm caused to the patient and not the potential harm that could have happened. The pharmacy body also suggested pharmacists should make sure that they complete a detailed outcome if an incident did lead to moderate or severe harm to the patient. This allows a thorough analysis to be undertaken by the NPA. Community pharmacists are also advised to ensure the incident form is fully completed, is accurate and includes sufficient details to allow meaningful analysis of the incident. Read full story Source: Pharmacy Business, 27 October 2020
  5. News Article
    A major acute trust has confirmed the health service inspectorate has begun a criminal investigation into three incidents at its hospitals. University Hospitals Birmingham FT told HSJ the Care Quality Commission (CQC) has started a criminal investigation into incidents involving potential errors around the provision of anti-coagulant medication. The trust received a letter from the CQC this month informing it that the regulator has begun the investigation under regulation 22 of the Health and Social Care Act 2008 (regulated activities) regulations 2014. The incidents happened at Queen Elizabeth Hospital in Birmingham and Good Hope Hospital — the trust’s two main sites. Regulation 22 says: “In order to safeguard the health, safety and welfare of service users, the registered person must take appropriate steps to ensure that, at all times, there are sufficient numbers of suitably qualified, skilled and experienced persons employed for the purposes of carrying on the regulated activity.” The CQC launched a prosecution into East Kent Hospitals University FT this month for failing to meet fundamental standards of care. The regulator also successfully prosecuted University Hospitals Plymouth Trust in September after it pleaded guilty to breaching the duty of candour. Read full story (paywalled) Source: HSJ, 23 October 2020
  6. News Article
    An independent review found that commissioners’ investigation of a young boy’s death was ‘mismanaged’, and heard allegations that the person who coordinated it was bullied over the contents. The independent review, commissioned by NHS England, has published its final report following an investigation into Bristol, North Somerset and South Gloucestershire clinical commissioning group’s LeDer review into the death of Oliver McGowan. Chaired by Fiona Ritchie, the independent review was commissioned last year after evidence emerged that the CCG had rewritten earlier findings of the review, removing suggestions his death at North Bristol Trust in 2016 was avoidable. Oliver died in November 2016 after being given anti-psychotic medication against his own and his parents’ wishes and despite medical records showing he had an intolerance to anti-psychotics. He developed severe brain swelling because of the drugs and died.A local LeDer review — part of a programme aimed at improving care based on deaths among people with learning disabilities — was launched in 2017, seven months after his death, by the CCG (then operating as three separate organisations), then published in 2018. In 2018, a coroner concluded Oliver’s care prior to his death was “appropriate” and made no recommendations. His death is also currently the subject of a police investigation. The lead reviewer (Ms A) stated in her panel interview that during the time she was undertaking this LeDeR she had felt bullied, overworked and overly stressed by the demands placed on her by the various correspondences with solicitors and her line management. The fact that Ms A believed she was isolated and unsupported during this review illustrates evident failures in the CCG assurance and management processes at the time. In a final report by the subsequent independent review, published today, the panel led by Ms Ritchie “unanimously” agreed Oliver’s death was “potentially avoidable”. Read full story (paywalled) Source HSJ, 20 October 2020
  7. News Article
    Patients have come to avoidable harm after a large private provider failed to deliver thousands of medicine prescriptions, according to a report from the Care Quality Commission. Healthcare at Home, which is based in Staffordshire but provides NHS-funded care and medicine supplies to patients’ homes across the country, has been rated “inadequate” and placed in special measures. A report published today said inspectors found more than 10,000 patients missed a dose of their medicine between October and December 2020 due to problems caused by the introduction of a new information system. Reviews have found some suffered avoidable harm as a result. Read full story (paywalled) Source: HSJ, 13 May 2021
  8. News Article
    A world-leading treatment that halves the risk of lung cancer patients suffering a return of the disease after undergoing treatment, is to be rolled out by NHS England. In a trial of the drug – the first of its kind – around nine out of ten patients treated, remained alive and disease-free after two years – compared to more than four in ten who hadn’t received the new therapy. Lung cancer is the most common cause of cancer death in the UK, accounting for one in five of all cancer deaths. Around 100 patients in England with a rare form of cancer will initially have access to the drug, called Osimertinib, with many more expected to benefit this year. Read full story Source: NHS England, 7 May 2021
  9. News Article
    Police are investigating allegations around the death of a patient who was under the care of Hertfordshire Partnership University Foundation Trust. The probe by Hertfordshire Constabulary relates to the case of Margaret Molyneux, 69, who according to a review by the trust’s commissioners, was prescribed doses of anti-psychotic medication which were significantly higher than recommended limits. Police said the investigation is ongoing and no arrests have been made. Ms Molyneux had been admitted to the trust’s mental health unit in Radlett in 2017, after which her physical health declined and she was admitted to Watford General Hospital with pneumonia and dysphagia, which relates to difficulties swallowing. She was discharged back to the Radlett unit, but died several weeks later at Watford General Hospital, after choking on her food and developing aspiration pneumonia. An inquest in February 2018 ruled she died from natural causes, but an investigation into her case commissioned by East and North Hertfordshire Clinical Commissioning Group, seen by HSJ, subsequently suggested high doses of Olanzapine, an anti-psychotic drug, were “likely to have at least contributed to some of the physical problems she experienced… including low blood pressure, falls and dysphagia”. Read full story (paywalled) Source: HSJ, 6 May 2021
  10. News Article
    Good quality evidence is urgently needed to inform doctors on how to discontinue antidepressants safely and effectively, a Cochrane review has highlighted. An international team of researchers assessed randomised controlled trials comparing approaches to discontinuation and continuation of antidepressants in patients who had used them for depression or anxiety for at least six months. But the team reached no firm conclusions about the effects and safety of the approaches reviewed because of the low certainty of evidence from the existing studies. Read full story (paywalled) Source: BMJ, 22 April 2021
  11. News Article
    An antiviral typically used to treat influenza is a “good contender” for a drug that could be taken at home by people infected with COVID-19, according to a scientist who is trialling the medicine. Favipiravir, licensed as a flu treatment in Japan since 2014, has already shown potential in reducing lung damage in hospitalised Covid patients and speeding up the time taken to clear the virus from the body. But two UK trials, in Glasgow and London, are investigating whether the drug could be taken by people in the community before their disease has progressed, therefore keeping them out of hospital. The government has promised to “supercharge” the search for and development of a new generation of easy-to-take, at-home drugs that can reduce transmission and quicken recovery from COVID-19. A new taskforce, modelled on the team behind Britain’s vaccine procurement programme, is to oversee this work. It intends to deliver two effective treatments - offered in tablet form - to the public as early as autumn. Read full story Source: The Independent, 22 April 2021
  12. News Article
    Patients have been significantly harmed, including suffering permanent damage to their liver, after being given accidental overdoses of paracetamol in hospital. The NHS safety watchdog the Healthcare Safety Investigation Branch (HSIB) has now launched a national investigation after a number of incidents where adults with a low bodyweight were given too much paracetamol through an infusion, or IV drip, directly into their bloodstream. The Independent understands there were three incidents reported by NHS staff in 2020 but there have been others in earlier years including the trigger event which sparked HSIB’s probe. Overdoses of IV paracetamol in both adults and children is a recurring problem. Safety alerts have been repeatedly issued to NHS hospitals over the problem, with one alert in 2010 highlighting more than 200 previous incidents of overdoses. In 2011 an inquiry into the death of 19-year-old Danielle Welsh, who died from liver failure due to a sustained paracetamol overdose in June 2008, found a junior doctor who prescribed the drug did not know she weighed only 35kg. The inquiry found: “There was a prevailing culture of assumed familiarity with the administration of IV paracetamol, a familiarity derived from the common use of oral paracetamol.” Now the independent Healthcare Safety Investigation Branch believes the problem of prescribing paracetamol without considering a patients’ weight is still going on. Read full story Source: The Independent, 19 April 2021
  13. News Article
    A cheap drug, commonly used to treat asthma, can help people at home recover more quickly from COVID-19, a UK trial has found. Two puffs of budesonide twice a day could benefit many over-50s with early symptoms around the world, said the University of Oxford research team. There are also early signs the drug could reduce hospital admissions. The NHS says it can now be prescribed by GPs to treat Covid on a case-by-case basis from today. At present, there are few options for treating people with Covid who are not in hospital, apart from paracetamol. This widely-available asthma drug works in the lungs, where coronavirus can do serious damage, and could improve the recovery of at-risk patients who are unwell with Covid at home. Prof Stephen Powis, national medical director of NHS England, said he was "delighted" by the trial results so far and he said GPs could prescribe it after "a shared decision conversation" with patients. Read full story Source: BBC News, 12 April 2021
  14. News Article
    Unpaid carers looking after terminally ill friends and relatives during the pandemic struggled to access pain relief, with some patients dying in unnecessary pain, a survey has found. The survey of 995 unpaid carers by Marie Curie also found people had difficulties getting personal care and respite nursing for loved ones. Figures show the number of people dying at home rose by 42% in the past year. Nearly two-thirds of carers surveyed by the charity said their loved one did not get all the pain relief they needed when they were dying. Susan Lowe, from Solihull, cared for her mother Sheila before she died with bowel cancer in April last year, aged 74. She said caring for her mum during lockdown was hard as "the system was just under so much pressure that we had to manage largely on our own". The public health worker says she struggled to get the right pain relief medication for her mother in her final weeks and spent hours travelling to different chemists. Susan, 50, told the BBC: "My biggest regret is that my mum died in pain - more pain than she needed to be. She really wanted to be comfortable at the end. She knew she was dying." "What she really wanted - and this is what she was assured would happen - was to be comfortable. She was told she would get the drugs that she needed for it to be as bearable as possible... I remember breaking down in tears a couple of times in the pharmacy when I was told the medication mum needed wasn't in stock." Read full story Source: BBC News, 8 April 2021
  15. News Article
    Doctors ignored the concerns of a seriously ill girl's parents before reducing her pain medication, an inquest has heard. Melody Driscoll, from Croydon, died aged 11 at King's College Hospital (KCH) in July 2018. Her mother Karina Driscoll and stepfather Nigel alleged the actions of KCH reduced Melody's quality of life. She told Southwark Coroner's Court that a reduction in painkillers also contributed to her daughter's death. The family had been in dispute with KCH over the treatment given to Melody, who had several conditions including Rett syndrome, a rare and life-limiting genetic disorder that causes mental and physical disability. Doctors wanted to wean Melody off painkillers, but her parents objected because the plan went against the treatment regime she had previously been prescribed at Great Ormond Street Hospital (GOSH). The court heard Melody suffered from very severe pain, requiring continuous relief, including morphine, for much of her life. In a written statement read out by barrister Patricia Woodcock QC, Mrs Driscoll said although her daughter could not speak, she made recognisable signs when she was in pain, including tensing her muscles. However, she claimed staff at KCH had a "we know best attitude" and did not listen to her concerns. "I would say that KCH took a very negative view about Melody, and us as a family, from an early age and, for example, started to believe that Melody's pain behaviours were not in fact expressions of pain but her simply 'acting out'," Mrs Driscoll said. Read full story Source: BBC News, 22 March 2021
  16. News Article
    More than a dozen NHS patients have stopped breathing and 40 others suffered serious effects after having powerful anaesthetic drugs mistakenly “flushed” into their systems by unsuspecting NHS staff. In one case a man has been left suffering nightmares and flashbacks after he stopped breathing on a ward when a powerful muscle relaxant used during an earlier procedure paralysed him but left him fully conscious. He only survived because a doctor was on the ward and started mechanically breathing for him. An investigation by the safety watchdog, the Healthcare Safety Investigation Branch (HSIB), found there had been 58 similar incidents in England during a three-year period. The mistakes happen when residual amounts of drugs are left in intravenous lines and cannulas and not “flushed” out after the surgery. When the IV lines are used later by other staff the residual drugs can have a debilitating effect on patients. In a new report HSIB said flushing intravenous lines to remove powerful drugs was a “safety-critical” task but that the process for checking this had been done was not being properly carried out, posing a life-threatening risk to patients. It said the use of a checklist by anaesthetic staff can be overlooked when doctors are busy with other tasks and they fail to engage with the process. Read full story Source: The Independent, 4 March 2021
  17. News Article
    Pregabalin may be associated with serious breathing problems in patients with compromised respiratory systems, according to a drug safety alert from the medicines regulator. Elderly patients, patients with neurological disease, renal impairment and those who are taking antidepressant medication are also at increased risk of breathing problems from the drug, the Medicines Healthcare Regulatory Agency (MHRA) said (18 February). Pregabalin is a medication that has increasingly been prescribed to treat chronic pain, however, it is also used to treat epilepsy, fibromyalgia, restless leg syndrome, and generalised anxiety disorder. The use of pregabalin combined with central nervous system depressants such as opioids has been associated with an increased risk of respiratory failure, coma, and deaths since 2018, said the MHRA. However, a recent review of the safety of the drug has found that the use of pregabalin alone can also cause ‘severe’ respiratory depression. "The review identified a small number of worldwide cases of respiratory depression without an alternative cause or underlying medical conditions. In these cases, respiratory depression had a temporal relationship with the initiation of pregabalin or dose increase. Other cases were noted in patients with risk factors or underlying medical history. The majority of cases reviewed were reported in elderly patients," the alert said. Health professionals have been advised to consider adjustments in dose or dosing regimen are necessary for patients at higher risk of respiratory depression. The alert also told them to report suspected adverse drug reactions associated with the use of pregabalin via the Yellow Card website. Existing advice asks healthcare professionals to check the patient for a history of drug abuse before prescribing pregabalin and to observe patients who have been prescribed the drug for signs of drug abuse and dependence. Read full story Source: Pulse, 23 February 2021
  18. News Article
    Relatives of patients who died after receiving "dangerous" levels of painkillers at Gosport War Memorial Hospital have called for new inquests. An inquiry found 456 patients died after being given opiate drugs at the hospital between 1987 and 2001, but no charges have ever been brought. Four families told the BBC they have requested judge-led "Hillsborough-style" hearings with a jury. The Attorney General's Office said it was reviewing the application. Police began a fresh inquiry in 2019 into 700 deaths after the Gosport Independent Review Panel found there was a "disregard for human life" at the hospital in Hampshire. Coroner-led inquests in 2009 found drugs administered at the hospital contributed to five deaths. However, lawyers representing some of the families told the BBC more wide-ranging inquests similar to those that examined the events of the Hillsborough disaster should be undertaken. Read full story Source: BBC News, 5 February 2021
  19. News Article
    Thousands of women living in the UK suffering from an aggressive type of breast cancer could be helped by a newly identified drug, according to a study. The research, carried out by The Institute of Cancer Research, found medicine presently used to help other breast cancers that have spread to another area of the body, could actually be utilised to help around a fifth of women who have triple negative breast cancer. Around 55,000 women are diagnosed with breast cancer in Britain each year, with approximately one in five of these being triple negative. Younger women and black women are more likely to develop this form of breast cancer which is generally more aggressive. Researchers’ realisation the drug palbociclib could be used far more widely than previously thought could “provide a much-needed targeted treatment” for those who are at higher risk of witnessing their cancer spread more quickly, becoming incurable and often unresponsive to conventional chemotherapy. Dr Simon Vincent, of Breast Cancer Now, a leading charity which funded the study, said: “It’s hugely exciting that this research has uncovered a new possible use for palbociclib as a targeted treatment for some women living with triple negative breast cancer." Read full story Source: The Independent, 28 January 2021
  20. News Article
    The Healthcare Safety Investigation Branch (HSIB) has launched an investigation into the risks involved in prescribing, dispensing and administering medicines to children. The investigation was triggered after HSIB was notified of an incident including a child aged four years, who, after being diagnosed with a blood clot in her leg following a surgical procedure, received ten times the intended dose of anticoagulant on five separate occasions, over three days. This, HSIB said, was owing to errors that occurred during the prescription, dispensing and administration processes. The errors resulted in the child being admitted to the paediatric intensive care unit, with evidence of a bleed in her brain, where she stayed for three months until she was discharged with an ongoing care plan. HSIB said that studies showed that prescribing errors were the most frequent type of medication error in children’s inpatient settings. The investigation will look at this and other incidents to examine the role of multidisciplinary teamworking and checking in medication errors, as well as considering the risks associated with the implementation of electronic prescribing and medication administration (ePMA) systems in clinical areas using weight-based paediatric prescribing. “‘Wrong dose’ errors are a particular risk in children’s wards,” said Alice Oborne, consultant pharmacist in safe medication practice and medicines safety officer at Guy’s and St Thomas’ NHS Foundation Trust. Read full story Source: The Pharmaceutical Journal, 26 January 2021
  21. News Article
    A new state of the art institute for antimicrobial research is to open at Oxford University thanks to a £100 million donation from Ineos. Ineos, one of the world’s largest manufacturing companies, and the University of Oxford are launching a new world-leading institute to combat the growing global issue of antimicrobial resistance (AMR), which currently causes an estimated 1.5 million excess deaths each year- and could cause over 10m deaths per year by 2050. Predicted to also create a global economic toll of $100 trillion by mid-century, it is arguably the greatest economic and healthcare challenge facing the world post-Covid. It is bacterial resistance, caused by overuse and misuse of antibiotics, which arguably poses the broadest threat to global populations. The world is fast running out of effective antibiotics as bacteria evolve to develop resistance to our taken-for-granted treatments. Without urgent collaborative action to prevent common microbes becoming multi-drug resistant (commonly known as ‘superbugs’), we could return to a world where taken-for-granted treatments such as chemotherapy and hip replacements could become too risky, childbirth becomes extremely dangerous, and even a basic scratch could kill. The rapid progression of antibacterial resistance is a natural process, exacerbated by significant overuse and misuse of antibiotics not only in human populations but especially in agriculture. Meanwhile, the field of new drug discovery has attracted insufficient scientific interest and funding in recent decades meaning no new antibiotics have been successfully developed since the 1980s. Alongside its drug discovery work, the IOI intends to partner with other global leaders in the field of Antimicrobial Resistance (AMR) to raise awareness and promote responsible use of antimicrobial drugs. The academic team will contribute to research on the type and extent of drug resistant microbes across the world, and critically, will seek to attract and train the brightest minds in science to tackle this ‘silent pandemic’. Read full story Source: University of Oxford, 19 January 2021
  22. News Article
    In July last year, the Independent Medicines and Medical Devices Safety Review – chaired by Baroness Cumberlege— published its landmark report, First Do No Harm. It followed a two-year review of harrowing patient testimony and a large volume of other evidence concerning three medical interventions: Primodos, sodium valproate and pelvic mesh. Yesterday, in a written statement to Parliament, the Minister for Patient Safety, Suicide Prevention and Mental Health, Nadine Dorries, gave an update on the government’s response to the recommendations of the Cumberlege Review. In an article in The Times today, Baroness Cumberlege welcomes that the government has now accepted the need for a patient safety commissioner for England and the amendment to the Medicines and Medical Devices Bill, which is being considered in the House of Lords today, which she hopes "will swiftly become law". However, she also states that "... a full response to the review's is still outstanding 6 months after publication. Action is urgently needed to ensure we help those who have already suffered and reduce the risk of harm to patients in future". Read full story (paywalled) Source: The Times, 12 January 2021
  23. News Article
    The first new sickle-cell treatment in 20 years will help keep thousands of people out of hospital over the next three years, NHS England has said. Sickle-cell disease is incurable and affects 15,000 people in the UK. And the National Institute for Health and Care Excellence said the hope of reducing health inequalities for black people, who are predominantly affected and often have poorer health to start with, made the drug worth recommending. It called it "an innovative treatment". Read full story Source: BBC News, 5 October 2021
  24. News Article
    Many patients are being prescribed unnecessary and even harmful treatments, a new report warns. The review, in England, suggests one-tenth of items dispensed by primary care are inappropriate or could be changed. Around 15% of people take five or more medicines a day - some are to deal with the side-effects of the others. The government is appointing a prescribing tsar to help with the issue and stop waste. Overprescribing can happen when: a better alternative is available but not given the medicine is appropriate for a condition but not the individual patient a condition changes and the medicine is no longer appropriate the patient no longer needs the medicine but continues to be prescribed it. Chief pharmaceutical officer for England, Dr Keith Ridge, said: "Medicines do people a lot of good and this report is absolutely not about taking treatment or services away from people where they are effective. But medicines can also cause harm and can be wasted." Read full story Source: BBC News, 22 September 2021
  25. News Article
    The use of opioids for pain relief soared during the pandemic as some patients waited longer for surgery, according to new research. The University of Aberdeen team focused on more than 450 patients due to have hip or knee replacement surgery. They said waiting times for these procedures increased by an average of 90 days and that the numbers of patients using opioids while waiting for surgery increased by 40% compared to pre-pandemic levels. The research, published in the BMJ Quality and Safety, looked at data collected from 452 NHS patients from the north east of Scotland. The university's Luke Farrow, who led the research, said alternative ways of managing severe arthritis pain needed to be found "urgently" for those waiting for this kind of surgery. Read full story Source: BBC News, 15 November 2021
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