Regulator patient safety alerts
Lack of clear responsibility for regulators (e.g., CQC) to review decisions not to comply with patient safety alerts.
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
Inquiry recommendation
100match
F41 - Use of information about compliance by regulator from: Patient safety alerts
The Care Quality Commission should have a clear responsibility to review decisions not to comply with patient safety alerts and to oversee the effectiveness of any action required to implement them. Information-sharing with the Care Quality Commission regarding patient safety alerts should continue following the transfer of the National Patient Safety Agency's functions in June 2012 to the...
Matched on
terms: alert, patient, regulator, safety
Inquiry recommendation
90match
11 - Regulatory system patient safety priority
We recommend that the government should ensure that the current system of regulation and the collaboration of the regulators serves patient safety as the top priority, given the ineffectiveness of the system identified in this Inquiry.
Matched on
terms: patient, regulator, safety
Committee recommendation
90match
#8 - Set out impact of Patient Safety Alerts on private prescribing and enforcement measures.
In their response to this report, the Government should set out what impact it believes National Patient Safety Alerts have on private prescribing and what scrutiny and enforcement measures are in place to ensure private prescribers adhere to these alerts.
Matched on
terms: alert, patient, safety
Inquiry recommendation
86match
F100 - National Patient Safety Agency functions
Individual reports of serious incidents which have not been otherwise reported should be shared with a regulator for investigation, as the receipt of such a report may be evidence that the mandatory system has not been complied with.
Matched on
terms: patient, regulator, safety
Inquiry recommendation
78match
BRIS-111 - Require National Patient Safety Agency to inform trusts and publish reports
The National Patient Safety Agency, in the exercise of its function of surveillance of sentinel events, should be required to inform all trusts of the need for immediate action, in the light of occurrences reported to it. The Agency should also be required to publish regular reports on patterns of sentinel events and proposed remedial actions.
Matched on
terms: patient, safety
PFD report
77match
Patrick Moran
An insulin overdose occurred due to the common practice of using incorrect syringes, exacerbated by the removal of diabetes from mandatory training and the lack of a system to review compliance with safety alerts.
Matched on
terms: alert, safety
PFD report
69match
Venetia Pierce
An EMIS system failed to flag a nitrofurantoin safety alert because it only triggered for pre-existing conditions, alongside generally low clinician awareness of the drug's pulmonary risks in the elderly.
Matched on
terms: alert, safety
Inquiry recommendation
68match
F32 - Interim measures
Where patient safety is believed on reasonable grounds to be at risk, Monitor and any other regulator should be obliged to take whatever action within their powers is necessary to protect patient safety. Such action should include, where necessary, temporary measures to ensure such protection while any investigation required to make a final determination is undertaken.
Matched on
terms: patient, regulator, safety
PFD report
65match
Roy Millar
Ward administrators in the Neurology Department were unaware of their responsibility to book follow-up appointments, leading to a large number of patients, including the deceased, not having appointments booked; a review revealed 146 patients did not have follow-up appointments booked.
Matched on
terms: patient
PFD report
65match
Aviva Otte, Oscar Barker and Yousef Al-Kharboush
A lack of clear reporting requirements for section 10 exempt entities regarding adverse events prevents crucial findings from being shared with regulatory bodies, other trusts, or the wider industry.
Matched on
terms: regulator
Inquiry recommendation
64match
F107 - Sharing concerns
If the Health Protection Agency or its successor, or the relevant local director of public health or equivalent official, becomes concerned that a provider's management of healthcare associated infections is or may be inadequate to provide sufficient protection of patients or public safety, they should immediately inform all responsible commissioners, including the relevant regional office of the NHS...
Matched on
terms: patient, safety
PFD report
61match
Daniel Paylor
Ambulance services exhibit inadequate regulatory control, safeguards, and auditing for drugs compared to hospitals, lacking sufficient peer supervision and requiring only single-person authority for drug access.
Matched on
terms: regulator
PFD report
61match
Pauline Taylor
Emollient creams with paraffin pose an unrecognised fire hazard due to inadequate warnings and lack of awareness, alongside insufficient patient risk assessments.
Matched on
terms: patient
PFD report
61match
Beryl Holland
Inconsistent hospital policies and a lack of national guidance for managing pressure ulcer risks in Emergency Departments led to prolonged waits and inadequate care for vulnerable patients.
Matched on
terms: patient
PFD report
61match
Robert Stevenson
Prescribing doctors may be unaware of a rare potential link between Ciprofloxacin/Quinolone antibiotics and suicidal behaviour, especially in depressed patients. Guidelines should be reviewed to increase awareness and mitigate this risk.
Matched on
terms: patient
PFD report
61match
Dominic Philip
The hospital lacked pre-screening for contrast allergies, and Lidocaine was inexplicably present in an allergic patient, raising concerns about medication contamination or poor stock control.
Matched on
terms: patient
Committee recommendation
60match
#9 - Fourth Report - The safety of maternity services in England
We recommend that a single set of stretching safety training targets should be established by the Maternity Transformation Programme board, working in conjunction with the Royal Colleges and the Care Quality Commission. Those targets should be enforced by NHSE&I’s Maternity Transformation Programme, the Royal College of Midwives, the Royal College of Obstetricians and Gynaecologists and the Care Quality...
Matched on
terms: patient, safety
PFD report
57match
Russell James Felstead
Doctors failed to access and read vital medical information within nursing notes, resulting in a four-day delay in ordering an urgent CT scan for the patient.
Matched on
terms: patient
PFD report
57match
Ozan Atasoy
A detained patient repeatedly absconded from a psychiatric unit's smoking area, often while escorted, indicating insufficient supervision and inadequate security protocols.
Matched on
terms: patient
PFD report
57match
George Stone
National guidelines for antidepressant warnings, specifically for Venlafaxine, fail to include the rare but severe risk of seizures, potentially leaving patients uninformed about a critical side effect.
Matched on
terms: patient
PFD report
57match
James Hedge
Insulin pump guidance inadequately highlights misuse dangers from incorrect cartridge insertion, and patient education fails to emphasize the rapid life-threatening nature of hyperglycaemia.
Matched on
terms: patient
PFD report
57match
Oli Hoque
The MHRA's inability to compel timely clinical data hinders robust safety investigations into potential vaccine adverse events, impacting public interest in drug safety.
Matched on
terms: safety
Committee recommendation
56match
#10 - Legislative changes necessary to address remediation barriers and strengthen freeholder enforcement.
Addressing some of these barriers will require legislative changes, for example, creating new obligations on landlords to remediate, and new enforcement powers for regulators to compel remediation or impose penalties. The Plan did not mention other barriers to pace highlighted by the NAO, such as the affordability of paying for defects that do not relate to cladding and...
Matched on
terms: regulator, safety
Committee recommendation
55match
#2 - Nineteenth Report - Protecting consumers from unsafe products
The OPSS has struggled to reach some businesses and consumers to prevent harm being caused by unsafe products. Businesses are responsible for ensuring that the products they make and sell are safe. The OPSS and local regulators therefore rely on influencing businesses to ensure they comply with the rules. Despite issuing guidance and advice, the OPSS has found...
Matched on
terms: regulator, safety
PFD report
53match
Roy Frank Fletcher
The Trust's post-incident review was inadequate, failing to interview a key witness or assess if similar events were persistent issues, thus hindering learning and preventing future deaths.
Matched on
classifier match
CQC action
52match
Park Cottages
CQC had not been notified of all incidents in line with regulatory requirements.
Matched on
terms: regulator
Committee recommendation
51match
#21 - Nineteenth Report - Protecting consumers from unsafe products
Local authority Trading Standards services have experienced significant resourcing challenges, including a 39% real-terms reduction in funding in the past 10 years. The OPSS told us that services’ funding varies enormously throughout the UK, as some Trading Standards are very well resourced to tackle product safety risks while others do not have the funding to deal with the...
Matched on
terms: regulator, safety
Committee recommendation
51match
#20 - Nineteenth Report - Protecting consumers from unsafe products
The OPSS is still quite a new regulator with only a £14 million budget for product safety operations. The Department told us that it is providing additional funding for goods checking at the border, while the OPSS noted that additional resources and tools would be needed to effectively regulate the scale of products now sold online.36 The OPSS...
Matched on
terms: regulator, safety
Committee recommendation
51match
#20 - 11th Report – Cosmetic procedures
While Scotland has taken steps to introduce a licensing scheme for non-surgical cosmetic procedures, Wales and Northern Ireland have yet to announce similar plans. This lack of regulatory alignment across the UK creates significant risks, including inconsistent safety standards and the potential for ‘cosmetic tourism’ within the UK, where individuals seek treatments in jurisdictions with weaker protections. (Conclusion,...
Matched on
terms: regulator, safety
PFD report
49match
Lee Adams
Doctors, particularly GPs, require greater awareness of propranolol's high toxicity at small doses and the lack of a specific antidote for overdose.
Matched on
classifier match
PFD report
49match
Margaret Clark
A change to new TOE probe sheaths (Ecolab) was linked to multiple fatal oesophageal tears, and these potentially unsafe sheaths may still be in use in other hospitals despite safer alternatives existing.
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classifier match
PFD report
49match
Adrian Green
The local authority failed to review independent care providers' contractual duties for vulnerable individuals, and a Disclosure and Barring Service referral regarding actions of a former manager received no response.
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classifier match
Committee recommendation
47match
#18 - Sixteenth Report - Principles of effective regulation
An outcomes-focused approach, however, can present a challenge for regulators and policymakers in measuring the influence or impact of regulation and the level of compliance by industry. A regulator’s influence over the industry it regulates—for example, how well businesses comply with standards—can be difficult to measure, particularly if there are not specific rules that can be easily monitored.38...
Matched on
terms: regulator
Committee recommendation
47match
#5 - Sixteenth Report - Principles of effective regulation
Outcomes-based regulation comes with benefits, but also presents challenges for regulators in measuring their influence and compliance by industry. In general, setting goals and facilitating business to meet them can be both a more effective and a less burdensome approach to meeting regulatory objectives than laying down lists of rules. A focus on outcomes can be important to...
Matched on
terms: regulator
Committee recommendation
47match
#20 - Ofgem's proposed energy debt relief scheme faces significant delay until winter 2025
The Department recognised this as a serious issue. It made clear that, because in the first instance consumers facing energy debts should contact their energy supplier, the regulatory regime should that require suppliers to offer “good, accurate and helpful advice” and that the Department was expecting this of Ofgem. It told us that it was exploring options around...
Matched on
terms: regulator
Committee recommendation
47match
#25 - 11th Report – Cosmetic procedures
The Government should assess whether outlets in the UK that are recruiting patients for medical treatment overseas should be brought into a regulatory regime and be subject to investigation and, where necessary, sanction. (Recommendation, Paragraph 97) Body image
Matched on
terms: patient, regulator
Committee recommendation
47match
#22 - 11th Report – Cosmetic procedures
The increasing number of cases requiring medical treatment after cosmetic surgery abroad raises serious concerns for patient safety and places additional financial strain on the NHS. However, the true extent will remain unknown until comprehensive data is collected. (Conclusion, Paragraph 94)
Matched on
terms: patient, safety
PFD report
45match
Desmond Statton
The provided text describes a procedural step (blood sampling) but does not detail any specific concerns.
Matched on
classifier match
PFD report
45match
John Gwynfryn Morris
Inadequate security measures at a residential dementia unit failed to prevent a resident with a known history of wandering from leaving the premises, despite previous escape incidents.
Matched on
classifier match
PFD report
45match
Helen Millard
The "traffic light" ligature risk classification system in psychiatric facilities is flawed; all ligature points, regardless of height, pose an extreme risk and should be categorized as "red" for urgent elimination.
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classifier match
PFD report
45match
Mary Nelson
Dangerous fluoxetine accumulation suggests a need to revise dosage guidance, especially for the elderly, and consider in-life drug testing. This death was also not reported to the Yellow Card system.
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classifier match
PFD report
45match
Jon James
There is no national NICE guidance on Acute Behavioural Disturbance, which is vital for emergency services and police, contributing to a rising number of related deaths.
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classifier match
PFD report
45match
Van Tuyen
Misplaced nasogastric tubes continue to cause avoidable deaths, despite being a 'never event', with no unified national approach to prevent recurrences across NHS Trusts.
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classifier match
PFD report
45match
Anita Graves
The visual similarity of carbimazole tablets of varying strengths, and to aspirin, creates an overdose risk. The community dispensing process fails to mitigate this danger, potentially exacerbating the risk.
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classifier match
PFD report
45match
Dumile Thompson
Insufficient national guidance and training on angioedema types, risk factors (including ethnicity), and diverging treatments, alongside poor medical record sharing between Trusts, hindered appropriate emergency care.
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classifier match
PFD report
45match
June Liddell
Critical error messages and equipment defect indicators are not documented in user instructions or known to staff. Machine maintenance procedures also fail to identify component wear and tear.
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classifier match
PFD report
45match
Melanie Walker
Heart monitors have a critical design flaw where disconnected leads do not continuously re-alarm after initial acknowledgement, risking unobserved and fatal cardiac events in other hospitals.
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classifier match
Committee recommendation
45match
#20 - Groceries Code Adjudicator lacks sufficient powers for Welsh agricultural sector
We recognise that there is some dissatisfaction among stakeholders concerning the effectiveness and scope of the Groceries Code Adjudicator. There remain concerns about whether the Groceries Code Adjudicator has sufficient powers to address the full spectrum of challenges facing the Welsh agricultural sector. (Conclusion, Paragraph 101) 43 The Future
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classifier match
Inquiry recommendation
44match
ICL-2 - New LPG Safety Regime
A new safety regime should be put in place governing the installation, maintenance, monitoring and replacement of all LPG systems.
Matched on
terms: safety
Committee recommendation
43match
#17 - Sixteenth Report - Principles of effective regulation
An outcomes-focused regulatory approach is one characterised by setting overall outcomes or principles expected of the regulated industry, rather than specifying rules. This has the benefit of often being more responsive to change because the regulatory objective or outcome remains the same even where the process or activity being regulated has changed. This was observed during the COVID-19...
Matched on
terms: regulator