Alcohol, drug and medication related deaths

Noted (AI summary) Optum conducted an internal review of the EMIS Web system and concluded that no software developments beyond the existing functionality are required to mitigate the risk raised in the report, explaining how the system manages repeat prescriptions and their expiration.

Noted (AI summary) Philips acknowledges the concerns, explains alarm configurations on its IntelliVue monitors, and states that the hospital has reset the "ECG Leads Off" alarm to the factory default. Philips says that they will continue to support customers with education and guidance to hospital staff on configuring alarms but does not propose further action to the default configuration of the devices at this time. NHS England states that the Greater Manchester ICB has reconfigured the monitors such that when an ‘ECG leads off’ alarm is generated, the monitor will give the visual yellow flashing banner. If the alarm is acknowledged, the yellow banner will remain and the audio will re-alarm after three minutes if the ECG leads are still not connected, whereas previously the monitor would ‘blink’ only and would not alarm. The Department of Health and Social Care reports that Philips issued a Field Safety Notice for users of their IntelliVue line of Patient Monitors which highlights that alarm function is user reconfigurable, and should hence be confirmed in use to ensure it is not accidentally left in the ‘alarm off’ state. The MHRA has published the document on its gov.uk platform, ensuring users across the healthcare system have access to this information.

Noted (AI summary) The Trust provided additional training on ‘The Deteriorating Patient’ in 2022. Since September 2023, the Trust has introduced additional recommended courses and in June 2024, the ward received teaching sessions about NEWS2 and response. The MHRA outlines existing regulations and guidance concerning paracetamol labelling, prescribing information, and safety monitoring. They have liaised with NHSE regarding the ePRaSE tool. The Royal Pharmaceutical Society will consider how to raise awareness of issues around duplication of medicines in electronic prescribing systems through future communications and engagement with the pharmacy sector. Lewisham and Greenwich NHS Trust describes safety features in its iCare electronic prescribing system, including 'hard stops' and 'soft stops' for paracetamol prescriptions. The Trust have reviewed their IPS very recently and are participating in a leadership exercise on this topic. Oracle Health (formerly Cerner) states its Millennium prescribing system features are appropriate and functioning as designed, and will continue to review and monitor awareness of this functionality among its Trust clients. The decision on whether to take a particular code or configuration enhancement remains with the client.

Noted (AI summary) The Home Office acknowledges the concerns and outlines government funding provided to West Midlands Police. Decisions around resourcing are the responsibility of the Police and Crime Commissioner and Chief Constable.

Noted (AI summary) The Royal College of Psychiatrists will remind members to adhere to NICE guidelines when prescribing ADHD medication and will discuss the case at a webinar on prescribing errors. They also highlight existing guidelines and resources and mention the TIMESPAN consortium is developing consensus recommendations for ADHD patients with increased cardio-metabolic risks. The Department of Health and Social Care acknowledges the concerns raised and states that the MHRA publishes guidance, the BNF provides evidence-based information, and professional bodies and regulators hold prescribers to account.