Product related deaths

Action Planned (AI summary) The General Pharmaceutical Council acknowledges the concerns and states they are considering publishing an anonymised summary of the case in their newsletter 'Regulate'. It highlights existing guidance and standards, including the importance of patient safety and a two-person check in dispensing, and also emphasizes its work with the MHRA and NHS England to improve adverse incident reporting. NHS England describes actions underway to improve medication safety, including publishing a new Patient Safety Alert on medication errors in March 2014. It also mentions a review of community pharmacy incident data to prepare a Patient Safety Alert, that would better describe risks arising from dispensing medicines, and safer practices including better use of technology and checking systems. The Royal Pharmaceutical Society acknowledges the concerns and says it could raise awareness and encourage use of 'read-back' as one technique amongst others to reduce errors in the guidance that they produce. They also indicate they can raise awareness of additional checks within guidance that they produce. The Department of Health describes actions taken to address concerns around dispensing errors, including the MHRA working with NHS England to simplify medication error reporting. An integrated reporting route has been introduced to share reports, and a National Medication Safety Network is being established to discuss safety issues and improve the safe use of medicines.

Action Planned (AI summary) OFGEM will monitor suppliers' performance regarding non-domestic disconnections and work with the coroner on reviewing the Safety Net provisions, considering how to promote them to non-domestic suppliers. They also provided context about existing protections for domestic consumers facing disconnection. Energy UK revised the Energy UK Safety Net to clarify protections for vulnerable domestic consumers using a shared non-domestic supply, publishing the updated version on their website. Signatories aim to implement required systems and processes by the end of 2014, with ongoing reviews and audits planned. Npower has briefed affected teams on process changes, organized face-to-face training with annual refresher, and introduced a trial period ceasing disconnection of shared commercial and domestic supplies during winter months. These measures are in addition to existing safeguards for vulnerable customers.