Case Studies

Patient Safety


The issue:

At 5pm on a Friday evening we received a call from a Trust staff member working in a jointly managed and staffed facility with the 
local council. The service was providing support for adults with 
learning disabilities in the community. 

The staff member reported that over 200 adults had not had 
their medicine regime reviewed in over 12 months and believed that 
a number of patients were at risk. They had tried previously to raise the concern but informed us that they were not heard or taken seriously. 

The outcome:

We raised this immediately as a red alert with the on-call executive team member at 6pm that evening (a bank holiday weekend). The executive immediately set about organising a project team to review the concern as a matter of urgency and a team was on site the following morning (Saturday) 
to begin to address the issues.

 This was without doubt a red alert in terms of patient safety and wellbeing 
and raised the additional concern as why the staff member had not being listen to. GSL continued to monitor this situation working with the Trust to ensure in this instance that staff raising such concerns would be heard in the future. The project team (on site the following morning) quickly implemented a review of all medicine regimes ensuring all were brought up to date.

The staff member informed us that we were their last port of call and if we could not help, they were on the verge of creating a whistleblowing case and going directly to the CQC.