Case study: Overdose of oral vitamin D related to frequency and duration of treatment

A coroner’s concern was highlighted in the media in relation to the prescribing of high strength vitamin D more frequently than recommended.  The inquest recorded the cause of death was intestinal bleeding due to high blood calcium levels caused by raised levels of vitamin D.

Vitamin D deficiency is treated with a short course of high dose vitamin D followed by regular low dose therapy.  After the issue was highlighted in the media, we reviewed the National Reporting and Learning System (NRLS) and identified 42 reports over two years where patients received high strength vitamin D more frequently than intended, some required treatment in hospital for high blood calcium levels.
We communicated with the British National Formulary (BNF) who revised information in the BNF and BNFC relating to vitamin D prescribing. We also liaised with Specialist Pharmacy Service who published “Safety considerations when using Vitamin D”.

We also asked the Medicines and Healthcare products Regulatory Agency (MHRA) to influence manufacturers to improve the clarity of information for clinicians and patients.
Our findings and actions also contributed to the Department of Health and Social Care’s Vitamin D: call for evidence (May 2022).

About our patient safety review and response work

The recording and central collection of patient safety events to support learning and improvement is fundamental to improving patient safety across all parts of NHS healthcare. The National Patient Safety Team identify new or under recognised patient safety risks, which are often not obvious at a local level. It does this through its core work to review patients safety events recorded on national systems, such as the National Reporting and Learning System (NRLS), the new Learn from Patient Safety Events service (LFPSE), and other sources.

In response to any newly identified risks, we develop advice and guidance, such as National Patient Safety Alerts, or work directly with partners as in the example above, to support providers across the NHS to take the necessary action to keep patients safe.

You can find out more about our processes for identifying new and under recognised patient safety issues on our using patient safety events data to keep patients safe and reviewing patient safety events and developing advice and guidance web pages.

You can also find more case studies providing examples of this work on our case study page.