The decision to issue a recall of patients is not something any health trust takes lightly. So, the fact the Belfast Health & Social Care Trust is asking 2,500 people to attend review appointments to ensure they are receiving the most appropriate treatment is hugely significant.
It comes after the trust and the Royal College of Physicians reviewed the notes of patients treated by Dr Michael Watt, one of Northern Ireland's most prominent consultant neurologists.
The trust is asking every patient under the care of Dr Watt to attend an appointment with an alternative consultant in the next three months.
It's an anxious and distressing time for everyone involved, not least the patients caught up in the situation, particularly as it has emerged that some people may have been wrongly diagnosed.
Dr Watt treats patients with a range of life-limiting, life-changing and degenerative brain conditions, including motor neurone disease, multiple sclerosis (MS), stroke, epilepsy and Parkinson's disease. A mistaken diagnosis or incorrect medication really could mean the difference between life and death.
For example, there are currently no drugs available that can reverse the damage caused by MS. It is therefore crucial that a person with the condition is diagnosed as soon as possible so they can receive medication to help limit damage to their nervous system.
At the same time, some of these medications are extremely toxic so patients and their doctors have to make careful decisions about the best treatment in each individual case. The Belfast Trust has written to every affected patient but other than apologising and providing a helpline staffed by people with no clinical experience, there has been very little offered in the way of reassurance.
In fact, there appears to be more questions than answers regarding the whole situation.
How many people have been adversely affected? Has anyone died or come to harm?
Of course, no-one can know the answer to these questions until the conclusion of the review appointments. The trust has said it is working with the General Medical Council (GMC) but neither organisation will say when the GMC was informed of the concerns about Dr Watt's work. The only thing we know for certain is that, as of yesterday, there were no restrictions placed on his license to practise.
The whole sorry situation has also raised a number of other difficult dilemmas. The trust, which already struggles to provide a timely service for neurology patients, is now faced with providing appointments for over 2,500 people in a 12-week period while continuing to run normal clinics.
It has scheduled evening and weekend appointments and is using the independent sector to ensure normal clinics do not have to be cancelled. This raises the question of cost to an overstretched service and why, in a specialty where more than 7,500 people were waiting longer than a year for a first neurology appointment at the end of last year, more has not been done before now to address waiting times.
After all, if resources can be found now to review Dr Watt's patients, why were they not made available before?
Then, of course, there is the very difficult problem posed by Dr Watt's private patients. No-one appears to know whose responsibility it is to inform them of the fact that his work is under review and who is responsible for their treatment. The trust has said that private patients can ring the NHS helpline, but they would encourage them to contact their private healthcare provider.
This assumes that all of Dr Watt's private patients have seen the news and are aware there are concerns in the first place.
Hillsborough Private Clinic, where Dr Watt worked, had last night not responded to queries on the matter and removed his name from the list of consultants on its website yesterday afternoon.
It does at this stage appear as though this cohort of patients have been somewhat left twisting in the wind.