Imperial errors review finds no patients were harmed
A review into internal ‘data reporting’ issues at a major NHS trust, which delayed hundreds of urgent two-week referrals, found that no patients came to clinical harm as a result of the errors.
The independent Waiting List Clinical Review group was set up in July, after Pulse revealed that the records of 1023 patients referred by GPs to Imperial College Healthcare were found to be incomplete. This forced the trust to write to GPs to ask for their help in urgently tracking patients down to check they had attended their appointment.
The group, chaired by NHS South East London’s medical director Dr Jane Fryer, reviewed more than 1,800 patients and a full year’s worth of trust data relating to measures of patient safety, but found none had come to any clinical harm following the delays.
The review included 74 suspected cancer patients who died following referral and 303 patients who died while on the inpatient waiting list.
The report said that it was clear from the clinical review that the information systems previously used to track these patients was incomplete and not up to date.
Information about patients referred back to their GP or to the trust had not been added into the patient tracking system, it said, but added that the Trust would address this problem when the new patient tracking system was being constructed.
Eight recommendations,which included ensuring referring GPs are informed when patients do not attend their outpatient appointments, were put to the Trust in the report.
Mark Davies, chief executive of Imperial College Healthcare NHS Trust, said he accepted the review and recognised that the failure of systems, management and record keeping were clearly not acceptable.
He said: ‘The Clinical Review Group’s independent report found no evidence of any clinical harm resulting from these failures but we are not complacent in any way. I am only too aware that both the poor standard of record keeping in the past, and the measures we have had to take to address this, may have resulted in concern for patients and their families and I would like to apologise unequivocally for any distress that might have been caused.’
He added that the Trust has carried out a data validation exercise to ensure records are accurate, implemented new systems for recording patient information, improved staff changing, and changed management structures.
Waiting List Clinical Review Group’s recommendations to the trust:
1. Produce and appropriately manage accurate cancer patient tracking lists
2. Timely validation of patient tracking lists for cancer and 18 weeks RTT
3. Reduce and eliminate the number of duplicate health records for patients
4. Reduce and eliminate the number of duplicate hospital numbers for patients
5. Ensure information on patients who do no attend their outpatient appointments is included in the health records
6. Ensure information is sent to referring GPs when patients do not attend their outpatient appointments
7. Ensure relevant information on patient care is include in health records
8. Reduce the number of entry points to the Trust for urgent suspected cancer referrals