Newcastle Hospitals NHS Trust has admitted failing to send out 24,000 letters from senior doctors to patients and their GPs after they became lost in a new computer system.
A report by the BBC revealed the problems occurred when letters requiring sign-off from a senior doctor were placed into a folder few staff knew existed.
The trust has revealed the problem, dating back to 2018, is ‘significant’ and the news has led to the healthcare regulator seeking urgent assurances over patient safety.
Most of the letters explain what should happen when patients are discharged from hospital.
But a significant number of the unsent letters are written by specialist clinics spelling out care that is needed for patients.
And it means that some crucial tests and results may have been missed by patients.
The issue was discovered following a routine inspection by regulator, the Care Quality Commission (CQC), in the summer, when staff at the trust raised concerns about delays in sending out correspondence.
A subsequent review of all the trust’s consultants revealed that most had unsent letters in their electronic records.
A source at Newcastle Hospitals told the BBC that consultants had been raising issues about the electronic patient record system for years, complaining it was slow and hard to use, but had not been listened to.
We took immediate action to request further detail from the trust to understand the extent to which people may be at risk, and evidence of the steps being taken to review the impact on patients, ensure people are safe, and mitigate any risk of avoidable delays in treatment going forward
And, in a letter sent to staff about the problem, which was seen by the BBC, the trust explains that letters drafted by one member of staff have to be signed off by a second clinician, who must change their user status to ‘signing clinician’, before they can be sent.
If that does not happen, letters end up in a consultant’s document folder and remain unsent until they are signed off correctly.
Sarah Dronsfield, the CQC’s interim director of operations in the North, said: “We took immediate action to request further detail from the trust to understand the extent to which people may be at risk, and evidence of the steps being taken to review the impact on patients, ensure people are safe, and mitigate any risk of avoidable delays in treatment going forward.”
An action plan
She said the trust had submitted an action plan and volunteered to provide weekly updates on its progress against that plan.
And the trust says it will immediately deal with a 6,000-letter backlog from the last year alone.
More than 1,200 of these relate to medicine and emergency care.
Commenting on the issue, Martin Wilson, the trust’s chief operating officer, said he wanted to reassure patients that ‘we are taking immediate steps to address the issue’.
This issue of files being put in new, or hard-to-find, places highlights how user-centred design needs to be front and centre of all digital transformation projects
“We sincerely apologise for any anxiety or inconvenience this may cause,” he added.
The hospital trust said it was working to understand if there had been any impact to ongoing care and treatment of patients.
And it is currently reviewing 24,000 documents from its electronic records, which accounts for less than 0.3% of all contact with patients, the trust said.
“If any concerns are identified, we will inform patients and their GPs directly,” Wilson said.
“We are taking this issue very seriously and are working quickly to put things right.”
Speaking to BBH, Iain O’Neil, managing partner for health at software company, TPXimpact, said the problem highlighted the need to ensure NHS digital transformation projects were designed to be user friendly.
He added: “Though the information that we have about what happened in this case is limited, this issue of files being put in new, or hard-to-find, places highlights how user-centred design needs to be front and centre of all digital transformation projects.
“Hospitals and technology providers cannot simply implement new systems and consider that as job done. They need to ensure that platforms are designed so that they meet the needs of staff and patients, while also training and upskilling users so they have a clear understanding of how to harness the technology correctly and effectively.
“At the same time, this incident only came to light after a CQC inspection, demonstrating how important it is that digital systems are included in regulatory reviews.
“Technology plays a key role in patient care these days, and must be regulated and monitored just like human care.”