Trust admits patient harm after cancer appointments not followed up

Ashford and St Peter’s Foundation Trust logged 22 serious incidents between 2011 and 2016 after a “failure to record clinical outcomes following patient consultations” meant that patient treatment plans were not reviewed.

Eight of the 22 suffered serious harm, four had “little or no impact” and the rest suffered “harm at a level which is difficult to assess.”

Three cancer patients have “either died or are now receiving palliative care”, the trust said. However it has not been established that the three would have survived if mistakes had not been made.

A further audit of 3,500 cancer patients, launched by the trust in November 2016, has identified 91 more patients who were “potentially lost to follow up”.

A spokeswoman for the trust said: “Work is on-going, but so far there is no evidence of [the 91] patients being harmed as a result of their patient records being lost.”

However, “learning had been taken from each case and changes made”.

The trust first discovered the problem in 2014 when a number of urology cancer patients were found to have had their patient pathways disrupted. This prompted the trust to examine pathways, first in urology, and then other disciplines as common themes emerged.

The initial root cause analysis for the 22 serious incidents between 2011 and 2016 was not able to identify exactly how the outpatient processes had failed.

However a further review found that a contributing factor was “failure to record clinical outcomes following patient consultations”, the trust told HSJ.

In some instances this was because a patient forgot to hand in their follow-up form to reception after a consultation. In other instances it was because the paper forms were mislaid by the trust.

The spokeswoman said: “In each case we liaised closely with the affected patients and their families, sharing the findings of our investigations and the actions we are taking to make improvements.”

Each of the 91 cases uncovered by the recent audit is currently being examined by an internal clinical review group.

The trust has also launched a new project to review and improve the administrative procedures for planned patient pathways for all outpatients.

The trust spokeswoman said the trust’s safety culture is “based on openness and transparency”.

“Staff are actively encouraged to report incidents in an open culture to ensure learning and continuous improvement.

“The patient pathway programme is reflective of that safety culture and is a positive and proactive approach to reducing a risk that is faced in many hospitals, within a complex administrative system that deals with over half a million patient contacts a year.”