One of England’s busiest accident and emergency departments failed to report breaches of the four hour treatment targets for at least four years, an independent report has said.

An audit covering just 17 months in that period has found 1,889 undeclared breaches of the target, but the total number of patients affected at Nottingham University Hospital Trust is still unknown.

We have essentially drawn a line in the sand now, and anyone who is found to be altering records from now on is likely to face disciplinary action

Times of discharge were changed on computer systems, a practice described as “back timing”. However, the report, commissioned by NHS East Midlands, does not explicitly say whether this was aimed at reducing the number of reported breaches, or who was responsible.

The report says there was “considerable pressure in the trust to hit the four hour target which led to the bending of the rules”. However, Dearden Consulting, which carried out the investigation, found the majority of staff interviewed believed they were following the rules.

The trust has decided not to discipline anyone in the department. It said: “We have essentially drawn a line in the sand now, and anyone who is found to be altering records from now on is likely to face disciplinary action.”

The report is critical of the trust’s procedures, including a lack of audit of the electronic information system in the emergency department; potential difficulties in establishing who recorded what information on computers because staff did not always log on and off; and inadequate communication and training of staff in the rules around the four hour target.

However, it said that patient care had not been compromised by the inaccurate reporting and there was no evidence that problems with reporting affected other areas of the trust.

It revealed that staff had raised concerns about four hour reporting back in 2005 but these had not got beyond the department.

The report - by Dearden Consulting - makes a number of recommendations including:

  • conducting a review of management structures to ensure clear accountability for managers
  • getting clarity over the responsibilities of the director of operations and deputy chief executive
  • conducting a review of the role of duty nurse in relation to targets
  • ensuring the trust the right capacity and capability to deliver on national targets
  • putting in place better systems to ensure issues raised by staff are dealt with
  • getting assurance that policies are correctly and consistently applied

It comments on the trust’s aim of becoming “England’s best acute trust by 2016” by saying: “Vision is not sufficient by itself. Equal attention needs to be given to detailed implementation.”