PERFORMANCE: Hundreds of patients waited hours for ambulances in London when call handlers were forced to rely on pen and paper for 15 hours during a software failure, a report seen by HSJ has revealed.
Just two per cent of the most life threatening calls were reached within eight minutes, against a target of 75 per cent. Nine per cent of the 2,000 callers waited more than two hours, compared with less than 1 per cent on a normal day.
London Ambulance Service commissioned an independent report into the failure, which happened on 8 June 2011 as the trust tried to switch over to a new call handling system. The report criticised senior management for failing to have a “detailed and tested” contingency plan in place.
During the 15 hours when pen and paper was used, the report said, mistakes increased and radio airwaves became overloaded.
In one case it took 15 minutes to dispatch an ambulance to a patient suffering a cardiac arrest who later died.
Another patient with less serious heart problems waited seven hours for a response.
A serious incident report into the first case concluded a quicker response was unlikely to have made a difference to the outcome. The patient involved in the latter case has now launched a legal claim against the trust.
A clinical audit found 8 per cent of calls raised some level of concern, although the report said data was too incomplete to draw conclusions.
Deputy chief executive Martin Flaherty told HSJ the trust was confident any other major concerns would have been identified on the day by clinicians in the control room, via the audit or through its normal feedback channels in the seven months since the incident.
He rejected criticism the trust had not had an adequate contingency plan in place or sufficient clinical and operational involvement in the project but accepted more could be done in future.
Prior to the go live date the new CommandPoint software, provided by American firm Northrop Grumman, had been tested using a simulator. However, it was not retested after being reconfigured to reflect national changes to performance targets for serious but non-life-threatening calls, a change that caused major problems.
The trust now plans to reintroduce the software in stages beginning with a three hour introduction overnight on the 21 and 22 February and working up to full implementation by the end of March.
If problems are encountered during this process go live will be shelved until after the London Olympics.
Mr Flaherty said: “We know that patients had delayed responses; some of those patients were elderly, some of those patents were in pain and we are very sorry about that.
“We don’t think that’s acceptable and we want to make sure it will never happen again.”
Information supplied to HSJ
20 January 2012