Patients missed urgent referrals after a hospital trust lost track of their records, HSJ can reveal.
St George’s Healthcare Foundation Trust has already admitted two patients came to “severe harm” as a result. It has now said that after checks of 47 patients whose records went missing and subsequently died, 13 had been due an “urgent” referral.
The trust has an ongoing process for determining if patients came to harm because of data problems that saw staff lose track of thousands of patient care pathways.
The trust checked records for 803 patients who had been due to receive further treatment at the time they died, to see if any had seen treatment had been delayed.
In a statement, St George’s said 47 of these had been “selected for review” and while 13 people had urgent referrals open, only one had come to “low harm”.
The trust said no one else had come to severe harm or died but said “we did not identify any patients that had come to severe harm as a result of waiting longer than they should for treatment… However, during this process, we did identify significant data quality issues, which were emblematic of the challenge we are trying to address.”
St George’s said no patient had died because of the delays and it was not a contributory factor in any deaths.
The investigation is being overseen by an external clinical review group chaired by NHS England associate medical director Nicola Payne.
HSJ has asked under the Freedom of Information Act for the serious incident reports into the severe harm that came to two patients.
St George’s suspended reporting of referral to treatment times in July 2016 and does not expect to start reporting again until 2018.
Minutes of a meeting about these issues held in June said a consultancy firm had found: “There [was] no single point of the system [that] could he held accountable, there are problems right through the end to end process, and the information that the trust has been reporting is of very poor quality and could not be relied upon.”
The minutes added: “[Then chief executive] Simon Mackenzie noted that… the root cause was the failure to implement the original Cerner [IT] solution properly”.
A non-executive director at the meeting, Sir Norman Williams, asked “whether there was any potential liability and what arrangements the trust had in place to manage this”? Professor Mackenzie said “that confirmation of the position on liability would be provided outside of the meeting”.
Information obtained by HSJ