Thousands Of Patients Could Be At Risk After Serious NHS Tech Blunder

Exclusive: a ‘serious incident’ has been declared, and Labour are demanding an inquiry.

Thousands of NHS patients may have been subjected to serious harm after a massive IT blunder left GPs without vital medical information about hospital discharges, HuffPost UK can reveal.

An urgent investigation has been launched by East and North Herts Hospital NHS Trust following the discovery that its Lorenzo software system at Lister Hospital in Stevenage had failed to send out up to 25,000 “discharge summary” letters to local doctors.

The letters contain crucial details of treatments received in hospital, medications and test results that a local GP depends on in order to ensure patients get the care they need.

Classed as a “serious incident”, regulators NHS Improvement and the Care Quality Commission have been alerted to the error, with 1,500 cases deemed “high priority”.

There are also calls to review the deaths of more than 1,000 people who were discharged since September 2017 to see if there was any link to the error.

Lorenzo, a patient records system run by private American company DXC, operates across several NHS trusts in England but has been dogged by controversy.

The IT system was described as “hopeless” by the former Commons Public Accounts Committee chair, Margaret Hodge, in 2013, who also described the firm running it as a “rotten” company.

One local clinician told HuffPost UK: “Apparently 25,000 letters have gone astray, but over 1,000 of patients involved have since died.

“This has been interpreted as being ‘fewer to chase’. Not, it would seem, ‘could delays in letters have contributed to any of these deaths?’”

New Health Secretary Matt Hancock
New Health Secretary Matt Hancock
Barcroft Media via Getty Images

The serious failure has emerged just days after Health Secretary Matt Hancock boasted of his plans to boost new technology in the NHS.

Shadow Health Secretary Jonathan Ashworth said the error was “staggering” and demanded to know why such a serious incident – which was first identified in July – had not been reported to Parliament or the public.

In a letter leaked to HuffPost UK, the NHS trust has told local doctors that “a detailed review has identified that insufficient evidence exists for some 14,600 records to be sure whether or not a discharge summary was written and sent”.

“This work is being investigated and reported upon as a serious incident… those with potentially unsent discharge summaries dating from 1 April to 31 July 2018 – which totals some 2,400 cases – are being prioritised based on clinical grounds.”

It is understood that some patients affected will be given one-to-one phone conversations about their cases.

A “very heated” meeting took place last week between the Trust and local doctors as the scale of the blunder became clear.

Beds and Herts Local Medical Committee (LMC), which represents GPs, made plain its anger in its own letter to local doctors, which has also been passed to HuffPost UK.

Peter Graves, the chief executive of the LMC, wrote: “All discharge summaries are being assessed by the consultants concerned to identify the patients that have come to harm, have been put at risk and/or still have outstanding actions following their discharge.

“From the 16,600 discharged since April, a risk assessment has been undertaken: some are known to have died, others (e.g. those that had endoscopy) were handed a summary, another group of patients has been seen as an outpatient since discharge.

“There remain 1,500 high priority cases under urgent investigation…. Should you discover that a patient has been harmed, within the Serious Incident criteria, you must notify the CCG [clinical commissioning group] immediately through the usual SI processes.”

Some local GPs had complained about the Lorenzo system’s failures last December, within weeks of its introduction at the Lister, but the trust “clearly failed to act appropriately back then”, Dr Graves’ letter claims.

It adds: “Most importantly, the Trust has reaffirmed that all patients affected are contacted by telephone, and any harmed patients have a face to face consultation with the consultants concerned.”

PA Wire/PA Images

The local clinician told HuffPost UK: “Immediately after it was introduced [Lorenzo] caused problems. Local GPs started complaining about inadequate or absent discharge letters - but were not listened to or fobbed off.”

They added that some local doctors had been told that inherent faults in the IT system meant that it could take 45 minutes for a hard-pressed junior doctor to go through the required steps to issue a single letter.

“In the absence of these letters, GPs don’t know whether instructions have changed on medication and could be writing the same repeat prescription even if the hospital has said the medication should be different,” the local clinician said.

“We don’t know whether this lack of communication had a potential impact on deaths, but we should be told.”

One local GP added: “I heard Matt Hancock assuring us we were going to get state of the art IT. Clearly we are not getting it now.”

Shadow Health Secretary Jon Ashworth
Shadow Health Secretary Jon Ashworth
PA Archive/PA Images

Ashworth said a full inquiry was now needed. “It’s staggering that a hospital trust failed to send up to 25,000 vitally important patients’ discharge summaries to local doctors. We now need a full inquiry into whether patients have been harmed or lives lost as a result,” he said.

“Our thoughts must be with the thousands of patients who will be going through worry and anguish as a result of these unacceptable failures.

“Let’s be clear, this is an absolute scandal and there are now serious questions for the technology company who provide this IT and for NHS bosses too. If a Serious Incident was reported in July why are we only learning about this now? Why was Parliament not informed?

“And the Secretary of State must tell us not only how many other hospitals trusts use this IT but crucially patients will now expect him to urgently outline what specific steps he has taken to ensure this is an isolated incident and not a more widespread failing involving other hospital trusts.”

A spokesman for East and North Herts NHS Trust said: “Inevitably patients will have died since being discharged from hospital, but there is no evidence that any patient has died as a result of not having had their discharge summary. However, this position will be kept under review whilst the incident investigation continues.

“At present, there is no evidence that any patients have to come harm. The Trust is prioritising the review of discharge summaries for those patients where a follow-up action (such as a further appointment or test being carried out) might have been needed.

“These patients will have their records reviewed individually and should any outstanding actions be discovered, the Trust will take the lead in getting them sorted - this will include informing any individual patients involved, as well as their GPs.

“Whilst we believe that the introduction of our new electronic patient record system has contributed to this incident, we also believe that Lorenzo has the potential to improve the timeliness and quality of discharge summaries going forward compared to the previous manual system.

“The Trust has kept its local commissioners and regulators aware of what was been happening and wrote to GPs at the first available opportunity when there was clear information that it could provide them with.”

A spokesman for DXC Technology declined to comment and instead said it would refer all inquiries to the NHS.

The Department of Health and Social Care said that the issue was a matter for the local trust but HuffPost UK understands that the DHSC believes it is important that it works to rectify the error and identifies any cases of patient harm.

Local MP for Stevenage, Conservative Stephen McPartland said: “I was aware there had been issues with the IT, but nothing at this level. It is shocking and I am grateful to the Local Medical Council for bringing it to my attention on Friday.

“I contacted the Chief Executive of the Trust immediately to identify how many of my constituents were affected and what has happened.”

In April this year, Barnsley Hospital NHS Trust decided to end its Lorenzo contract after 2020, signing up to a rival system run by System C.

Earlier this year, DXC Technology won a six-year £250m contract to deliver the IT infrastructure services for NHS Supply Chain’s new management function.

Last year, West Suffolk Hospitals NHS Trust revealed problems with its own Cerner system for hospital discharge records. It initially rated the errors as a potentially ‘catastrophic/major harm’ risk.