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Thousands of patients left at risk from failure to deliver NHS documents

Posted: 27/06/2017


At least 1,700 patients – and likely many more – have been exposed to potential delays in diagnosis and treatment as a result of NHS administrative errors. The National Audit Office (NAO) has investigated and identified that between 2011 and 2016 over 700,000 notes were stockpiled in a warehouse instead of being delivered to their correct destination. The documents include test results, among them the outcomes of investigations into suspected cancer.

The NAO has identified that the cause of the problem lay with NHS Shared Business Services (SBS), a company that is part-owned by the Department of Health. SBS is responsible for delivering to the correct recipient the NHS documents that are incorrectly addressed or need re-directing, for example, because a patient has moved home and changed GP. SBS covers NHS services in North-West London, the Midlands and the South West of England.

The review of the notes has found that at least 1,700 patients may have been harmed by the failure to deliver documents on time. This figure is likely to increase as a third of the records are yet to be reviewed.

The NAO audit has found that SBS was aware of a risk to patients as long ago as January 2014, but failed to address the problem. In 2015, a member of SBS staff reported concerns that some records were being destroyed, but it was not until March 2016 that SBS apparently informed NHS England and the Department of Health. It took an investigation by The Guardian newspaper earlier this year to bring the problem to public attention.

Andrew Clayton of Penningtons Manches’ clinical negligence team comments: “The NAO audit raises questions on a number of important issues. The most serious is the risk to patient safety of important investigative and diagnostic results being left for prolonged periods without action. Some of these may well have been time critical and mandated referral for treatment, including for cancer. It remains to be seen how many patients have been affected and this will be a concerning time for those worried about the several hundred thousand documents that are yet to be reviewed. The cost of investigating and dealing with this episode is estimated at over £6.5 million, so lessons need to be learned.

“There are separate issues about NHS governance and the controls the Department of Health should have been exercising over SBS. It is reported that NHS England tried to investigate the issue, but found SBS obstructive and unhelpful. The internal management of SBS and its failure to act promptly as soon as it became aware of the problem has compounded the potential damage to patients and is itself unacceptable. It is particularly concerning that, despite the NHS’s ‘duty of candour’ to hold up its hands to errors affecting patients, SBS appears to have contrived to prevent this problem from being investigated and addressed promptly. Instead, it left patients at potential risk over a prolonged period.”


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