Poor training, clerical ‘second-guessing’ and a failure to pass on information are among the ‘multitude’ of errors to blame for West Herts cancer treatment delays, an investigation has found.
Two people may have died as a result of the breaching of two-week hospital referral guidelines for suspected cancer patients in the area.
The mistake by West Herts Hospitals NHS Trust was first announced in February after an internal review had been launched by health bosses in November.
National guidance is that patients with suspected cancer referred to hospital by their GP should receive an urgent outpatient appointment within two weeks. If they miss this, they should be given another appointment. West Herts Hospitals NHS Trust chief executive Samantha Jones and her team discovered in October that they were instead being discharged by the organisation.
This affected 810 people between January 2010 and November 2013.
An external investigation by former NHS chief executive Stephen Ramsden was then launched, the results of which were published today.
Ms Jones said: “I apologised in February and I apologise again to any patient and every patient and family who has been affected by the failings of the Trust.”
She was speaking at a press conference about the findings of Mr Ramsden’s investigation into the treatment delays this morning.
Answering to questions from the Gazette, she said: “There were three patients who were potentially harmed by this.
“Two patients unfortunately had died and we have been working very closely with their families since February. We will be sharing the findings of the review with them personally.”
She said that she could not say whether they would be suing the trust for compensation.
Addressing the Trust’s failure to book adequate follow-up appointments for cancer patients, Mr Ramsden said: “Why did this happen? We found a multitude of reasons.”
He said that hospital clerks often couldn’t find ‘urgent care’ appointments available for suspected cancer patients within two weeks, so would book them into routine appointment slots instead.
This meant that if they did not attend, they were discharged back to the GP.
Mr Ramsden said: “The system was not able to identify that these were urgent care referrals.
“What exacerbated that is that sometimes clinicians did not complete a form at the end of the clinic that said whether they wanted to give the patient another referral.
“Clerks had to second-guess what should happen with these patients.”
Often they would ring a patient three times within a 24-hour period, and if they got no response in that time, would just book an appointment regardless.
This would then be recorded as a referral – even if the patient could not make the appointment.
Mr Ramsden said: “There had been little training over many years for these administrative staff.”
He said that an earlier chance to spot the problem was missed by the Trust after a complaint was received from a GP.
He said a letter signed by the director at that time had called for a full audit and for a proper system of urgent care referrals to be implemented.
Ms Jones said the complaint was received in November 2012, investigated and a response was sent back to the GP by the Trust’s deputy chief executive in July 2013.
But she said: “Unfortunately that person then left the Trust and there weren’t robust enough systems in place at that time to pick up complaints and link it to any incidents that we would review normally. That is now in place.”
The problem was identified again in October last year during the training of clerical staff, leading to a full review by the trust.
Mr Ramsden criticised the trust’s archaic use of fax to book hospital appointments.
He said: “We are probably one of the few remaining industries that relies on fax rather than electronic systems.”
But Ms Jones said the Trust is investing more than £30m in upgrading its IT systems to make them ‘fit for purpose now and in the future’.
She said: “We will be getting our IT up to 2014 and longer standards.”
Mr Ramsden has drawn up a list of 25 recommendations for the trust to implement to improve its care for patients.
Ms Jones said many of them are already in the process of being implemented. An update on this will be given to the Trust’s board in November.