[London, UK] The combined use of paper and electronic notes has resulted in a patient’s death at St Bartholomew’s Hospital in London, a new Care Quality Commission (CQC) report reveals.
St Bartholomew’s, part of Barts Health NHS Trust, is the oldest hospital in Britain. It provides a suite of local and specialist services.
Released yesterday, the CQC report shows inspectors were told an ‘unnecessary’ operation had been performed due to lack of access to previous records, leading to the death of a patient.
“Staff used a combination of paper notes and electronic notes for patient observations and risk assessments,” it is stated.
“Although staff told us this system worked well a serious incident had occurred resulting in a patient’s death because staff had performed an unnecessary procedure when they could not find previous important notes as a result of the dual system.
“The senior divisional team had investigated this incident and reported it as resolved but this had not resulted in a defined change to the dual notes system.”
A spokesperson for Barts Health NHS Trust told BJ-HC the incident was related to the lack of sharing of information between different trusts:
“At the time not all reports were able to be shared electronically, and we are sorry that it meant that a patient underwent an additional test.
“The cause of death was multi factorial and there were significant other factors involved in the patient sadly passing away. These reports are now shared with referring trusts electronically.
‘It is important that our staff can view patient information and we have taken steps to make sure that dual electronic and paper systems are robust, accessible and well organised in areas of care where a wholly electronic system is unavailable. It is our ambition that all care is recorded electronically as the trust enhances its ICT systems.”
The CQC report includes various references to the ‘reliability’ of the trust’s IT infrastructure.
In January this year, Barts Health was hit by a cyber attack that disrupted operations for four days, and in April it suferred a severe pathology and imaging IT failure.
The trust was one of the hardest hit in the May WannaCry attack and, according to the most recent board papers, the Chief Executive said the incident was expected to ‘have an impact on performance against national standards’.
Further figures show that the cyber attack had a severe impact on the trust’s financial deficit, among others, due to the ‘loss of patient treatment income’.
