By Tony Collins
Three year-old Samuel Starr died in the arms of his parents as his they read him his favourite stories at the local hospital.
At an inquest this week his parents, and specialists, raised questions about whether long delays in arranging appointments on a new Cerner Millennium system at Bath’s Royal United Hospital, which replaced an old “TDS” patient administration system, was a factor in his death.
Ben Peregrine, the speciality manager for paediatrics at the RUH in Bath, told the inquest:
“Samuel’s appointment request must have fallen through the cracks between the old and new system.”
After successful heart surgery at 9 months, Samuel should have had regular scans to see if his condition had worsened. But he didn’t have any scans for 20 months, in part because of difficulties in organising the appropriate appointments on Bath’s new Millennium systems.
Though there is no certainty, Samuel may be alive today if he’d had the scans.
In a review of Samuel’s death, which took place in November 2012, the details of which have only just been made public, Bristol Children’s Hospital concluded that appointment delays might have played a part.
It said: “Death was felt to be possibly modifiable if [there had been] earlier surgery before cardiac function deteriorated.”
Samuel had his first surgical procedure, open heart surgery at Bristol Royal Hospital for Children, on 3 March 2010. He was discharged six days later, and referred to the Paediatric Cardiac Clinic at the Royal United Hospital in Bath for check-ups.
This week’s inquest heard that the first check-up took place in Bristol in October 2010, when an echocardiogram, also known as an ‘echo’, was carried out. Samuel’s parents, Paul Starr and Catherine Holley, expected a follow-up appointment in January 2012 but by March they’d not received one.
Their community nurse rang the hospital five times in as many months for a follow-up appointment but could not arrange one. When another echo was eventually taken in June 2012 – 20 months after the first – it was found that Samuel needed urgent surgery which proved more complicated than expected. He died on 6 September 2012.
Paul Starr told the BBC that during the long delays in obtaining an appointment for a further scan Samuel’s heart function went from good to bad. He said: “It is not like he had bad care in that time. He had no care at all.”
Ben Peregrine, the speciality manager for paediatrics at the hospital, told the inquest:
“The new system is now up and running as best as it can be, but as long as there is still humans entering the information there will always be room for error.”
The BBC reported that the delay in Samuel’s treatment “came after a new computerised appointment booking system was introduced at the RUH in 2011. It was only after an appointment had been set that doctors discovered the three-year-old, from Frome in Somerset, needed open heart surgery.”
BBC West’s Inside Out obtained a hospital document “Issues for discussion including any action or learning to be taken as a result of the child’s death. Issues that require broader multi-agency discussion” that has as its first bullet point:
“Failure of the RUH Millennium computer software to organise appointments at the designated time leading to a delay of three months before Samuel was seen by (redacted) in Bath.
“Parents have since told me that Samuel had not had an ECHO for 20 months prior to June 2012. At his previous cardiac appointment (April 2011) [redacted] failed to carry out an ECHO because he was not expecting to see Samuel despite Samuel’s parents being sent an appointment for this day.”
It appears that events at Bath after the Cerner go-live have, in the main, followed a pattern at a dozen or so other trusts that have installed the Millennium system.
The pattern was outlined in a Campaign4change post in December 2012:
– a trust admission that potential problems, costs and risks were underestimated
– a public apology to patients
– a trust promise that the problems have been fixed
– trust board papers that show the problems haven’t been fixed or new ones have arisen
– ongoing difficulties producing statutory and regulatory reports
– provision in trust accounts for unforeseen costs
– continuing questions about the impact of the new system on patients
– a drying-up of information from the trust on the full consequences of the EPR implementation, other than public announcements on its successful aspects.
Catherine Holley, Samuel’s mother, believes the Millennium implementation at the Royal United Hospital at Bath might have followed the above cycle.
Bath went live with Cerner Millennium at the end of July 2011. An upbeat trust statement at the time to E-Health Insider said:
“We can confirm that the new Cerner Millennium IT system successfully went live on Friday 29 July – as planned – at Royal United Hospital Bath NHS Trust.
“BT and Cerner worked closely with the trust and the Southern Programme for IT on the implementation over the past year – a complex and major change management programme.”
As part of its investigation into Samuel’s death, the BBC asked the RUH how many appointments were overdue to delayed because of the new computer system. Said the BBC’s Inside Out West programme:
“They told us there were 63 overdue appointments some with delays of up to 2 years before they were discovered.”
Separately an FOI request to the trust on the Millennium installation brought the response that there have been 65 cardiac outpatients’ appointments “that have been identified as being were missed due to problems with the delayed and that occurred around implementation of Cerner Millennium… All of these appointments have been followed up and actioned as required.”
The RUH is not discussing Samuel Starr’s death. A spokesperson said the inquest is expected to give Samuel’s family and everyone involved in his care a clearer indication of the circumstances surrounding his death. “We have offered our sincere condolences to the family of Samuel Starr following his sad death.”
RUH Board reports on Millennium’s deployment have had a general “good news” tone. But some of the reports have mentioned potentially serious problems. This was in an RUH board report in 2011 on Millennium:
“… there were significant issues with clinic templates and data that had not been migrated. This affected encounters with long term follow up appointments. As a result this meant that there was unplanned downtime across Outpatients and backlogs developed in addition to those produced as a result of planned downtime”.
What’s striking about the reports to the Bath board of directors on the Cerner Millennium implementation is their similarity, in tone and substance, to the “good news” reports of deployments of Millennium at other trusts.
The go lives are nearly always depicted as successes for clinicians that have had minor irritations for administrators.
Now we know from the RUH Bath’s implementation of Millennium that when appointments are delayed as a result of inadequate preparations for, and structural settlement of, a new patient administration system, it can be a matter of life and death.
Indeed the BBC, in its investigation into Samuel Starr’s short life, raises the question of whether delayed appointments have been a factor in other deaths.
But do trusts genuinely care about the bigger picture, or do they regard each case of harm or death as an individual, unique event, to be reviewed after the problems come to light?
At the RUH Bath, IT appears to be treated as a separate department, too little interweaved with care and treatment. Managers talked enthusiastically of smartcard use, the work of the service desk, the need for more printers, resolving BT outages, the benefits of the service security model, champion users and floorwalkers, completing the Readiness Workbook, and keeping the Deployment Hazard Document up to date – while the parents of Samuel Starr could not get an appointment on the new system for their son to have a vital heart scan.
In 2011 a senior executive at Bath told his trust staff: “Our partners BT and Cerner are describing it [the go-live of Cerner Millennium] as the smoothest deployment yet” and “we now have the foundation in place to meet the future needs of the Trust and the NHS”.
Will things improve?
The comment in my post of December 2012, which was about Royal Berkshire’s implementation of Cerner Millennium, seems apt so some it may be worth repeating (below).
“Some Cerner implementations go well and bring important benefits to hospitals and their patients. Some implementations go badly. One question the NHS doesn’t ask, but perhaps should, is: what level of problems is acceptable with a new electronic patient record system?
“It appears from some EPR implementations in the NHS that there is no such thing as a low point. No level of disruption or damage to healthcare is deemed unacceptable.
“Berkshire’s chief executive Edward Donald speaks the truth when he says that the trust’s implementation of Cerner was more successful than at other NHS sites. This is despite patients at his trust attending for clinics that did not exist, receiving multiple requests to attend clinics and not receiving follow-up appointments…
“The worrying thing for those who use the NHS is that, as far as new IT is concerned, it is like flying in a plane that has not been certified as safe – indeed a plane for which there has been no statutory requirement for safety tests. And if the plane crashes it’ll be easy for its operators and supplier to deny any responsibility. They can argue that their safety and risk ratings were at “green” or “amber-green”.
“The lack of interest in the NHS over the adverse effect on patients of patient record implementations means that trusts can continue to go ahead with high-risk electronic patient record system go-lives without independent challenge.”
This very thing seems to have happened at the RUH Bath – with possibly tragic consequences.
Thank you to openness campaigner Dave Orr for drawing my attention to the BBC’s investigation into Samuel Starr’s death.
RUH booking system might have contributed to boy’s death – BBC
Boy died after scan delay – BBC
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My sincere condolences to the Starr family for their loss.
Failure of implementation indeed. This is an assumption on my part as the Cerner product has been implemented in many organisations without such issues in respect of appointments (I assume these are out patient appointments) being raised.
In my 16+ years experience in system design and implementation certain processes have always been followed. These processes provide the quantifiable evidence that the new system is fit for purpose at day one. There is not the scope here to go into detail but I will say that the new system must do everything the old system did and more. Moreover the outputs of the new system, be they next appointments, admissions, reports etc should be the same when tested with old system data. Assuming all this goes to plan, the most important aspect of the implementation is the transition period between old and new. In every implementation I have worked on there has been a period of dual running where both systems are run in parallel with the same data to evidence compliance and reduce risk.
In my experience the key to this has been the data migration process itself and the manner in which it was performed. I have never ever come across a situation where the same process used to move data from the old system to the new could be re-used as is, even if the old system was the same. It is the nature of NHS organisations to have their systems do what they want for them leading to instance to instance variations. I am not suggesting that this is what happened at Bath, but, what is clear is that the data was not appropriately migrated and that migration appropriately tested.
This I fear is what comes from centrally procured and mandated solutions.