Coroner criticises hospital’s new IT after boy’s death

By Tony Collins

Avon coroner Maria Voisin said yesterday that a new booking system at the Royal United Bath was responsible for three year-old Samuel Starr not being seen and given timely treatment.

It’s rare for a coroner to criticise a hospital’s new IT in direct terms. It is also rare for evidence to emerge of a link between the introduction of new hospital IT and harm to a patient.

Since patient administration systems began to be installed as part of the National Programme for IT in 2005, the disruption arising from go-lives has led to thousands of patient appointments being delayed at a number of trusts. Usually  trusts contend that no patients have suffered serious harm as a result.

Yesterday at the coroners court near Bristol, the coroner Voisin said: “Due to the failure of the hospital outpatients booking system, there was a five-month delay in Samuel being seen and receiving treatment. Samuel’s heart was disadvantaged and he died following urgent surgery.”

Catherine Holley, Samuel’s mother, said her first warning of Cerner implementation problems came in June 2012, about three months before her son’s death, when the RUH cardiologist’s post clinic letter said:

“I apologised to the parents that I should have seen him in January of this year, but I am afraid a few patients have fallen foul of the Millennium changeover and I suspect this is the case here”.

The RUH installed the Cerner Millennium system at the end of July 2011. After the go-live the trust’s board reports, and a post-implementation review of the system by Pwc in February 2012, raised no serious concerns.

One of Pwc’s main criticisms of the system was the lack of clinical engagement – a common problem with NPfIT deployments.

Some excerpts from Pwc’s report:

“Given the issues and delays there is a still a good deal of uncertainty about whether the planned benefits can be realised. It is therefore important that there is a concerted effort to focus on driving out these benefits, early in 2012.”

“The go live itself did have some issues, but most of those interviewed felt that, relative to other Cerner Millennium implementations, it had gone well. Since the go-live the Trust has been working hard to address the issues, and to help users use the system more effectively…”

“There are a number of issues which arose during the audit which, although not directly covered within the audit objectives, are important in ensuring that the trust realises all the potential benefits from the Cerner Millennium implementation. These are as follows:

“There is a need for greater clinical engagement to ensure that clinicians are using the system in the most effective way – the Trust operates a Clinical Engagement Group which meets on a monthly basis.

“However feedback from a number of interviewees is that this meeting isn’t as productive as it might be and that the Trust needs to think of other ways to improve clinical engagement.”

Pwc said that the trust needed a clinical lead for Cerner Millennium who would focus on key clinical priorities and “sell” the benefits of Millennium to other clinicians. The trust also needed a CIO who would be responsible for IM&T, the Business Intelligence Unit, the Care Records Service team, Records Management, and managing the end of a [local service provider] contract with BT in 2015.

Pwc said the risks included:

• The end of the contract with BT in 2015
• Recent issues with BT delivery, with several significant outages of service
• The issues with clinical engagement.

None of the trust reports – or Pwc’s review –  mentioned any adverse impact of the new system’s implementation on patients.

In 2011, several months after the go-live, the RUH’s “Insight” magazine quoted the Chief Executive James Scott as suggesting the go-live had been a success.

“Thanks to everyone for their hard work and patience during the switchover period,” Scott is quoted as saying. “It has been a major project for the RUH (and our partners BT and Cerner are describing it as the smoothest deployment yet), but we now have the foundation in place to meet the future needs of the Trust and the NHS.”

Care plan?

Catherine Holley expected Samuel to go onto a care plan after he had successful heart surgery at the age of nine months, in 2010. But it proved difficult to arrange an appointment for a scan on the new Cerner Millennium system installed at Royal United Hospital, Bath.

When the scan was eventually carried out Samuel’s heart had deteriorated and he died in September 2012 after an operation that was more complicated than expected.

This week’s three-day inquest at Flax Bourton Coroners Court heard that although Samuel’s medical records had been created on Millennium, no appointments were transferred across.

Speaking after the inquest, Samuel’s parents said they believe the system at Bath failed their son and that mistakes were made.

“It was devastating to hear evidence that an improperly implemented computer appointments system and a series of human errors resulted in the death of our son,”said Paul Starr’s Samuel’s father.

“We accept that mistakes happen but we believe that leaving a child unmonitored for as long as Samuel was, with so many opportunities to attend to him, goes beyond a simple error.

“Our three year old son had a complex cardiac condition and had been scheduled for regular cardiac reviews. In fact he was not properly assessed or nearly 21 months because of further delays.”

A Freedom of Information request revealed that there were 63 missed paediatric cardiac appointments as a result of problems arising from the Cerner implementation – some of which took nearly two years to discover.

Comment

It’s unlikely to have been the Cerner system itself at fault but an  implementation that involved several organisations including the Southern Programme for IT, a branch of the dismantled National Programme for IT.  As such nobody is likely to held responsible for what the coroner called a “failure” of the IT system.

Then again blaming an individual would be pointless.  Learning lessons – the right ones, and not just technical ones – is the objective. It may make a world of difference if those in charge of major go-lives in hospitals acknowledged that delayed appointments, or difficulties arranging them, and a disrupted administration, can harm patients – or worse.

IT in the NHS is seen as an integral part of hospital care when the technology, clinicians, nurses, administrators and other users are working in alignment. But when the IT is not working well, it is seen as something techie which has little or nothing to do with patient care and treatment.

Samuel Starr’s inquest draws attention to the fact that the difference between a good and bad IT implementation in a large hospital can be the difference between life and death.

But hospital deployments of patient administration systems have been going wrong with remarkable regularity for many years.  Isn’t it time to learn the right lessons?