Agenda item

The report is attached.

Jo Ohlson provided an update in respect of a recent serious incident at Central Middlesex Hospital UCC involving patients who had apparently not been discharged from the IT system and therefore it could not be confirmed that those with radiology reports had been reviewed for missed pathology.  She advised that most of the patients affected had been contacted promptly once the problem was discovered, and of the 97 patients that had remained outstanding, 76 had subsequently been contacted, with 48 of these requiring no further action.  Of the others, fifteen had been offered appointments, six had been re-called at the correct time following the initial x-ray, three referred by GPs to another health facility, three advised to contact their GP and one had sought follow up from a different provider.  Of the remaining 21 who had not been contacted, twelve had left no contact details, six had failed to respond.  However, three had subsequently been contacted following information provided by their GP.  Jo Ohlson advised that of those with no contact details, GPs were being asked if they held any records.  A report was due to be published on 6 June to identify how the error had happened.

Councillor Leaman asked how many of the 97 patients involved were children.  He asked when the earliest failure to record a case had happened and why had the lack of discharging from the IT system not been picked up earlier.  He asked whether NHS Brent had any view at this stage with regard to Care UK’s role about the situation.  Councillor Hunter commented that if the build-up of patients who had not been discharged on the IT system had been happening over an extended period of time, then it appeared that there must be a fundamental system failure.  She also enquired what specific action had not been done that had resulted in the incident.  Councillor Daly expressed concern about the incident and felt the number of patients involved was not acceptable.  She felt that NHS Brent had failed to monitor the contract with Care UK properly and she asked what steps were being taken to address this as well as seeking clarification as to who was leading the investigation into the incident.  Further explanation was also sought in respect of lack of patient contact details for those affected by the incident.

Mansukh Raichura (Brent LINk) was also invited to comment and he stated that it was important that all departments of the hospital worked closely together to ensure such incidents did not happen in future.

In reply to the issues raised, Jo Ohlson advised that of the 97 patients, four of these were children and it was understood that these had been contacted.  The earliest failure to record a case had occurred sometime after the UCC had opened in 2011, although the red cases which were of more concern were much more recent.  At this stage, it was no possible to pinpoint the specific reasons for the failure whilst the investigative report was awaited.  However Care UK had accepted overall responsibility and their contract was quality monitored by three clinical leads from the Clinical Commissioning Group (CCG) and regular meetings took place with them.  The investigation was being led by Care UK and one of the clinical directors.  Upon the conclusions of the investigative report, if Care UK were found to be seriously at fault, amongst the options available included financial penalties or even termination of contract.  Members noted that the risk of harm to patients affected was very low and that incidents of this sort did happen from time to time in healthcare, although in this particular case once the problem was identified NHS Brent had been informed promptly.  With regard to problems contacting patients, this was mainly due to the lack of information that some patients had provided.

The Chair requested that the investigation report due for publication on 6 June be sent to Andrew Davies with a view to including this item for discussion at the next meeting.