Agenda item
Incident involving pathology service for Brent and Harrow PCTs
There have been problems reported with pathology services being provided to Brent GPs. These are currently being investigated and the report outlines the findings and position to date.
Minutes:
Pauline Johnson (Interim Head of Quality and Safety, Brent CCG) informed the Committee that TDL had been contracted to provide a pathology service on behalf of Brent PCT, Harrow PCT and North West London Hospitals since May 2012. She explained that serious concerns were raised in December 2012 by Dr Patel, such as skewed results, results being grouped differently and results being filed without requiring actioning. It was noted that further complaints and concerns were received including abnormal potassium and calcium levels as well as missing second sample results. Following a thorough investigation, among the root causes for the issues found were; the introduction of a new IT system and a malfunctioning robotic arm. Other contributory factors were found such as lack of communication with GPs, organisational, training and human errors. Dr Patel felt that the committee should feel reassured by the alertness of GPs and as a result; no patients came to any harm.
Members expressed their concern that an incident of this nature could occur again and highlighted that they did not feel reassured that the issue could reoccur. It was queried whether all patients had been contacted. Dr Patel explained that as well as GPs individually contacting patients with abnormal results for re-tests, TDL had also re-examined any irregular results with patients outside of normal ranges to be alerted.
It was queried whether the machines had been tested and what quality control checks were in place to avoid such incidents. Dr Patel informed the Committee that the machines used by TDL were used nationwide successfully. Alternative reagents had been used which altered some of the reference ranges despite reference ranges requiring to be standardized by the Department of Health. Dr Patel felt that the failures in equipment and issues caused by changes to the IT infrastructure could not have been foreseen. Members queried the lack of communication with GPs and felt that it was unacceptable that training was not provided in advance. Dr Patel agreed that communication should have been greater and GPs would be informed of future procurements and the timescales entailed. It was noted that the IT system presented results in a standardised way as agreed with the Department for Health and following concerns raised by Brent GPs, this system would be taken back at a national level and addressed before being cascaded down to GPs.
The report circulated was an interim report with a full report and action plan due to come back before the Committee. It was explained that many lessons had been learnt and action already taken to address issues, as well as a proactive and vigilant approach undertaken to avoid future reoccurrences. Hourly checks were taking place until the pathologists had full confidence in the system. It was clarified that a nine month embedding period existed within the contractor to address any issues early on, after which severe financial penalties could be served upon TDL. Dr Patel highlighted that some of the errors were human errors particularly in terms of incorrect form filling. Ethie Kong explained the use of forums and the knowledge shared between practitioners. She continued to highlight that training was given to the pilot practices which had trialled the system successfully however acknowledged that training may not have been received by all.
Members thanked all for the update and requested that the final report be sent to the Committee as soon as it was available.
RESOLVED:-
Members noted the report.
Supporting documents: