UK Coroner Fingers NHS Computer System in Toddler’s Death

IT Hiccups of the Week

The number of IT-related errors, ooftas, and deficiencies reported last week reverted back towards the mean from the previous week's overabundance. We start off this edition of IT Hiccups with a sad case of a child’s death in the UK. The tragedy is being attributed in part to the past effort to fully computerize the UK’s National Health Service.

According to the Bristol Post, a coroner in charge of the inquest into the death of Samuel Starr, aged three, indicated in a narrative verdict that, “Due to the failure of the [Royal United] hospital's outpatient booking system, there was a five month delay in Samuel being seen and receiving necessary treatment.” It is very rare for a coroner to criticize a hospital IT system so directly.

Samuel Starr was born with “complex congenital heart disease” in 2009. His parents were told at the time of his birth that Samuel would need several operations before he was five, and in fact, Samuel underwent an operation when he was nine months old. The Post reported that he made a good recovery, and was due to have regular checkups and further treatment at the Pediatric Cardiac Clinic at the Royal United Hospital (RUH) in Bath. Samuel received a checkup in October 2010 and one in April 2011, at which time his parents were told by his doctor to schedule another in about nine months for a more extensive examination of his heart.

However, a new electronic health record system, called Cerner Millennium, was being installed in 2011 at the hospital as part of the NHS’s National Program for IT (NPfIT), which was shortly thereafter cancelled. Though the main program was cancelled, certain elements, such as its national Choose and Book system for patient scheduling, remained. (Hospitals, like at Royal United, that were already installing electronic health record systems were given the go-ahead to proceed if they wished).

According to the Daily Mirror, “glitches” in the Royal United patient booking system caused Samuel not to receive his scheduled appointment with heart specialists as required, despite pleas for an appointment by his parents and a primary care specialist. The Mirror stated that medical secretary for Samuel's doctor insisted that she had taken down the appointment details and forwarded them on to a dedicated appointments team, but they were apparently not logged in. “While Samuel's medical records had been created on the new Millennium computer program, no appointments had been transferred across [from the old scheduling system],” the Mirror explained.

By the time Samuel was eventually seen, his heart condition had taken a turn for the worse, and he required immediate surgery. Unfortunately, the child died after enduring a series of cardiac arrests a few weeks after his surgery.

While it is not certain that Samuel would have lived if he had been seen earlier, the inquest did highlight that he was not the only patient who didn't receive timely medical care due to problems with that same hospital’s appointments system. BBC Newsreported that, “Minutes of board meetings in RUH a year before Samuel's death show the hospital was fully aware of the problems with their new computer system. They reveal ‘there were significant issues with...data that had not been migrated which affected...long-term follow-up appointments.’” Some 63 overdue pediatric cardiac appointments in all were uncovered, “with some taking nearly two years to discover,” the BBC story stated.

The Royal United Hospital has since corrected its booking/EHR system problems, and has apologized to Samuel Starr’s family. However, the episode does lead one to wonder why hospital administrators didn’t work harder to look for missing patient appointments after the issue was identified not only at their hospital, but also at other NHS hospitals implementing the same booking and EHR system during the same time frame.

Votes Go Missing for Two Years

An AP story last week reported that 3971 early votes cast in Warrick County, Indiana, during the 2012 general election went uncounted until recently “because of an error by an electronic voting machine technician.”

The AP story said that the missing votes were discovered “by a Democratic precinct leader who recently was cross referencing precinct summary reports with a state voter history report.” The precinct leader was surprised to find out that the summary reports of tallied machine and paper votes for the county had a discrepancy of more than 3700 votes.

Further investigation revealed that “Indianapolis‐based MicroVote General Corp., which services the county's electronic voting machines, found that one of their technicians incorrectly uploaded early votes,” the AP story said.

Luckily, the missing votes would not have changed the outcome of the election. There was no word as to what would have happened if they had.

In a similar vote-delay incident, the Port Arthur News in Texas reported that “a misplaced flash drive and, later, a software glitch, delayed election results in Jefferson County by more than four hours on Tuesday.” The flash drive, the News stated, was found in a locked-up early voting station polling machine, while “a glitch in the software deleted information containing the number of registered voters in each precinct” and necessitated manually inputting the precinct voter registration numbers.

Delhi Police “Lost” Password for Eight Years

The Indian Express reported last week that some 667 complaints by the public regarding the conduct of the Delhi Police that were forwarded by the Central Vigilance Commission (CVC)—which investigates the complaints and either addresses them itself or sends them via an online portal to the police to deal with—have been awaiting resolution for the past eight years.

The reason? The Express stated that the “Delhi Police didn’t know the password to access the portal or how to operate it, a lapse that went undetected since 2006.”

It wasn’t until January of this year that two high ranking Delhi police officers were given the needed training by the CVC to access and operate the portal.

The Express reported that the CVC hosts meetings every year with government departments to review the complaints it receives about those agencies. However, since 2006, “the CVC had got no feedback on complaints pending with the police.” For an unexplained reason, the CVC finally became curious over the lack of feedback early this year, and discovered the reason behind it.

Delhi police officials indicate that they are now addressing the backlog of complaints against the department.

Coroner Says NHS Computer System Partly to Blame for Toddler’s Death

Coroner Blames “Failure” of NHS Computer System for Boy's Death

Three-year-old Dies after New NHS Computer System Delays Heart Treatment Appointment

Hospital Booking System “May Have Contributed to Death”

Coroner Criticizes Hospital’s IT System After Boy’s Death

Votes Found Two Years after Election

Jefferson County Finds 3700 Untallied Votes from 2012 Election

Software Glitch Delays Port Arthur Election Count

Delhi Police Finally Address Complaints Against It, Some From Eight Years Ago

667 Vigilance Complaints Pile Up as Delhi Police Claim Password Ignorance

Delhi Police Complaints Mount as Police Lose Password for Eight Years