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UK NHS Review Finds 25 Incorrect Organ Donations

Errors traced to software glitch going back to 1999

2 min read
UK NHS Review Finds 25 Incorrect Organ Donations

In April, I blogged about the discovery of a software problem that existed for over 10 years without being noticed in the UK's National Health Service's (NHS) Blood and Transplant (NHSBT) Special Health Authority organ donation system. The problem caused the organ donation wishes of some 800,000 people on the NHS Organ Donor Register (ODR) to be in error. At the time, there were at least twenty cases identified where organs were taken without proper consent.

Then UK Health Secretary Andy Burnham expressed his deep "regrets" over the distressed caused, and asked Professor Sir Gordon Duff of Sheffield University to carry out a review of the situation to prevent it from happening again.

A story in today's London Daily Mail says Sir Gordon's review (PDF here) found that a total of 25 improper organ donations occurred - not many considering the number of people and length of time involved.

Sir Gordon found that the reason for the error was that when a new organ donation computer system was installed by the NHS in 1999, the organ donation check boxes on the form were not linked correctly to what the computer system was programmed to read. So someone indicating that they were willing to donate their corneas were actually agreeing to having their heart removed instead.

Sir Gordon's report goes into the details of what happened, why it took so long to be discovered, and why (luckily) more incorrect organ donations did not happen, which always puzzled me.  I suggest you give the report a read: it makes for an interesting case study starring all the usual suspects: lack of clear specifications, poor end-to-end testing, etc.

Sir Gordon, the Daily Mail says, "recommended that as soon as resources allow, NHS Blood and Transplant should design and commission a new register which will be better equipped to deal with the operational demands now placed on it."

For its part, the NHSBT said that:

"We accept in full the recommendations of Professor Sir Gordon Duff, which will contribute significantly to strengthening the ODR and public confidence in it as a way to record organ donation wishes. "

It also "sincerely regrets that the error was not uncovered earlier."

The Conversation (0)

Why Functional Programming Should Be the Future of Software Development

It’s hard to learn, but your code will produce fewer nasty surprises

11 min read
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A plate of spaghetti made from code
Shira Inbar
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You’d expectthe longest and most costly phase in the lifecycle of a software product to be the initial development of the system, when all those great features are first imagined and then created. In fact, the hardest part comes later, during the maintenance phase. That’s when programmers pay the price for the shortcuts they took during development.

So why did they take shortcuts? Maybe they didn’t realize that they were cutting any corners. Only when their code was deployed and exercised by a lot of users did its hidden flaws come to light. And maybe the developers were rushed. Time-to-market pressures would almost guarantee that their software will contain more bugs than it would otherwise.

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