Robert Wrinch
25 Jul 2018 · Coroner Alison Mutch · Manchester (South)
This report repeats 1 earlier warning, and was raised again 3 times later. See the linked reports.
The coroner's concerns
1. lack of sample tracking system
“The Inquest heard evidence that the pathology department at the Trust had no system for tracking samples. As a result, it was unclear when samples had been received and analysis had taken place. There was no documentation of conversations with other clinicians and so, it was difficult to be clear about the chronology of events. Transmission dates of the sample to another Trust were unclear. It was also difficult to know on what date the report of the pathologists findings had been issued to the”
2. reliance on paper system causing delay
“The Trust had a system of issuing reports digitally to clinicians to speed up receipt. In addition the Inquest were told that due to preferences of clinicians paper copies were also produced and sent via interna! mail to the treating clinicians. The Inquest heard that the responsible orthopaedic consultant relied on wholly on the paper system although this built in delay.”
3. inconsistent tracking systems across departments
“At the Trust, some departments such as the respiratory department had clear tracking systems to identify outstanding pathology reports. Other departments such as orthopaedics did not. As a result, clinicians could not readily identify where there was delay in receipt of information required to assess and diagnose a patient.”
4. incompatible IT systems
“The I.T systems of the pathology department of the Trust and other hospital Trusts were incompatible with each other. This meant that transfer of information between trusts to obtain a second opinion were more difficult.”
5. backlog in sample analysis
“The Inquest heard that the delay in analysis of the sample taken was due to a backlog. The backlog was not unique to the Trust and such backlogs were prevalent across pathology departments nationally due to a local and national shortage of pathologists.”
Linked reports
Closely relatedConfidence 0.85 · high
Earlier report
“The computerised note keeping system used in the Emergency Department is not able to”
This report
“The I.T systems of the pathology department of the Trust and other hospital Trusts were incompatible with each other. This meant that transfer of information between trusts to obtain a second opinion were more difficult.”
Identical hazardConfidence 0.90 · high
This report
“The I.T systems of the pathology department of the Trust and other hospital Trusts were incompatible with each other. This meant that transfer of information between trusts to obtain a second opinion were more difficult.”
Later report
“The inquest heard evidence that the lack of a single IT system across NHS trusts meant that information sharing was more difficult.”
Closely relatedConfidence 0.96 · high
This report
“The I.T systems of the pathology department of the Trust and other hospital Trusts were incompatible with each other. This meant that transfer of information between trusts to obtain a second opinion were more difficult.”
Later report
“The Inquest heard evidence that incompatible/different IT systems at the District General Hospital and Tertiary Centre made communication and information sharing in relation to patients more difficult.”
Closely relatedConfidence 0.90 · high
This report
“. The I.T systems of the pathology department of the Trust and other hospital Trusts were incompatible with each other. This meant that transfer of information between trusts to obtain a second opinion were more difficult.”
Later report
“There are multiple software programmes for record keeping for these organisations, which makes transfer and sharing of clinical information cumbersome and difficult, as direct sharing is not possible.”
Responses
No published response was found on judiciary.uk.