Northern Care Alliance IT disruption resulted in one serious incident

IT disruption at the Northern Care Alliance NHS Foundation Trust resulted in one serious incident which involved incorrect information about a patient being sent to a coroner, a report to the trust’s board has revealed.

Back in May 2022, the trust confirmed it has been experiencing “disruption and instability issues” with some of its IT systems and then later some systems were moved to a “stable platform”.

The affected sites were The Royal Oldham Hospital, Fairfield General Hospital in Bury, Rochdale Infirmary and North Manchester General Hospital (which is operated by Manchester University NHS Foundation Trust).

At the time of the incident, details surrounding what had happened were not released but a report presented to the Northern Care Alliance’s board in July 2022 revealed that the issues related to the trust’s virtual infrastructure and that a software defect in the VMware vSAN software was the “root cause”.

According to the report, early analysis of the incident has stated that as a result of the disruption, there was one serious incident where a referral was made to the coroner containing incorrect patient information. There was also two incidents of moderate harm – one medication error and one surgery related incident.

Furthermore, there were 327 incidents of low harm reported, with the top three areas of risk being medications related (of which almost half relate to missed drug dosage), documentation and IT security.

The report also revealed that the cost of managing and recovering from the outage has been estimated currently at £675,000.

On top of that, around “1000 appointments/procedures were cancelled with the biggest impact on high volumes specialities such as ophthalmology and rheumatology”.

The trust’s radiology departments were also impacted as systems were unavailable and there was a reduction in outpatient clinics and some theatre sessions. This meant that reporting and treatment capacity was reduced. For radiology this temporarily halted the ability to continue progress in reducing the scanning and reporting backlog reduction programme.

Following on from the outage, the trust has made a number of recommendations, which include:

• Explore the use of developing a backup cloud-based system for critical clinical systems such as e-prescribing.
• The development of a process to allow all user emails to be circulated out of hours in the absence of a member of the communications team needs to be agreed.

In addition, the report to the board also confirms it will work with NHS Digital to create an incident review which will “identify any further learning or service improvement insight which can help mitigate any future risk and inform the design of the new cluster”.