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East and North Hertfordshire NHS Trust

Coreys Mill Lane


7 September 2018

To: GPs and Practice Managers

I am writing to you to alert you and your practice colleagues to a problem that the Trust has
identified with discharge summaries that may not have been issued properly. Before explaining
what has happened, and just as importantly the actions being taken by the Trust to address this
important matter, I wanted to apologise to you and your patients that have been affected. The
Trust not only takes full responsibility for what has happened, we are also determined to ensure
that it is fixed in a way that limits the workload of our primary care colleagues.

As you may know, the Trust implemented two major new computerised systems in September
2017- Lorenzo (our replacement patient administration service) and Nervecentre, a clinical
information system. Although feedback was received over the following months from GPs about
missing discharge summaries, the experience of other NHS trusts that have introduced new
electronic patient record systems suggested that this was not to be unexpected.

Following further concerns being raised by GPs a little earlier this year about discharge
summaries and the Lister’s emergency department, the Trust carried out a review. That work
established that in some instances either the GP and/or the patient may not have received their
discharge summary. Between September 2017 and July 2018, around 48,000 patients have
been discharged from the Trust’s care. Working with our colleagues at the East and North
Hertfordshire CCG, which is taking the lead on behalf of all neighbouring CCGs, a detailed review
has identified that insufficient evidence exists for some 14,600 records to be sure whether or not
a discharge summary was written and sent.

This work is being investigated and reported upon as a serious incident, with the group managing
the process having CCG, GP and practice manager representation. The Trust’s regulators –
NHS Improvement and the Care Quality Commission – are also aware of what is taking place.
The aim of the group’s work is not just to understand and rectify all historical issues, but to ensure
that the right steps are taken to prevent the problem reoccurring in future.

Although this work involves our consultants looking at a large number of individual records, those
with potentially unsent discharge summaries dating from 1 April to 31 July 2018 – which totals
some 2,400 cases – are being prioritised based on clinical grounds; and within that cohort, those
patients who attended acute medical services will be reviewed first. Once this work has been
completed, our consultants will start looking at the remaining 12,200 records.

Where an outstanding action is identified and established as not having happened, the Trust will
take the lead in working to make sure that this is acted upon quickly and that each patient is
spoken to individually by a member of our staff. In such cases, the patient’s GP will also be kept
informed of what is happening and why.
Where discharge summaries are identified with no listed actions for GPs and where it cannot be
confirmed that they have been sent out, then we will be sending them to both the patient and their
GP. The summary that goes to the patient will have a cover letter and Q&A explaining that
although they may have had the letter already, for example hard copies given to them by a ward
team, there is nothing that they need to worry about as there are no outstanding actions. The
copy of the summary going to the GP electronically will be marked clearly as being part of this
exercise so that it can be identified easily.

The Trust is very aware of the potential additional workload this may cause for its GP practice
colleagues, for which we apologise and in response, we are committed to doing two things:

 Taking a phased approach, so that each practice's outstanding discharge summaries

arrive in small batches over an agreed period of time.
 Where outstanding actions are identified, the Trust will take the lead in completing them
but at the same time keeping GPs aware of what is taking place.

In this way, we hope that GP practice workloads can be managed effectively.

As stated earlier, in the first phase of this review, our team is prioritising the most recent cohort of
discharge summaries from April to July 2018, which totals 2,422 records. Of these, 2,045 relate
to GP practices within East and North Hertfordshire, with the remaining 377 belonging to patients
associated with practices in our six neighbourging CCGs.

We will be writing to each GP practice affected over the next few weeks to let them know the
number of discharge summaries they will be receiving, when they will arrive and over what
timescale. In this way, we will set out a clear picture for each GP practice, so they know what to
expect locally.

I am aware that the timeliness and quality of the Trust’s discharge summaries has been an issue
for referring GPs for some time. Whilst some improvements have been made, we have had a
system in place since July 2018 that identifies any potentially unsent discharge summaries –
which is being monitored on a weekly basis, with our clinical divisional teams being held to
account for their performance. This should reduce the amount of time you and your colleagues
expend contacting both us and our colleagues at the CCG about missing, late or unclear
summaries – which has to be a good thing for all of us, but especially our patients.

Should you have any further questions, we have enclosed a Q&A that you may find helpful –
including if you have patients asking you questions; you are also free to contact our GP liaison
team directly (01438 284613 or gpliaison.enh-tr@nhs.net).

Yours sincerely

Michael Chilvers
Medical Director
Discharge summary letters – your questions answered

What was the problem with the Trust’s discharge summaries?

Back in September 2017, the Trust introduced a new electronic patient record system called Lorenzo.
These are very complex systems and initial teething problems are always expected as staff get used
to moving from old ways of recording patient information to a completely new system like Lorenzo.

During the first few months of using Lorenzo, we did get reports about some missing discharge
summaries from patient’s GPs – but this was not an unexpected occurrence, as such issues have
been reported by other NHS trusts introducing new electronic patient record systems. Where such
reports were received, they were addressed individually.

However, a little earlier this year more significant questions arose about discharge summaries that
would have been issued by the Lister’s emergency department. A thorough investigation revealed
that a more systemic problem may exist. Looking across all of the Trust’s service dating back to
September 2017 when the new electronic patient record was installed, some 14,600 records have
been identified where it is not clear on the system whether or not the discharge summary was sent to
both the patient and their GP.

We will be reviewing these records, starting with the most recent (some 2,400 dating from April to July
2018, as these are the ones where the greatest clinical priority rests), before then reviewing the
remainder. It is our expectation that the majority of these records will either turn out to have been
issued or if not, then no follow-up action is required. In the latter cases, issuing the discharge
summary is about completing people’s health record.

At the same time, we will be checking for those summaries that were not issued and where a follow-
up action has not happened – in such cases, the Trust will make contact with the patient and their GP,
taking the lead in making sure the action is taken.

Why do you believe that only 14,600 records need to be reviewed – why not all 48,000?
In introducing Lorenzo, the Trust had – for the first time – a Trust-wide system that recorded every
step of whether or not a discharge summary has been written, approved and sent. Of the some
48,000 summaries that should have been written and sent since the system went live in September
2017, clear evidence exists for all but 14,600 that the discharge summaries were sent – but we will
also be carrying out spot checks to provide further reassurance to ourselves, the CCG and, of course,
our GP colleagues.

But even of those 14,600 records that will be checked by the Trust, it is expected that a very
significant percentage will have been issued to the patient and/or their GP – it’s just that these actions
have not been recorded properly. There will, of course, be a significant number where this has not
happened, which is why each record is being reviewed individually by the relevant consultant.

Why stop looking at summaries in July 2018?

The problem was identified in July, so the Trust is now monitoring what is happening to discharge
summaries on a weekly basis, so the management of this review is looking at the summaries that may
not have been issued properly between September 2017 and July 2018.

How long will this work take?

As we are at the start of this review, it is not possible to give a timescale yet – but we are committed to
keeping our GP colleagues up-to-date on what is happening, providing regular updates.
But the Trust has always had a problem with discharge summaries – what’s different now?
The Trust’s old patent administration system (PAS), which was replaced in September 2017, was very
old. So old in fact, that it was no longer supported by the original provider. In seeking national support
from NHS Digital to replace it, switching to Lorenzo was the only option available to the Trust – and
not to have taken that step would have put patient safety at risk had the old PAS failed.

Whilst we accept, without reservation, that the quality and timeliness of the Trust’s discharge
summaries prior to September 2017 was something about which GPs raised concerns regularly, it
was not until Lorenzo was brought in to the Trust that we had a system that could help identify where
such problems existed. Now that we know what has happened, not only can we address the missing
summaries that were not issued between September 2017 and July 2018, we also have made
changes that ensure we can identify and address, on a weekly basis, problems that may be arising.
We have also made changes to Lorenzo and we are providing further training to our doctors to
minimise the risk of a discharge summary not being completed and sent out on time. Part of this work
is also to improve the quality of the information contained with each discharge summary.

Could this happen again?

Because we are reviewing performance with our clinical divisions on a weekly basis, whilst at the
same time making changes to our systems and training for clinicians, we are confident that such a
problem cannot happen again – but we will remain vigilant, carrying out spot checks regularly

Who can my patients talk to if they have a concern?

They are very welcome to get in touch with the Trust’s patient advice and liaison service (PALS) team
- 01438 285811 (Monday to Friday, office hours only) or pals.enh-tr@nhs.net.