Fourteen patients suffered severe harm and 20 moderate harm after they were “lost to follow-up” by a hospital trust, it has admitted

Maidstone and Tunbridge Wells Trust said two of the patients who were harmed are now pursuing clinical negligence cases against it.

The majority of the 34 cases involved “cancer pathway/referral issues” between January 2022 and April this year. 

The trust has informed patients in all appropriate cases, it said, but has not provided further details to HSJ of the cases where negligence action is being taken.

A “deep dive” review was launched earlier this year after staff noticed they were seeing more serious incidents than usual involving patients being “lost to follow-up”.

People are generally “lost to follow-up” when an appointment should take place – such as after a scan, after a fixed duration, or after an attempt to transfer specialty – but does not. It can result in harm when it means concerns are not picked up and treated, particularly if diagnostics are not properly acted on in cancer pathways.

The trust indicated similar issues are likely to be widespread in the NHS, saying in a statement: “Patients ‘lost to follow-up’ is an issue across the NHS, and this has been acknowledged within national investigations by the Health Services Safety Investigations Body along with recognition of the impact of clinical booking systems as a key theme.

“At a local level the trust recognised [it] needed to be addressed. The deep dive was held to identify areas where improvements could be made, and this work is in progress.”

The review cites the practice of “excess patient related results/paper referrals being left in piles in office environment”, multiple waiting lists in place for some services, and information being lost when lists were transferred to spreadsheets.

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Source: HSJ, 20 December 2024