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  • HSIB: Clinical investigation booking systems failures - written communications in community languages (April 2023)

    • UK
    • Investigations
    • Pre-existing
    • Original author
    • No
    • HSIB
    • 26/04/23
    • Health and care staff, Patient safety leads


    This Healthcare Safety Investigation Branch (HSIB) investigation focuses on the systems used by healthcare providers to book patient appointments for clinical investigations, such as diagnostic tests and scans.

    ‘Clinical investigation booking systems’ are used throughout the NHS to support the delivery of patient care. Healthcare services use paper-based or fully electronic systems, or a combination of the two (hybrid systems), to communicate to patients the time, date and location of their appointment. These systems also produce information for patients about actions they need to take to prepare for their appointment. Written patient communication is a key output of clinical investigation booking systems.

    This investigation examines the safety implications of patient communications, produced by booking systems, that do not account for the needs of the patient. In addition, it looks at why patients are ‘lost to follow-up’ after an appointment is cancelled, rescheduled or not attended. Lost to follow-up is the term used to describe a patient who does not return for planned appointments (whether for continued care or evaluations) or is no longer being tracked in the healthcare system when they should be.


    The reference event for this investigation was a child of Romanian ethnicity who was referred for an MRI scan, which required a general anaesthetic. The scan was booked, and a letter was sent to the child’s parents including the appointment details and pre-appointment instructions.

    The Trust’s booking system was only able to produce appointment letters in English, and there were no Trust processes or policies to routinely translate written appointment information.

    The family recognised key details in the written information, including the time, date and location of the scan. However, they were not able to understand the instructions about the child not eating or drinking (fasting) for a certain amount of time before the scan.

    When the family attended the appointment for the scan, the child had eaten. This meant the MRI scan could not be completed and it was therefore cancelled. When the scan was finally carried out cancer was diagnosed. The child received treatment, but sadly the disease progressed and they were placed on a palliative care pathway and died.


    • Written communications to patients about radiology appointments are routinely sent in English only.
    • Healthcare staff expect that written appointment information will be translated by a patient’s friend or family member.
    • NHS England standards do not require written appointment information to begiven in any non-English language, other than for people with a disability.
    • Confusion about the requirements for appointments can result in delayed care and additional costs if appointments need to be rebooked.
    • The language needs of patients are not always clearly understood. There is differing national guidance as to whether written communication needs should be recorded.
    • The national NHS system that holds patient information and populates it into many trust systems (the Personal Demographics Service) can store information on patients’ preferred written communication methods. However, this information is often not entered into the system.
    • Administrative staff are not routinely involved in assessing and testing electronic booking systems before they are implemented.


    • HSIB recommends that NHS England develops and implements a standard for healthcare providers on supplying written appointment information in languages other than English.

    Safety observations

    • It may be beneficial for NHS care providers to explore options for the translation of written appointment communications, including pre-attendance guidance, for patients whose preferred written language is not English.

    Safety actions

    • It may be beneficial if the ‘preferred written communication method’ field of the Personal Demographics Service system is completed for patients who require written communications in a language other than English.
    • It may be beneficial if NHS trusts identify mechanisms to appreciate the language needs of their patient demographic and adjust the written communications accordingly.
    • It may be beneficial to clarify the roles and functions of national organisations in supporting the health inequalities landscape.
    • It may be beneficial for NHS healthcare providers to incorporate the NHS Service Standard into agreements with third-party developers of electronic clinical investigation booking systems.
    HSIB: Clinical investigation booking systems failures - written communications in community languages (April 2023) https://hsib-kqcco125-media.s3.amazonaws.com/assets/documents/hsib-report-clinical-investigation-booking-systems-failures.pdf
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