HSSIB Interim report: Electronic referrals for ongoing care: risk of losing patient referrals (22 October 2026)

Summary

This is the second interim report in Health Services Safety Investigations Body (HSSIB)s investigation into electronic patient record systems and electronic referrals for ongoing care. It has been published to highlight a risk to patient safety associated with the electronic referral service (e-RS), where referrals may be removed from healthcare provider organisation worklists without warning or recognition.

The e-RS system generates digital worklists, which are used by provider organisations to manage patient referral processes. Referrals are automatically removed from a provider’s worklist within e-RS when a user performs an action, like accepting a referral or booking a patient appointment, or when 180 days pass with no action since the unique booking reference number (the patient referral) entered a worklist.

The 180-day function was designed into e-RS to reduce the risk of large worklists affecting the performance of the service. However, the investigation found that the function also creates a hazard to patients.

Content

Findings

• Incidents were identified in which referrals disappeared from e-RS worklists without provider organisations’ knowledge. These included referrals that disappeared for unknown reasons and those automatically removed after 180 days without action, before patients had been booked for appointments.

• There is an ongoing risk that patients may experience missed or delayed care as a result of the 180-day function. The level of risk is difficult to determine but has potentially increased in light of demands on outpatient services and longer waits for appointments.

• The 180-day function is not new, but recognition of it as a hazard to patient safety has not been formally documented. At the time of writing, available national digital clinical risk documentation for e-RS (in line with the DCB0129 digital clinical safety standard) did not refer to the function.

• e-RS was not designed to manage the current volume of referrals seen across the NHS, particularly since the COVID-19 pandemic. The 180-day function was heard to be necessary and the associated risk cannot currently be eliminated.

• Management of the risk created by the 180-day function has been delegated to provider organisations. The investigation identified gaps in organisational knowledge about the function and, as a result, gaps in how the risk is managed.

• Local management of the risk relies on administrative processes, which vary in their formality and effectiveness. Where processes have been weakened by reduced administrative capacity or unclear roles and responsibilities, repeat incidents have occurred.

• Providers deploying e-RS were unable to provide evidence that they had achieved compliance with required digital clinical safety standards (as set out in DCB0160). The deployment of e-RS into local pathways, and the risks associated with that deployment, had not been assessed.

HSSIB notes the following safety action

Safety action A/2026/003:

NHS England, as the supplier of the electronic referral service, is reviewing and updating the associated digital clinical risk management documentation (in line with the DCB0129 digital clinical safety standard) to recognise the hazard associated with the 180-day function. This will be made available to provider organisations to support local assessment and management of associated risks to patient safety.

Local-level learning

HSSIB investigations include local-level learning where this may help provider organisations respond to a patient safety issue at the local level. Informed by the findings in this report, the investigation shares the following prompts to help provider organisations manage risks, including those associated with the 180-day function.

• Does your organisation have a responsible clinical safety officer for the electronic referral service (e-RS)?

• How does your organisation support collaboration between digital, patient safety, patient experience and complaint teams to identify incidents where patient referrals may have been lost?

• Has your organisation formally assessed and documented the clinical risk of patients disappearing from e-RS worklists, including as a result of the 180-day function?

• Has your organisation developed and evaluated measures to reduce risks to patient safety created by the 180-day function in e-RS?

• Does your organisation meet the DCB0160 digital clinical safety standard requirements for e-RS deployment and ongoing use, including maintaining a local hazard log?

• What local processes has your organisation formally established to identify, validate and manage referrals that have dropped off e-RS worklists?

• Does your organisation routinely review the EBSX12 weekly worklist drop-off extract and act on the findings?

• How does your organisation assess whether administrative processes for managing referrals, reviewing worklists and validating dropped-off referrals remain effective, including during periods of staffing change or service pressure?

• How does your organisation learn from incidents where patients are lost within referral processes, including where referrals have dropped off worklists, to strengthen the resilience of referral management?