Collection
Case Study: Outdated referral process sees hospital appointment and cancer diagnosis delayed
Published on
Last updated on
Published on
Last updated on
Marie complained to the Ombudsman when a mix-up in referral letters resulted in an important medical appointment not being made and a diagnosis of cancer being delayed by up to eight months. Marie was a transplant patient. During a routine appointment a skin lesion was noticed by staff in the Nephrology Unit in St Vincent’s University hospital, Dublin. The lesion was of some concern as transplant patients are more susceptible to skin cancers.
In early March, the Nephrology Unit issued a hard copy appointment letter to the hospital’s Dermatology unit. While the Nephrology Unit had printed the letter, it never arrived in the Dermatology department. In May, Marie was attending another appointment at the Nephrology Unit and asked about the appointment for Dermatology. A second referral letter was sent, but again Marie received no notification of an appointment.
In August, Marie contacted the Dermatology Unit directly and received a date for an appointment in October. The lesion was removed and later turned out to be malignant.
The hospital confirmed to the Ombudsman that the initial referral letter, dictated by the consultant at the time, had been typed and printed in the Nephrology Unit within a few days of the initial appointment. There was no record of it having been received by Dermatology.
The hospital accepted that there was a deficiency in its process for issuing referral letters and ensuring they were followed-up. It proposed that it establish a new centralised ‘print room’ where all referral letters between departments would be printed to mitigate the risk of any future letters being lost.
Having examined the hospital’s proposal, the Ombudsman believed that a ‘print room’ was insufficient as it still relied on a hard copy letters being printed and delivered. The Ombudsman proposed that the hospital develop an ICT-based solution to ensure efficient and effective referral of appointments and tracking. The Ombudsman also believed that the hospital should apologise to Marie for the delay in her diagnosis.
As a result, the hospital implemented a new internal electronic referral system between departments. This system was designed specifically for the purpose of removing the possibility of referral letters being lost. It works by recording the referral on an online form. Staff check this daily for new referrals which are logged to the relevant consultant, removing the requirement for letters to be dictated or sent in the internal post. The hospital also apologised to Marie for the failures and the difficulties that she encountered.