Hospital IT meltdown that delayed transplant was preventable
‘There was some initial confusion on the day about the availability of water supply on the roof ’
AN IT meltdown at the UK’S largest hospital, which delayed an organ transplant, could have been prevented, an internal report has concluded.
Guy’s and St Thomas’ Foundation Trust (GSTT) said its clinical IT system shutdown last July during the 40C (104F) heatwave, which, combined with its “ageing infrastructure”, caused an outage at two of its data centres. Staff worked on pen and paper and the incident was not resolved for “weeks”, which caused “widespread frustration”, according to the trust’s report.
During the “catastrophic” incident, one patient suffered “moderate harm” after their pancreas transplant could not go ahead. While another 20 experienced “low harm”, including medicine errors or delays obtaining results, which affected their care. GSTT said the failure of the data centres caused by an event such as a heatwave was “a risk that might have been predicted and was therefore potentially a preventable event”.
The report, which was overseen by Jane Fryer, NHS England London’s medical director, adds: “Whilst risk prediction, mitigation and reporting necessarily requires judgments to be made, and is not an exact science, it is self-evident that these processes did not predict, mitigate or prevent this event. This represents a failure of the trust’s risk management processes to mitigate the risk of data centre failure.”
Following the heatwave forecasts, the trust planned to manually hose down the air conditioning condensers, which can improve airflow and prevent it from overheating, at St Thomas’ Hospital data centre. But the team had issues with a hose connector, delaying the hosing down and meaning it was “not as effective as it could have been”.
“At Guy’s, no such preparations were made and there was some initial confusion on the day about the availability of water supply on the roof,” the report found. Summing up the root causes of the IT failures, the report said: “Earlier action to cool the condensers by hosing with cold water could have kept the temperature in the data centres lower and prevented failure.”
A timeline of events from July 19, when temperatures reached 40.3C in London, show the temperature inside the data centre at Guy’s reached 50.3C, when the normal operating temperature is around 20C.